Report to the Honorable Eleanor 

Holmes Norton, House of 

Representatives 

United States General Accounting Office 

GAO

May 2002 VIOLENCE AGAINST 

WOMEN 

Data on Pregnant 

Victims and 

Effectiveness of 

Prevention Strategies 

Are Limited 

GAO-02-530 
Page i GAO-02-530 Violence Against Women 

Letter 1

Results in Brief 2

Background 4

Available Data on Pregnant Victims of Violence Are Incomplete 

and Lack Comparability 6

Multiple Strategies Designed to Prevent Violence, But Effect Is 

Unknown 12

Concluding Observations 17

Agency Comments 17

Appendix I Scope and Methodology 19 

Appendix II Description of the Pregnancy Risk Assessment 

Monitoring System 21 

Appendix III Pregnancy Status Questions on States’ Death 

Certificates 23 

Appendix IV Comments from the Department of Health and 

Human Services 24 

Appendix V GAO Contacts and Staff Acknowledgments 29 

Table 

Table 1: PRAMS Estimates of the Prevalence of Physical Abuse by 

Husband or Partner during Pregnancy, 1998 22

Figure 

Figure 1: Pregnancy Status Categories on Proposed U.S. Standard 

Death Certificate Revision 11

Contents 
Page ii GAO-02-530 Violence Against Women 

Abbreviations 

ACOG American College of Obstetricians and Gynecologists 

BJS Bureau of Justice Statistics 

CDC Centers for Disease Control and Prevention 

FBI Federal Bureau of Investigation 

HHS Department of Health and Human Services 

HRSA Health Resources and Services Administration 

NIH National Institutes of Health 

NIJ National Institute of Justice 

NVDRS National Violent Death Reporting System 

OJP Office of Justice Programs 

PRAMS Pregnancy Risk Assessment Monitoring System 

SAMHSA Substance Abuse and Mental Health Services 

 Administration 

UCR Uniform Crime Reporting Program 

VAWA Violence Against Women Act 

VAWO Violence Against Women Office 
Page 1 GAO-02-530 Violence Against Women 

May 15, 2002 

The Honorable Eleanor Holmes Norton 

House of Representatives 

Dear Ms. Norton: 

Violence against women, including violence that results in homicide, is a 

significant health and criminal justice problem. The problem is magnified 

when the victim of violence is pregnant because there are additional 

health risks to both the woman and her unborn child. Objectives to 

decrease violence against women were included in Healthy People 2010, 

the nation’s health promotion and disease prevention strategy.1

 In 

response to its concerns about violence against women, the Congress 

passed the Violence Against Women Act (VAWA),2

 which funds, among 

other things, programs to shelter battered women, training for law 

enforcement officers and prosecutors, and research on violence against 

women. 

Violence against women largely involves intimate partners, such as 

husbands, boyfriends, and dates. A recent federal report estimated that 

about 2.1 million women are raped or physically assaulted annually.3

 Of 

surveyed women who reported being raped or physically assaulted since 

the age of 18, about three quarters reported being victimized by a current 

or former spouse, cohabiting partner, or date. 

Due to your concern about pregnant women being victims of homicide and 

other violence, you asked us to provide information on this problem. In 

response to your request, this report will discuss (1) the availability of 

 1

U.S. Department of Health and Human Services, Healthy People 2010: Understanding 

and Improving Health, 2nd ed. (Washington, D.C.: U.S. Government Printing Office, 

November 2000). 

2

VAWA was enacted in 1994 as Title IV of the Violent Crime Control and Law Enforcement 

Act of 1994, P.L. No. 103-322, 108 Stat. 1796, 1945. In 2000, VAWA was reauthorized and 

amended—adding several new programs. See Victims of Trafficking and Violence 

Protection Act of 2000, P.L. No. 106-386, 114 Stat. 1464, 1491. 

3

Patricia Tjaden and Nancy Thoennes, Prevalence, Incidence, and Consequences of 

Violence Against Women: Findings From the National Violence Against Women Survey, 

NCJ 172837 (Washington, D.C.: U.S. Department of Justice, November 1998). 

United States General Accounting Office 

Washington, DC 20548 
Page 2 GAO-02-530 Violence Against Women 

information on the prevalence and risk of violence against pregnant 

women and on the number of pregnant women who are victims of 

homicide and (2) strategies and programs to prevent violence against 

pregnant women. 

To answer these questions, we interviewed and obtained documents from 

officials at the Department of Health and Human Services’ (HHS) Centers 

for Disease Control and Prevention (CDC), National Institutes of Health 

(NIH), and Health Resources and Services Administration (HRSA) and the 

Department of Justice’s Office of Justice Programs (OJP) and Federal 

Bureau of Investigation (FBI). We also interviewed and collected 

information from researchers and representatives of four states’

departments of health and vital statistics, medical examiners’ offices, local 

law enforcement, domestic violence coalitions, violence prevention 

programs, health care professional organizations, and advocacy groups. 

We reviewed literature on the prevalence and risk of violence toward 

women during pregnancy; we identified 11 studies published since 1998 

that contained prevalence estimates. We conducted our work from July 

2001 through April 2002 in accordance with generally accepted 

government auditing standards. (For additional information on our 

methodology, see app. I.) 

Available data on the number of pregnant women who are victims of 

violence, including violence that results in homicide, are incomplete and 

lack comparability. Our review found that there is no current national 

estimate of the prevalence of violence against pregnant women—that is, 

the proportion of pregnant women who experience violence. Estimates 

that are available cannot be generalized or projected to all pregnant 

women. For example, CDC’s Pregnancy Risk Assessment Monitoring 

System (PRAMS) produces estimates of the prevalence of violence, but 

only for women whose pregnancies resulted in live births and only for 

participating states. For 1998, PRAMS prevalence estimates for the 15 

participating states ranged from 2.4 percent to 6.6 percent. Many studies 

focus on narrowly defined populations and use varying definitions of 

violence, producing prevalence estimates that are not comparable. 

Research findings on whether women are at increased risk for violence 

during pregnancy are inconclusive. CDC reported that, while additional 

research is needed in this area, current study findings suggest that for 

most abused women, the risk of physical violence does not seem to 

increase during pregnancy. Moreover, some women who previously 

experienced violence do not experience violence during their pregnancies. 

Factors that studies have found to be associated with violence during 

Results in Brief 
Page 3 GAO-02-530 Violence Against Women 

pregnancy include violence before pregnancy, younger age of the victim, 

and unintended pregnancy. 

Little information is available on the number of pregnant homicide victims. 

Federal homicide data collected by CDC and the FBI do not capture the 

pregnancy status of female victims. Seventeen states try to collect 

pregnancy data on death certificates, but these data may understate the 

number of pregnant homicide victims because autopsies, if conducted, 

might not include examinations for pregnancy, and pregnancies, if 

identified, might not be reported on death certificates. Officials in the four 

states we contacted have attempted to improve the data by linking 

multiple data sources, such as medical examiners’ reports and death 

certificates. However, some of these officials told us that they do not have 

the resources to conduct such database links on a continuing basis. CDC 

has begun two initiatives that could result in better data on homicides of 

pregnant women—a revision to the U.S. standard death certificate to 

include pregnancy status and a proposed national violent death reporting 

system, both of which involve federal and state participation. Continued 

federal-state collaboration to gather and analyze more complete and 

comparable data, such as these initiatives and PRAMS, could improve 

policymakers’ knowledge of violence against women and guide future 

research and resource allocation. 

Health and criminal justice officials have designed multiple strategies to 

prevent violence against women, but their effect is unknown. Strategies to 

prevent violence against pregnant women are similar to those to prevent 

violence against all women. These strategies include public health efforts 

to keep violence from occurring in the first place and intervention 

activities that identify and respond to violence after it occurs, as well as 

criminal justice strategies that focus on incarcerating or rehabilitating 

batterers. Screening, or asking women about their experience with 

violence, is generally the initial component of interventions. However, 

recent studies found that fewer than half of physicians routinely screen for 

violence during prenatal visits. Reasons cited for physicians’ reluctance to 

screen include lack of training on how to conduct screenings and not 

knowing how to respond if a woman discloses violence. Little information 

is available on the effectiveness of strategies to prevent violence against 

women, including batterer prevention programs and routine screening. 

CDC has not recommended routine screening for intimate partner violence 

because of the lack of scientific evidence about its effectiveness. HRSA is 

currently funding four small prevention projects, each of which includes 

an evaluation component. Evaluating the outcomes of violence prevention 
Page 4 GAO-02-530 Violence Against Women 

programs and strategies could help identify successful approaches for 

reducing violence against women. 

We requested comments on a draft of this report from the Attorney 

General and the Secretary of HHS. Justice informed us that it did not have 

any comments. HHS agreed that limited information is available on 

violence against pregnant women. In addition, HHS discussed several 

issues and efforts that it considers important regarding violence against 

women. 

Violence against women can include a range of behaviors such as hitting, 

pushing, kicking, sexually assaulting, using a weapon, and threatening 

violence. Violence sometimes includes verbal or psychological abuse, 

stalking, or enforced social isolation. Victims are often subjected to 

repeated physical or psychological abuse. 

The federal public health agencies that address violence against women 

include CDC, NIH, HRSA, and the Substance Abuse and Mental Health 

Services Administration (SAMHSA). They focus on activities such as 

defining and measuring the magnitude of violence, identifying causes of 

violence, and evaluating and disseminating promising prevention, 

intervention, and treatment strategies. CDC’s National Center for Injury 

Prevention and Control and National Center for Chronic Disease 

Prevention and Health Promotion have funded efforts to document the 

prevalence of violence against women, improve maternal health, and 

prevent intimate partner violence. CDC’s National Center for Health 

Statistics operates the National Vital Statistics System, which maintains a 

national database of death certificate information. The National Center for 

Health Statistics has a contract with each state to support routine 

production of annual vital statistics data, generally covering from onefourth to one-third of state vital statistics operating costs. NIH has funded 

research to study violence against women through several of its 

institutes—the National Institute on Alcohol Abuse and Alcoholism, 

National Institute of Child Health and Human Development, National 

Institute on Drug Abuse, National Institute of Nursing Research, and 

National Institute of Mental Health—and the National Center for Research 

Resources. HRSA’s Maternal and Child Health Bureau, as part of its 

mission to promote and improve the health of mothers and children, funds 

demonstration grant programs that focus on violence against women 

during the prenatal period. SAMHSA funds efforts focused on the mental 

health and substance abuse treatment of women who have been victims of 

violence. 

Background 
Page 5 GAO-02-530 Violence Against Women 

The federal criminal justice agencies that address violence against women 

are OJP’s Violence Against Women Office (VAWO), National Institute of 

Justice (NIJ), and Bureau of Justice Statistics (BJS). Using VAWA funds, 

VAWO administers grants to help states, tribes, and local communities 

improve the way criminal justice systems respond to intimate partner 

violence, sexual assault, and stalking. VAWO also works with victims’

advocates and law enforcement agencies to develop grant programs that 

support a range of services for victims, including advocacy, emergency 

shelters, law enforcement protection, and legal aid. VAWO administers 

these funds through both formula and discretionary grant programs.4

 NIJ 

conducts and funds research on a variety of topics, including violence, 

drug abuse, criminal behavior, and victimization. BJS collects, analyzes, 

publishes, and disseminates information on crime, criminal offenders, 

victims of crime, and the operation of justice systems at all levels of 

government. 

The FBI administers the Uniform Crime Reporting Program (UCR). Under 

this program, city, county, and state law enforcement agencies voluntarily 

provide information on eight crimes occurring in their jurisdictions: 

criminal homicide, forcible rape, robbery, aggravated assault, burglary, 

larceny-theft, motor vehicle theft, and arson. The FBI assembles and 

publishes the data and distributes them to contributing local agencies, 

state UCR programs, and others interested in the nation’s crime problems. 

CDC homicide data indicate that from 1995 through 1999, homicide was 

the second leading cause of death for women aged 15 to 24, after 

accidents. CDC data also show that almost 2,600 women of childbearing 

age (15 through 44) were homicide victims in 1999. BJS reported that 

intimate partner homicides accounted for about 11 percent of all murders 

nationwide in that year.5 Seventy-four percent of these murders (1,218 of 

1,642) were of women. About 32 percent of all female homicide victims 

were murdered by an intimate partner, in comparison to about 4 percent 

of all male homicide victims. 

 4

VAWA funds programs in both Justice and HHS. Justice’s fiscal year 2002 appropriation for 

VAWA programs was $390.6 million. HHS’s fiscal year 2002 appropriation for VAWA 

programs was $176.7 million for battered women’s shelters, a domestic violence hotline, 

rape prevention and education, and community programs on intimate partner violence. 

5

Callie Marie Rennison, Intimate Partner Violence and Age of Victim, 1993-99, Bureau of 

Justice Statistics Special Report, NCJ 187635 (Washington, D.C., U.S. Department of 

Justice, October 2001). 
Page 6 GAO-02-530 Violence Against Women 

There is no current national estimate of the prevalence of violence against 

pregnant women. Estimates that are currently available cannot be 

generalized or projected to all pregnant women. CDC’s PRAMS develops 

statewide estimates of the prevalence of violence for women whose 

pregnancies resulted in live births; 1998 estimates for 15 participating 

states ranged from 2.4 percent to 6.6 percent. Research on whether women 

are at increased risk for violence during pregnancy is inconclusive. 

However, CDC reported that study findings suggest that, for most abused 

women, physical violence does not seem to be initiated or to increase 

during pregnancy. National data are also not available on the number of 

pregnant homicide victims, and such data at the state level are limited. The 

two federal agencies collecting homicide data, the FBI and CDC, do not 

identify the pregnancy status of homicide victims. CDC is exploring 

initiatives that could result in better data on homicides of pregnant 

women. 

There is no current national estimate measuring the prevalence of violence 

during pregnancy—that is, the proportion of pregnant women who 

experience violence. Some state- and community-specific estimates are 

available, but they cannot be generalized or projected to all pregnant 

women. 

CDC developed PRAMS, an ongoing population-based surveillance system 

that generates state-specific data on a number of maternal behaviors, such 

as use of alcohol and tobacco, and experiences—including physical 

abuse—before, during, and immediately following a woman’s pregnancy. 

CDC awards grants to states to help them collect these data. The number 

of states that participate in PRAMS has increased since its inception. Five 

states and the District of Columbia participated in fiscal year 1987 and 32 

states and New York City participated in fiscal year 2001. CDC officials 

reported that lack of funds has prevented additional states from being 

added; six states were approved for participation in PRAMS but were not 

funded in 2002. CDC’s goal is to fund all states that want the surveillance 

system. 

The estimated 1998 PRAMS prevalence rates of physical abuse by husband 

or partner during pregnancy, which CDC reported for 15 states, ranged 

Available Data on 

Pregnant Victims of 

Violence Are 

Incomplete and Lack 

Comparability 

Knowledge of Prevalence 

of Violence during 

Pregnancy Is Limited, 

Although Several Risk 

Factors Have Been 

Identified 
Page 7 GAO-02-530 Violence Against Women 

from 2.4 percent to 6.6 percent.6 (See app. II for PRAMS prevalence 

estimates for the 15 participating states and a description of PRAMS’s 

methodology.) States participating in PRAMS use a consistent data 

collection methodology that allows for comparisons among states, but it 

does not allow for development of national estimates because states 

participating in PRAMS were not selected to be representative of the 

nation. In addition, PRAMS data cannot be generalized to all pregnant 

women because they represent only those women whose pregnancies 

resulted in live births; the data do not include women whose pregnancies 

ended with fetal deaths or abortions or women who were victims of 

homicide.7

 PRAMS is based on self-reported data and, because some 

women are unwilling to disclose violence, the findings may underestimate 

abuse. 

Studies have also estimated the prevalence of violence within certain 

states and communities and among narrowly defined study populations. 

These estimates lack comparability and cannot be generalized or projected 

to all pregnant women. Many of the studies do not employ random 

samples and are disproportionately weighted toward specific demographic 

or socioeconomic populations. Most of the 11 such studies we reviewed, 

which were published from 1998 through 2001, found prevalence rates of 

violence during pregnancy ranging from 5.2 percent to 14.0 percent. In a 

CDC-sponsored 1996 review of the literature, the majority of studies 

reported prevalence levels of 3.9 percent to 8.3 percent.8

 The variability in 

estimates could reflect differences in study populations and 

methodologies, such as differences in how violence is defined, the time 

period used to measure violence, and the method used to collect the data. 

Research on whether being pregnant places women at increased risk for 

violence is inconclusive. CDC reported that additional research is needed 

in this area, but that current study findings suggest that for most abused 

women, physical violence does not seem to be initiated or to increase 

 6

The most recent year for which CDC has reported comprehensive data for PRAMS is 1998. 

CDC reported data for those 15 participating states that had fully implemented PRAMS data 

collection procedures and achieved CDC’s required response rate of at least 70 percent. 

One additional state participated in PRAMS but did not meet these criteria. 

7

CDC reported that, in 1997, 63 percent of pregnancies resulted in live births. 

8

Julie A. Gazmararian and others, “Prevalence of Violence Against Pregnant Women,”

JAMA 275, no. 24 (1996): 1915-1920. 
Page 8 GAO-02-530 Violence Against Women 

during pregnancy.9 Although some women experience violence for the first 

time during pregnancy, the majority of abused pregnant women 

experienced violence before pregnancy. In one study we reviewed, only 2 

percent of women who reported not being abused before pregnancy 

reported abuse during pregnancy.10 The same study also found that, for 

some women, the period of pregnancy may be less risky, with violence 

abating during pregnancy; 41 percent of the women who reported abuse in 

the year before pregnancy did not experience abuse during pregnancy. 

Studies have found other factors to be associated with violence during 

pregnancy, including younger age of the woman, lower socioeconomic 

status, abuse of alcohol and other drugs by victims and perpetrators of 

violence, and unintended pregnancy.11

To increase the generalizability of research on the prevalence and risk of 

violence to women during pregnancy, researchers have reported the need 

for more population-based studies that would allow for comparisons of 

pregnant and nonpregnant women. These studies would draw their 

samples from all pregnant women, not just those receiving health care or 

giving birth, as well as nonpregnant women. Such research could indicate 

whether pregnant women are at increased risk for violence compared to 

their nonpregnant counterparts. Researchers have also suggested using 

methodologies that consistently define and measure the prevalence of 

violence. A recent report by the Institute of Medicine on family violence 

recommended that the Secretary of HHS establish new, multidisciplinary 

education and research centers to, among other things, conduct research 

on the magnitude of family violence and the lack of comparability in 

current research.12

 9

Melissa Moore, “Reproductive Health and Intimate Partner Violence,” Family Planning 

Perspectives 31, no. 6 (1999): 302-306, 312. 

10Sandra L. Martin and others, “Physical Abuse of Women Before, During, and After 

Pregnancy,” JAMA 285, no. 12 (2001): 1581-1584. 

11For example, see Mary M. Goodwin and others, “Pregnancy Intendedness and Physical 

Abuse Around the Time of Pregnancy: Findings from the Pregnancy Risk Assessment 

Monitoring System, 1996-1997,” Maternal and Child Health Journal 4, no. 2 (2000): 85-92; 

and Vilma E. Cokkinides and others, “Physical Violence During Pregnancy: Maternal 

Complications and Birth Outcomes,” Obstetrics & Gynecology 93, no. 5 (1999): 661-666. 

12Family violence includes intimate partner violence, child abuse and neglect, and elder 

abuse. Institute of Medicine, Confronting Chronic Neglect: The Education and Training 

of Health Professionals on Family Violence (Washington, D.C.: 2001). 
Page 9 GAO-02-530 Violence Against Women 

There is also little information available on violence against pregnant 

women that results in homicide. The FBI and CDC are the two federal 

agencies that collect and report information on homicides nationwide; 

however, neither agency collects data on whether female homicide victims 

were pregnant or recently pregnant. According to CDC, 17 states, New 

York City, and Puerto Rico collect data related to pregnancy status on 

their death certificates, but the data collected are not comparable. 

Included in these data are victims who may not have been pregnant at the 

time of death but had been “recently” pregnant; in addition, states’ criteria 

for recent pregnancy ranged from 42 days to 1 year after birth. (See app. III 

for a list of the questions on pregnancy status that states include on their 

death certificates.) 

The ability to identify pregnant homicide victims from death certificates is 

limited. While there are questions on some states’ death certificates 

regarding pregnancy status, officials in the four states we contacted 

(Illinois, Maryland, New Mexico, and New York) told us that these data are 

incomplete and may understate the number of pregnant homicide victims. 

For example, if the pregnancy item on the death certificate is left blank, 

there is no way to easily determine whether an autopsy, if conducted, 

included a test or examination for pregnancy. Moreover, researchers have 

reported that physicians completing death certificates after a pregnant 

woman’s death failed to report that the woman was pregnant or had a 

recent pregnancy in at least 50 percent of the cases.13

To address these limitations, all four states we contacted are making 

efforts to compare death certificate data with other datasets and records—

such as medical examiners’ reports—to identify pregnant or recently 

pregnant homicide victims. They told us that they are reviewing the data in 

order to determine if there is something they can do to prevent violent 

deaths of pregnant women or help women who are victimized. For 

example, the Maryland medical examiner’s office conducted a study of the 

deaths of females aged 10 to 50 to determine if these women were 

pregnant when they died. Several sources of data—death certificates, 

medical examiners’ reports, and recent live birth and fetal death records—

from a 6-year period were linked. Of the 247 women who were identified 

as pregnant or recently pregnant, 27 percent were identified through 

 13Isabelle L. Horon and Diana Cheng, “Enhanced Surveillance for Pregnancy-Associated 

Mortality—Maryland, 1993-1998,” Journal of the American Medical Association 285, no. 11 

(2001): 1455-1459. 

Pregnancy Status Often 

Not Reflected in Data on 

Homicide Victims 
Page 10 GAO-02-530 Violence Against Women 

examining cause of death information on death certificates. The remaining 

73 percent were identified by matching the woman’s death certificate with 

recent birth and fetal death records and by reviewing data from medical 

examiners’ records, such as autopsy reports or police records. Similarly, 

New York officials determined through dataset links (death certificates, 

fetal death records, recent birth certificates, and hospital discharge 

records) that, in 1997, 9 of 174 female homicide victims aged 10 to 54 were 

pregnant or recently pregnant at the time of death, rather than the 1 of 174 

that death certificate data alone would have indicated. Officials from New 

York and Maryland told us these efforts to link datasets are dependent on 

records being computerized. Some state officials also told us they did not 

have the resources to conduct these analyses on a continuing basis. 

There are two federal initiatives under development that propose to 

collect data on the number of homicides of pregnant women. CDC is 

proposing a revision of the U.S. standard certificate of death used for the 

National Vital Statistics System to include five categories related to 

pregnancy status. (See fig. 1.) Each state has the option of adopting the 

U.S. standard certificate for its death certificate or excluding or adding 

data elements. If the revision is approved, CDC expects several states to 

implement it in 2003, with an increasing number using it each year. 
Page 11 GAO-02-530 Violence Against Women 

Figure 1: Pregnancy Status Categories on Proposed U.S. Standard Death Certificate 

Revision 

Source: CDC. 

CDC is also beginning to implement the National Violent Death Reporting 

System (NVDRS), which, as currently envisioned, would collect data that 

could determine the number of pregnant homicide victims. CDC plans to 

collect data from a variety of state and local government databases on 

deaths resulting from homicide and suicide. Like the Maryland and New 

York efforts, NVDRS would link several databases, such as death and 

medical examiners’ records, to identify pregnant homicide victims. 

According to CDC, implementation of NVDRS depends on future funding; 

full implementation would take at least 5 years. The estimated federal cost 

of this system is $10 million in start-up costs and $20 million in annual 

operating costs; these estimates primarily consist of expenditures for 

providing technical assistance to the states and funding for state personnel 

to collect the data. 

Not pregnant within past year

Pregnant at time of death

Not pregnant, but pregnant within 42 days of death

Not pregnant, but pregnant 43 days to 1 year before death

Unknown if pregnant within the past year

If female:
Page 12 GAO-02-530 Violence Against Women 

Violence prevention strategies for both pregnant and nonpregnant women 

include measures to prevent initial incidents of violence, such as educating 

women about warning signs of abuse, and intervention activities that 

identify and respond to violence after it has occurred. Typically, the initial 

component of an intervention is screening, or asking women about their 

experiences with violence. Many health care organizations and providers 

recommend routine screening for intimate partner violence. Studies have 

found, however, that fewer than half of physicians routinely screen for 

violence during prenatal visits. Reasons for physicians’ reluctance to 

screen include lack of training on how to screen and how to respond if a 

woman discloses violence. Violence prevention strategies also include 

criminal justice measures, which focus on apprehending, sentencing, 

incarcerating, and rehabilitating batterers. Little information is available 

on the effectiveness of violence prevention strategies and programs. 

Researchers have reported the need for evaluations of the effectiveness of 

screening protocols and batterer intervention programs. 

Measures to prevent violence against pregnant women are similar to those 

to prevent violence against all women. Public health violence prevention 

programs can include primary prevention measures to keep violence from 

occurring in the first place and interventions that ask women about their 

experiences with violence and respond if violence has occurred. Criminal 

justice strategies to prevent violence against women focus on 

apprehending, sentencing, incarcerating, and rehabilitating batterers. 

Efforts to prevent initial incidents of violence concentrate on attitudes and 

behaviors that result in violence against women. These efforts include 

educating children, male and female, about ways to handle conflict and 

anger without violence and social norms about violence, such as attitudes 

about the acceptability of violence toward women. They also include 

training parents, police officers, and other community officials to be 

resources for youth seeking assistance about teenage dating violence. 

Primary prevention efforts also have been targeted to pregnant women. 

For example, the Domestic Violence During Pregnancy Prevention 

Program in Saginaw, Michigan, provided 15-minute counseling sessions to 

pregnant women who reported that they had not experienced violence.14

Women were educated about intimate partner violence and given tools 

and information to help prevent abuse in their lives, including information 

 14This program is a component of the Saginaw Fetal-Infant Mortality Review Program. 

Multiple Strategies 

Designed to Prevent 

Violence, But Effect Is 

Unknown 

Violence Prevention 

Programs Use Health and 

Criminal Justice Strategies 
Page 13 GAO-02-530 Violence Against Women 

on behaviors typical of abusive men, warning signs of abuse, and 

community resources. 

Interventions to deal with violence that has occurred are designed to 

identify victims and to prevent additional violence through such actions as 

providing an assessment of danger, developing a safety plan, and providing 

information about and referral to community resources. For example, 

HRSA has funded a demonstration program to develop or enhance 

systems that identify pregnant women experiencing intimate partner 

violence and provide appropriate information and links to services. The 

HRSA program funds four projects; each project is funded at $150,000 a 

year for 3 years.15

Screening for the presence of violence is generally the initial component of 

intervention efforts to prevent additional violence against pregnant 

women. Many experts view the period of pregnancy as a unique 

opportunity for intervention. Pregnant women who receive prenatal care 

may have frequent contact with providers, which allows for the 

development of relationships that may facilitate disclosure of violence. For 

example, the American College of Obstetricians and Gynecologists 

(ACOG) recommends that physicians screen all patients for intimate 

partner violence and that screening for pregnant women occur at several 

times over the course of their pregnancies. Some women do not disclose 

abuse the first time they are asked, or abuse may begin later in pregnancy. 

Some of the barriers to women’s disclosure of violence are fear of 

escalating violence, feelings of shame and embarrassment, concern about 

confidentiality, fear of police involvement, and denial of abuse. In 

addition, some health care officials told us that the period of pregnancy 

may be a difficult time for a woman to leave or take action against the 

abuser because of financial concerns and pressures to provide the child 

with a father. 

 15The projects are the Comprehensive Services for Pregnant Women Experiencing 

Substance Abuse and Violence in Baltimore, Maryland; Systems for Pregnancy Education 

and Awareness of Safety in New York, New York; Improving Systems of Care for Pregnant 

Women Experiencing Domestic Violence in St. Clair County, Illinois; and Perinatal 

Partnership Against Domestic Violence: Improving Systems of Care for Pregnant/Post 

Partum Women in the Asian and Pacific Islander Community in Seattle, Washington. HRSA 

is planning to initiate another demonstration program in June 2002 to address family 

violence during or around the period of pregnancy. The primary focus of the program is 

women experiencing violence, but its projects will also link to child abuse, elder abuse, and 

perpetrator rehabilitation programs. 
Page 14 GAO-02-530 Violence Against Women 

Studies have found that fewer than half of physicians routinely screen 

women for violence during pregnancy. For example, a survey of ACOG 

fellows reported that 39 percent of respondents routinely screened for 

violence at the first prenatal visit.16 The study found that screening was 

more likely to occur when the obstetrician-gynecologist suspected a 

patient was being abused. Another study that surveyed primary care 

physicians who provide prenatal care found that only 17 percent of 

respondents routinely screened at the first prenatal visit and 5 percent at 

follow-up visits.17 Across the 15 states with PRAMS data for 1998, from 25 

percent to 40 percent of women reported that a physician or other health 

care provider talked to them about intimate partner violence during any of 

their prenatal care visits. 

CDC and providers of prevention services have reported that reasons for 

physicians’ reluctance to screen women for violence include lack of time 

and resources, personal discomfort about discussing the topic, concern 

about offending patients, belief that asking invades family privacy, and 

frustration with patients who are not ready to leave or who return to their 

abusers. Lack of training and education on how to screen for intimate 

partner violence and lack of knowledge about what to do if a woman 

reports experiencing intimate partner violence have also been cited as 

barriers to physician screening. In its report on family violence, the 

Institute of Medicine stated that health professionals’ training and 

education about family violence are inadequate and recommended that the 

Secretary of HHS establish education and research centers to develop 

training programs that prepare health professionals to respond to family 

violence. 

Criminal justice approaches to preventing violence against women include 

apprehending and sanctioning the batterer, preventing further contact 

between the abuser and the victim, and connecting the victim to 

community services. In addition, batterer intervention programs, which 

have existed for over 20 years as a criminal justice intervention, are often 

used as a component of pretrial or diversion programs or as part of 

sentencing. Batterer programs can include classes or treatment groups, 

 16Deborah L. Horan and others, “Domestic Violence Screening Practices of ObstetricianGynecologists,” Obstetrics & Gynecology 92, no. 5 (1998): 785-789. 

17Linda Chamberlain and Katherine A. Perham-Hester, “Physicians’ Screening Practices for 

Female Partner Abuse During Prenatal Visits,” Maternal and Child Health Journal 4, no. 2 

(2000): 141-148. 
Page 15 GAO-02-530 Violence Against Women 

evaluation, individual counseling, or case management; their goals are 

rehabilitation and behavioral change. 

To assist communities, policymakers, and individuals in combating 

violence against women, the National Advisory Council on Violence 

Against Women and VAWO developed a Web-based resource for 

instruction and guidance.18 These guidelines include recommendations for 

strengthening prevention efforts and improving services and advocacy for 

victims. For example, the guidelines recommend that communities 

increase the cultural and linguistic competence of their sexual assault, 

intimate partner violence, and stalking programs by recruiting and hiring 

staff, volunteers, and board members who reflect the composition of the 

community the program serves. The guidelines also recommend that all 

health and mental health care professional school and continuing 

education curricula include information on the prevention, detection, and 

treatment of sexual assault and intimate partner violence. 

Researchers have reported that little information is available on the 

effectiveness of strategies to prevent and reduce violence against women. 

For example, many health care organizations and providers advocate 

routine screening of pregnant women for intimate partner violence, but 

questions have been raised about the effectiveness of screening, the most 

effective way to conduct screening, and the optimal times for conducting 

screening. In addition, limited information is available on the impact of 

screening on women and their children. 

A CDC official told us that CDC has not issued guidelines or 

recommendations related to routine screening for violence in health care 

settings, primarily due to the lack of scientific evidence about the 

effectiveness of screening. CDC recently funded a cooperative agreement 

to measure the effectiveness of an intimate partner violence intervention 

that includes evaluation of a screening protocol and computerized 

screening.19 The results of the study are expected to provide data on the 

array of outcomes that need to be considered in implementing 

 18National Advisory Council on Violence Against Women and the Violence Against Women 

Office, Toolkit to End Violence Against Women (Washington, D.C.: U.S. Department of 

Justice, November 2001). http://toolkit.ncjrs.org (downloaded on February 12, 2002). 

19The cooperative agreement is between CDC, Johns Hopkins University, and the State 

University of New York at Albany. 

Little Information Is 

Available on the 

Effectiveness of Violence 

Prevention Programs 
Page 16 GAO-02-530 Violence Against Women 

intervention programs to decrease intimate partner violence. CDC officials 

told us that additional studies are necessary to evaluate screening and 

intervention strategies and that CDC is in the process of identifying 

additional study topics and designs that could complement this effort. 

CDC and other researchers on violence against women and providers of 

prevention services have identified several other areas in which research 

could be fruitful. For example, they have reported the need to 

• develop information on the most effective ways to promote women’s 

safety after screening; 

• develop and evaluate the effectiveness of programs that coordinate 

community resources from the medical, social services, law enforcement, 

judicial, and legal systems; and 

• develop and evaluate the effectiveness of prevention strategies that 

incorporate cultural perspectives in serving ethnic and immigrant 

populations. 

An example of an effort to conduct such research is HRSA’s program to 

improve interventions for pregnant women experiencing violence; 

however, the projects’ evaluation components are small and, according to 

HHS, their results may not be generalizable to the nation. Each funded 

project will evaluate whether its intervention was effective in improving 

rates of screening, assessment, and referral or links to community 

services; the projects may also assess the impact of the intervention on 

women’s behaviors. For example, the Comprehensive Services program in 

Baltimore is assessing whether the project was effective in linking families 

to needed services and whether women report improvement in their 

physical or psychosocial status after the intervention. The Systems for 

Pregnancy Education and Awareness of Safety in New York is evaluating 

whether the project increases the number of women who disclose 

violence and receive services and referrals to community services, such as 

shelters. The Perinatal Partnership Against Domestic Violence in Seattle is 

evaluating the effectiveness of screening protocols and interventions that 

are tailored to the culture and values of women who are Asian and Pacific 

Islanders. 

Researchers have also reported that there is little evaluative information 

on the effectiveness of violence prevention programs for batterers. A 

VAWO-funded study of the effectiveness of batterer programs concluded 

that they have modest effects on violence prevention when compared with 

traditional probationary practices and that there is little evidence to 

support the effectiveness of one batterer program over another in 
Page 17 GAO-02-530 Violence Against Women 

reducing recidivism.20 The study concluded, however, that batterer 

programs are a small but critical element in an overall violence prevention 

effort that includes education, arrest, prosecution, probation, and victim 

services. The study authors advocated experimenting with different 

program approaches and performing outcome evaluations of batterer 

programs. 

The magnitude of the problem of violence against pregnant women is 

unknown. Current collaborative efforts by federal and state governments 

to gather and analyze more complete and comparable data could improve 

policymakers’ knowledge of the extent of this violence and guide future 

research and resource allocation. These efforts can also help in setting 

priorities for prevention strategies. Continuing evaluation of prevention 

strategies and programs could help identify successful approaches for 

reducing violence against women. 

We provided a draft of this report to Justice and HHS for comment. Justice 

informed us that it did not have any comments. HHS agreed with our 

finding that limited information is available regarding violence against 

pregnant women. HHS also noted reasons why the data are incomplete, 

such as the difficulty of collecting data from a representative sample of 

pregnant victims because they are such a small percentage of the U.S. 

population. Other reasons HHS cited are legal and ethical issues in 

conducting research on this population, such as maintaining privacy and 

confidentiality. HHS commented that several states are conducting 

mortality reviews to better understand pregnancy-related deaths and their 

underlying causes. 

HHS raised several issues that it considers important regarding violence 

against women, such as the need to evaluate factors correlated with 

violence against women, and identified additional efforts within the 

department that focus on intimate partner violence. We recognize that 

there are many issues and efforts related to violence against women; 

however, our focus was on violence against pregnant women, and 

therefore much of our discussion relates to this population. HHS noted 

 20Larry Bennett and Oliver Williams, Controversies and Recent Studies of Batterer 

Intervention Program Effectiveness, Grant number 98-WT-VX-K001 (Washington, D.C.: 

U.S. Department of Justice, 2001). 

Concluding 

Observations 

Agency Comments 
Page 18 GAO-02-530 Violence Against Women 

that although HRSA’s demonstration program to improve interventions for 

pregnant women experiencing violence will result in new qualitative 

information, the evaluation component is small and the findings would 

likely be limited. We modified our discussion of this program to indicate 

that it is a small demonstration program and its results may not be 

generalizable to the nation. In response to HHS’s comments, we added a 

description of another demonstration program focused on violence against 

pregnant women that HRSA plans to initiate in June 2002. HHS also 

provided technical comments, which we incorporated where appropriate. 

(HHS’s comments are reprinted in app. IV.) 

As arranged with your office, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days after its 

issue date. We will then send copies to the Secretary of Health and Human 

Services; the Attorney General; the Administrator of the Health Resources 

and Services Administration; the Directors of the Centers for Disease 

Control and Prevention, National Institutes of Health, Office of Justice 

Programs, and Federal Bureau of Investigation; appropriate congressional 

committees; and others who are interested. We will also make copies 

available to others on request. 

If you or your staff have any questions, please contact me at (202) 512-8777 

or Janet Heinrich, Director, Health Care—Public Health Issues, at (202) 

512-7119. Additional GAO contacts and the names of other staff members 

who made contributions to this report are listed in appendix V. 

Sincerely yours, 

Paul L. Jones 

Director, Tax Administration and Justice 
Appendix I: Scope and Methodology 

Page 19 GAO-02-530 Violence Against Women 

To do our work, we interviewed and obtained information from officials at 

the Department of Health and Human Services’ Centers for Disease 

Control and Prevention (CDC), Health Resources and Services 

Administration (HRSA), and National Institutes of Health, and the 

Department of Justice’s Office of Justice Programs (OJP) and Federal 

Bureau of Investigation (FBI). We also interviewed representatives of and 

obtained information from the American College of Obstetricians and 

Gynecologists, Institute of Medicine, Family Violence Prevention Fund, 

National Coalition Against Domestic Violence, and National Association of 

Medical Examiners; several state domestic violence coalitions; and 

researchers. 

To determine the availability of information on the prevalence and risk of 

violence against pregnant women, we reviewed literature on the 

prevalence and risk of violence to women during pregnancy. We identified 

11 studies published since 1998 that contained prevalence estimates and 

assessed their methodologies to ensure the appropriateness of the data 

collection and analysis methods and the conclusions. We also interviewed 

CDC officials and reviewed data collected through CDC’s Pregnancy Risk 

Assessment Monitoring System (PRAMS). 

To determine the availability of data on the number of pregnant women 

who are victims of homicide in the United States, we interviewed officials 

and collected and analyzed homicide statistics and reports from CDC, the 

FBI, and OJP’s Bureau of Justice Statistics. We also interviewed officials 

from state departments of health and vital statistics in Illinois, Maryland, 

New Mexico, and New York to determine how they collect and use data on 

pregnant homicide victims. We selected these states because, in addition 

to collecting pregnancy data on their state death certificates, they are 

active in collecting and analyzing information from various sources to 

study maternal health issues. The states were not intended to be 

representative of all states. We also interviewed and obtained information 

from CDC and Justice officials to identify federal initiatives that are under 

way to improve the availability of information on homicides of pregnant 

women. 

To identify strategies and programs to prevent violence against pregnant 

women, we gathered information through a literature review and 

interviews with and information collected from researchers and officials 

from federal agencies, health care associations, and advocacy groups. We 

reviewed a HRSA-funded program (with projects located in Illinois, 

Maryland, New York, and Washington) and two other programs (located in 

Michigan and Pennsylvania) because they focused specifically on violence 

Appendix I: Scope and Methodology 
Appendix I: Scope and Methodology 

Page 20 GAO-02-530 Violence Against Women 

against pregnant women and served varied populations, including 

adolescents, diverse ethnic groups, and women with substance abuse 

problems. 

We conducted our work from July 2001 through April 2002 in accordance 

with generally accepted government auditing standards. 
Appendix II: Description of the Pregnancy 

Risk Assessment Monitoring System 

Page 21 GAO-02-530 Violence Against Women 

CDC developed PRAMS, a population-based survey of women whose 

pregnancies resulted in live births. CDC awards grants to states to help 

them collect information on women’s experiences and behaviors before, 

during, and immediately following pregnancy. CDC funded about $6.2 

million for PRAMS in fiscal year 2001; grant awards to states ranged from 

$100,000 to $150,000. CDC’s funding for PRAMS also includes costs for 

CDC staff and contractors to provide technical support to the states. 

States participating in PRAMS use a consistent methodology to collect 

data. Each state selects a stratified sample of new mothers every month 

from eligible birth certificates and then collects data through mailings and 

follow-up telephone calls to nonrespondents. A birth certificate is eligible 

for the PRAMS sample if the mother was a resident of the state. For 1998, 

the most recent year for which CDC has reported comprehensive data for 

PRAMS, states used a standardized questionnaire that asked women if 

their husbands or partners physically abused them during their most 

recent pregnancy. PRAMS defined physical abuse as pushing, hitting, 

slapping, kicking, or any other way of physically hurting someone.1

 Table 1 

lists 1998 PRAMS estimates of the prevalence of intimate partner violence 

during pregnancy. 

 1

Some states have also added questions on verbal and emotional abuse. 

Appendix II: Description of the Pregnancy 

Risk Assessment Monitoring System 
Appendix II: Description of the Pregnancy 

Risk Assessment Monitoring System 

Page 22 GAO-02-530 Violence Against Women 

Table 1: PRAMS Estimates of the Prevalence of Physical Abuse by Husband or 

Partner during Pregnancy, 1998 

State Percentagea

Alabama 3.8 

Alaska 3.8 

Arkansas 5.5 

Colorado 2.8 

Florida 4.1 

Illinois 4.1 

Louisiana 5.2 

Maine 2.5 

New Mexicob 6.6 

New Yorkc 2.4 

North Carolina 4.2 

Oklahoma 5.1 

South Carolina 3.9 

Washington 3.5 

West Virginia 4.7 

Note: PRAMS includes data only for women whose pregnancies resulted in live births. 

a

This column represents the proportion of pregnant women who reported physical abuse (i.e., 

pushing, hitting, slapping, kicking, or any other way of physically hurting someone). 

b

Data represent births from July 1997 through December 1998. 

c

Data do not include New York City. 

Source: L.E. Lipscomb and others, PRAMS 1998 Surveillance Report (Atlanta, Ga.: Division of 

Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers 

for Disease Control and Prevention, 2000). 
Appendix III: Pregnancy Status Questions on 

States’ Death Certificates 

Page 23 GAO-02-530 Violence Against Women 

State Question 

Alabama Was there a pregnancy in last 90 days or 42 days? 

Florida If female, was there a pregnancy in the past 3 months? 

Georgia If female, indicate if pregnant or birth occurred within 90 days of 

death. 

Illinois If female, was there a pregnancy in the past 3 months? 

Indiana Was decedent pregnant or 90 days postpartum? 

Iowa If female, was there a pregnancy in the past 12 months? 

Louisiana If deceased was female 10-49, was she pregnant in the last 90 

days? 

Maine Indicate if the decedent was pregnant or less than 90 days 

postpartum at time of death. 

Maryland If female, was decedent pregnant in the past 12 months? 

Missouri If deceased was female 10-49, was she pregnant in the last 90 

days? 

Nebraska If female, was there a pregnancy in the past 3 months? 

New Jersey If female, was she pregnant at death or any time 90 days prior to 

death? 

New Mexico Was decedent pregnant within last 6 weeks? 

New York If female, was decedent pregnant in last 6 months? 

New York Citya If female under 54, pregnancy in last 12 months? 

North Dakota Was deceased pregnant within 18 months of death? 

Puerto Rico If female, was deceased pregnant? 

Texas Was decedent pregnant at time of death; within last 12 months? 

Virginia If female, was there a pregnancy in last 3 months? 

Note: According to CDC, these are the only states that include questions on pregnancy status on their 

death certificates. The term “states” includes New York City and Puerto Rico. 

a

According to New York state officials, New York City uses a different death certificate from the rest of 

the state. The New York City death certificate is used for the five boroughs of the city: Manhattan, 

Brooklyn, Queens, the Bronx, and Staten Island. 

Source: CDC. 

Appendix III: Pregnancy Status Questions on 

States’ Death Certificates 
Appendix IV: Comments from the Department of Health and Human Services 

Page 24 GAO-02-530 Violence Against Women 

Appendix IV: Comments from the 

Department of Health and Human Services 
Appendix IV: Comments from the Department of Health and Human Services 

Page 25 GAO-02-530 Violence Against Women 
Appendix IV: Comments from the Department of Health and Human Services 

Page 26 GAO-02-530 Violence Against Women 
Appendix IV: Comments from the Department of Health and Human Services 

Page 27 GAO-02-530 Violence Against Women 
Appendix IV: Comments from the Department of Health and Human Services 

Page 28 GAO-02-530 Violence Against Women 
Appendix V: GAO Contacts and Staff 

Acknowledgments 

Page 29 GAO-02-530 Violence Against Women 

Weldon McPhail, (202) 512-8644 

Helene F. Toiv, (202) 512-7162 

In addition to those named above, contributors to this report were Janina 

Austin, Nancy Kawahara, Emily Gamble Gardiner, Geoffrey Hamilton, 

Anthony Hill, Hiroshi Ishikawa, Alice London, Behn Miller, and 

Sara-Ann Moessbauer. 

Appendix V: GAO Contacts and Staff 

Acknowledgments 

GAO Contacts 

Staff Acknowledgments 

(440056) 
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