Violence Against Women: Data on Pregnant Victims and Effectiveness of Prevention Strategies Are Limited
Released: 2002-06-18T00:00:00

Letter

Background

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.

Available Data on Pregnant Victims of Violence Are Incomplete and Lack Comparability

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.

Knowledge of Prevalence of Violence during Pregnancy Is Limited, Although Several Risk Factors Have Been Identified

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.

Pregnancy Status Often Not Reflected in Data on Homicide Victims

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.

Multiple Strategies Designed to Prevent Violence, But Effect Is Unknown

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.

Violence Prevention Programs Use Health and Criminal Justice Strategies

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.

Little Information Is Available on the Effectiveness of Violence Prevention Programs

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.

Concluding Observations

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.

Agency Comments

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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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.

Appendix I: Scope and Methodology

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.

Appendix II: Description of the Pregnancy Risk Assessment Monitoring System

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.

Appendix III: Pregnancy Status Questions on States’ Death Certificates

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?

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

Appendix V: GAO Contacts and Staff Acknowledgments

GAO Contacts

Staff Acknowledgments

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.