Violence Against Women: Data on Pregnant Victims and Effectiveness of Prevention Strategies Are Limited
Published: 2002-05-15T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Violence Against Women Act funds programs that shelter battered women, training for law enforcement officers and prosecutors, and research on violence against women. Available data on the number of pregnant women who are victims of violence are incomplete and lack comparability. There is no current national estimate of the prevalence of violence against pregnant women. Available estimates cannot be generalized to all pregnant women, and little information is available on the number of pregnant homicide victims.
section_title: What GAO Found
paragraphs: 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 and include public health efforts to prevent violence in the first place, intervention activities that identify and respond to violence after it occurs, and criminal justice strategies that focus on incarcerating or rehabilitating batterers.

section_title: Letter
paragraphs: 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. In  response to its concerns about violence against women, the Congress  passed the Violence Against Women Act (VAWA), 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. 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  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.)
subsections: section_title: Background
paragraphs: 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 one- fourth 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.
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. 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. 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.
section_title: Available Data on Pregnant Victims of Violence Are Incomplete and Lack Comparability
paragraphs: 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.
subsections: section_title: Knowledge of Prevalence of Violence during Pregnancy Is Limited, Although Several Risk Factors Have Been Identified
paragraphs: 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  from 2.4 percent to 6.6 percent. (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. 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. 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  during pregnancy. 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. 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.
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.
section_title: Pregnancy Status Often Not Reflected in Data on Homicide Victims
paragraphs: 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.
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  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.
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.
section_title: Multiple Strategies Designed to Prevent Violence, But Effect Is Unknown
paragraphs: 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.
subsections: section_title: Violence Prevention Programs Use Health and Criminal Justice Strategies
paragraphs: 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.  Women were educated about intimate partner violence and given tools  and information to help prevent abuse in their lives, including information  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.
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.
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. 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. 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,  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. 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.
section_title: Little Information Is Available on the Effectiveness of Violence Prevention Programs
paragraphs: 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. The results of the study are expected to provide data on the  array of outcomes that need to be considered in implementing  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    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  reducing recidivism. 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.
section_title: Concluding Observations
paragraphs: 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.
section_title: Agency Comments
paragraphs: 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  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.)
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section_title: Appendix I: Scope and Methodology
paragraphs: 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  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.
section_title: Appendix II: Description of the Pregnancy Risk Assessment Monitoring System
paragraphs: 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. Table 1  lists 1998 PRAMS estimates of the prevalence of intimate partner violence  during pregnancy.
section_title: Appendix III: Pregnancy Status Questions on States’ Death Certificates
paragraphs: Question  Was there a pregnancy in last 90 days or 42 days?  If female, was there a pregnancy in the past 3 months?  If female, indicate if pregnant or birth occurred within 90 days of  death.  If female, was there a pregnancy in the past 3 months?  Was decedent pregnant or 90 days postpartum?  If female, was there a pregnancy in the past 12 months?  If deceased was female 10-49, was she pregnant in the last 90  days?  Indicate if the decedent was pregnant or less than 90 days  postpartum at time of death.  If female, was decedent pregnant in the past 12 months?  If deceased was female 10-49, was she pregnant in the last 90  days?  If female, was there a pregnancy in the past 3 months?  If female, was she pregnant at death or any time 90 days prior to  death?  Was decedent pregnant within last 6 weeks?  If female, was decedent pregnant in last 6 months?  If female under 54, pregnancy in last 12 months?  Was deceased pregnant within 18 months of death?  If female, was deceased pregnant?  Was decedent pregnant at time of death; within last 12 months?  If female, was there a pregnancy in last 3 months?
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Staff Acknowledgments
paragraphs: 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.