The Prevalence of Domestic Violence Among

Women Seeking Abortion

SUSAN S. GLANDER, MD, MARY LOU MOORE, PhD, RNC,
ROBERT MICHIELUTTE, PhD, AND LINN H. PARSONS, MD

Objective: To determine the prevalence of self-reported individual by a current or past intimate partner. This
abuse in a population of women aged 18 years or older may include physical, sexual, or emotional abuse. How-
seeking elective pregnancy termination, and to compare ever, due to the difficulty inherent in screening for
abused and nonabused women with respect to the primary
emotional abuse, this study focused on physical (in-
reasons for pregnancy termination.
Methods: A self-administered questionnaire was returned
cluding sexual) abuse. The actual incidence of abuse is
by 486 women seeking outpatient abortion. The survey difficult to determine but has been estimated conserva-
included demographic information, abuse screening, and tively at 3.4% of all women or approximately 2 million
items regarding partner involvement/awareness of the preg- women per year.1 One in four women will experience
nancy, and abuse as a determinant of the abortion decision. abuse by a male partner at some point in their lives.2
One open-ended item asking the primary reason for preg- Battered women comprise 22–35% of women seeking
nancy termination was included. care in emergency departments for any reason; most are
Results: The prevalence of self-reported abuse in this
seen by nontrauma services. Similarly, in ambulatory
population was 39.5%. White women were significantly
care medicine clinics, 14% of women are abused, and
more likely to report any history of abuse than nonwhite
women. Relationship issues were the only reason for preg- twice as many have an abuse history.3 Battered women
nancy termination given more often by women with an account for approximately 25% of suicide attempts and
abuse history than by nonabused women. Women with 25% of women seeking psychiatric services.3
abuse histories were significantly less likely than nonabused Studies1 of abuse during pregnancy have variously
women to inform the partner of the pregnancy or to have reported its prevalence to range from 4 to 17%, depend-
partner support for or involvement in the abortion decision. ing on the population studied and screening method
Conclusion: The prevalence of abuse reported by women used. Prior abuse is the most predictive factor for abuse
in this population suggests that many women seeking abor-
during pregnancy, with 87.5% of women abused during
tion services may have abuse histories. Abused women may
pregnancy reporting prior abuse.4 Until recently, little
have different reasons for pregnancy termination than non-
abused women and may be more likely to make the abortion
attention has been directed toward the prevalence of
decision without partner involvement. When routine screen- abuse in the population of women in early pregnancy
ing for abuse is included in abortion counseling, health who seek abortion services. Whether fear of continua-
providers have the opportunity for developing a safety plan tion or intensification of abuse influences a woman’s
and initiating appropriate referral. (Obstet Gynecol 1998;91: decision to terminate a pregnancy is not known, al-
1002– 6. © 1998 by The American College of Obstetricians though some research suggests that women in abusive
and Gynecologists.) relationships are more likely to consider termination.5
A recent study6 of women seeking pregnancy termina-
tion used a single screening interview and identified
Over the past several years, the problem of domestic 31% of women with any history of abuse and 22% with
violence has gained increasing attention from the me- a history of abuse in the preceding calendar year.
dia, social scientists, and health care professionals. The purpose of this study was to investigate the
Domestic violence is defined as the victimization of an prevalence of self-report of abuse, forced intercourse,
and recent physical injury in a population of women 18
or older seeking elective pregnancy termination. We
From the Departments of Obstetrics and Gynecology and Family and
Community Medicine, Wake Forest University School of Medicine, hypothesized that the issues of fear and control, central
Winston-Salem, North Carolina. to abusive relationships, may influence prevention of

1002 0029-7844/98/$19.00 Obstetrics & Gynecology

PII S0029-7844(98)00089-1
unwanted pregnancies and decisions regarding preg- hit, slapped, kicked, or otherwise physically hurt by
nancy outcome. Accordingly, a disproportionate num- someone? 4) Was this pregnancy the result of forced or
ber of abused women may seek pregnancy termination. voluntary sex? and, 5) Was your first intercourse forced
We attempted to determine whether the history of or voluntary? Women were classified as having a his-
abuse was associated with the decision to terminate and tory of abuse if they answered yes to questions 1, 2, 3, 4,
whether the decision was made individually or jointly, or 5. If women answered no to all five questions, they
or was forced by a third party. were classified as having no history of abuse. Two of
the authors independently reviewed and categorized
the responses to the open-ended question. The first two
Methods
responses given by individuals who provided more
Approval was obtained from the Institutional Review than one reason were included.
Board at the Bowman Gray School of Medicine before Data were entered into a computerized database
initiation of the study. To preserve complete anonymity using Excel (Microsoft Corp., Redmond, WA). Abuse
for respondents, written consent was not obtained. was examined as a dichotomy (0 for never abused, 1 for
Because all participants were legally consenting adults, ever abused), and significance of association with the
consent to participate was considered implied by com- abuse variable was examined using the x2 statistic.
pleting the questionnaire. A cover letter accompanying Fisher exact test was used for variables with small
the questionnaire explained the voluntary and anony- expected cell frequencies. Because multiple tests were
mous nature of the study and stated that the purpose of conducted in identifying factors associated with abuse,
the study was to identify reasons for pregnancy termi- the criterion level of significance was set using a simple
nation and partner involvement in decision making. Bonferroni adjustment (0.05/number of comparisons).
Community resource and referral information for The criterion for statistical significance was set at P ,
women in abusive relationships was provided upon .003 (0.05/18).
request at the end of the interview.
Between February 1, 1996, and September 1, 1996, a
Results
self-administered questionnaire was offered by clinic
personnel to all women age 18 years or older who The median age of women who returned questionnaires
presented for pregnancy termination at a single urban was 25 years. There were 226 (46.5%) white respon-
outpatient setting. Women under age 18 were not dents, 223 (45.9%) blacks and 37 (0.08%) Asians, His-
included because of the requirement for parental con- panics, and others of unspecified ethnicity. Table 1
sent in that age group. Six hundred questionnaires were summarizes the demographic characteristics of the
provided to the clinic. Questionnaires were returned by study population and results of the questionnaire com-
486 women. No record was kept of women declining to paring those with any abuse history and nonabused
take or return the questionnaire. Pregnant females age women.
18 years or older seeking pregnancy termination who Overall, 192 (39.5%) women identified themselves as
were able to read English were included. The male having any history of abuse. Twenty-nine women iden-
partner was absent during the administration and com- tified as abused denied a history of abuse in response to
pletion of the questionnaire. the first screening question but answered yes to one of
Questions were administered in the following se- the other four screening questions. Sixteen of these
quence: demographic information (age, race, relation- women admitted to a history of forced intercourse at
ship with the father of the pregnancy), a five-question first coitus. White women were significantly more likely
abuse assessment screen modified from that of McFar- to report any history of abuse than black or other
lane et al,7,8 items regarding partner knowledge of the nonwhite women.
pregnancy and involvement with the abortion decision, Abused and nonabused women were compared for
use of contraception, and one open-ended question other demographic and psychosocial characteristics as
regarding the primary reason for the abortion decision. well. No difference was found between abused and
The survey concluded with a direct question regarding nonabused groups regarding relationship status with
abuse as a factor in the abortion decision. the father of the pregnancy. Also, use and mode of
The five-question abuse assessment screen included contraception did not differ between abused and non-
the following questions in sequence: 1) Have you ever abused women. However, abused women were signif-
been physically abused by your partner or someone icantly less likely than nonabused women to inform the
close to you? 2) Within the last year, have you been hit, partner of the pregnancy, less likely to have partner
slapped, kicked, or otherwise physically hurt by some- support for the abortion decision, and less likely to
one? 3) Since you have been pregnant, have you been involve the father of the pregnancy in the abortion

VOL. 91, NO. 6, JUNE 1998 Glander et al Domestic Violence and Abortion 1003
Table 1. Characteristics of Sample Population Comparing five women with an abuse history but by none of the
Abused and Nonabused Women nonabused women. Other common reasons offered for
Abused Nonabused pregnancy termination revealed no significant differ-
(n 5 192) (n 5 294) ences between abused and nonabused groups. These
Median age 25 y 24 y P
reasons included age, career goals, emotional issues,
Race Black 70 (36.5) 153 (52.0) .001* family pressure, medical concerns, teratogen exposure,
White 109 (56.8) 117 (39.8) marital status, and desire to remain childless.
Hispanic/Asian/ 13 (6.8) 24 (8.2)
other
Relationship with Cohabiting 62 (32.3) 112 (38.1) .013 Discussion
father of (married or
pregnancy unmarried) Researchers in a number of studies have attempted to
Unmarried or not 113 (58.9) 175 (59.5) define the optimal method of screening for abuse dur-
cohabiting
ing pregnancy. A 1991 study of an obstetric population
Unknown/single/ 17 (8.9) 7 (2.4)
other by McFarlane et al8 determined that a personal inter-
Use of Condom 31 (17.6) 49 (19.0) .685 view incorporating four abuse assessment screening
contraception Oral 16 (9.1) 29 (11.2) questions increased identification of abuse over volun-
contraceptives tary reporting from 7.3% to 29.3%. A more recent study
None 129 (73.3) 180 (69.8)
by Norton et al9 demonstrated that a personally admin-
Partner knowledge Yes 146 (78.5) 248 (89.2) .002*
of pregnancy No 40 (21.5) 30 (10.8) istered structured five-question abuse assessment
Partner support Yes 116 (61.1) 220 (76.7) ,.001* screening tool at the first prenatal visit resulted in a
for abortion No 19 (10.0) 30 (10.5) higher detection of violence in all categories than a
decision Does not know 46 (24.2) 28 (9.8) standard interview (41% versus 14% for any history of
Does not care 9 (4.7) 9 (3.1)
abuse). Our study used a five-question abuse assess-
Partner Yes 82 (42.9) 188 (64.6) ,.001*
participation in No 100 (52.4) 93 (31.6) ment screening tool, but due to financial and logistic
decision Partner forced 4 (2.1) 2 (0.7) constraints, personal interview was not conducted. On
Other 5 (2.6) 9 (3.1) the basis of our knowledge from these earlier studies,
Significance level P , .003. we believe the prevalence of abuse detected in our
Data are presented as median or n (%). study population may have been higher if personal
* Significant.
interviews had been conducted. Nonetheless, the 39.5%
prevalence of abuse history in this population is higher
than that in most published reports and is similar to the
decision (Table 1). Nonparticipation in the abortion prevalence estimate reported by Norton et al.9
decision may occur for one of two reasons: 1) the Nonrandom selection also may have biased our re-
partner may be aware of the pregnancy but excluded sults. The questionnaire was given to a nonrandom,
from the decision, or 2) the partner may be unaware of nonconsecutive group of patients. Some individuals
the pregnancy. When partner participation in the deci- were not offered participation because of reduced staff-
sion was reexamined excluding women whose partner patient ratios on certain days. However, we have no
did not know about the pregnancy, 79 of 146 (54.1%)
abused women and 179 of 248 (72.2%) nonabused
Table 2. Reasons for Abortion
women decided with their partner (P , .001).
The primary reasons for choosing pregnancy termi- Abused Nonabused
(n 5 192) (n 5 294) P
nation were compared for abused and nonabused
groups (Table 2). Timing of the pregnancy was men- Timing 65 (33.9) 121 (41.2) .100
tioned most commonly as the reason for pregnancy Financial 54 (28.1) 71 (24.1) .327
Relationship issues 31 (16.1) 20 (6.8) .001*
termination by abused and nonabused women and did
Career/Education 25 (13.0) 56 (19.0) .600
not differ significantly for the two groups. The second Emotional 19 (9.9) 16 (5.4) .063
most common reason offered by abused and nonabused Unmarried 10 (5.2) 14 (4.8) .824
groups involved financial concerns. Relationship issues Age 9 (4.7) 17 (5.8) .600
were significantly more likely to be stated as the pri- Medical 8 (4.2) 10 (3.4) .105
Never want children 5 (2.6) 14 (4.8) .230
mary reason for abortion by women with an abuse
Drug use 5 (2.6) 0 (0) .005
history than nonabused women. This was the only Family pressure 3 (1.6) 3 (1.0) .597
significant difference between women with and without Teratogen exposure 2 (1.0) 11 (3.7) .071
an abuse history. Involvement with drugs or alcohol by Data are presented as n (%).
either partner was offered as a reason for abortion by * Significant.

1004 Glander et al Domestic Violence and Abortion Obstetrics & Gynecology

evidence of specific biases introduced through this Although five women with an abuse history reported
procedure. It is not known whether abused women are drug or alcohol use by the partner as a reason for
more or less likely than nonabused women to agree to abortion and none of the nonabused women reported
complete a self-administered questionnaire regarding this reason, the numbers were too small to accurately
abuse history. However, in light of other studies that assess this variable. Drug and alcohol use has been
underscore the difficulty in eliciting this information at reported as a significant risk in pregnancy for abused
all, abused women may be less likely to volunteer to women.11–14
participate. Abused women also may have been selected This study suggests that a past or present abusive
out of our sample population due to the requirement that relationship does influence a woman’s decision to ter-
the male partner be absent during administration and minate a pregnancy. The abusive relationship in the
completion of the questionnaire. Abusive males fre- study sample appeared to affect the reason for the
quently accompany their partners to medical visits be- abortion decision and the dynamics of the decision-
cause of the issues of control and domination central to making process. Because reproductive decisions may be
these relationships. The most likely result of all of the influenced by the abusive male partner,15–18 some
factors contributing to possible bias in this study is an abused women may attempt to reclaim control by elimi-
underestimate of the true prevalence of abuse in this nating the partner from the abortion decision. In this
population. study, women with abuse histories seemed to have rela-
There is no way to ascertain clients’ motivation for tionships characterized by little communication with their
participating in any study. The cover letter and ques- partners. This pattern appeared to be perpetuated in
tionnaire were possible sources of bias. The cover letter subsequent relationships regardless of whether the cur-
stated the purpose of the study was to examine reasons rent partner was abusive. Whatever the motivation, past
for pregnancy termination and the level of partner and ongoing abuse apparently affect the process.
participation in the women’s decision to abort. A state- Domestic violence is a common health problem.
ment explaining that abuse is a common problem in Health care providers for women should be aware of
women was included to explain the presence of the the potentially high prevalence of past or present abuse
abuse assessment questions. It is possible this influ- in women seeking pregnancy termination. Systematic
enced participation. The sequence of questions was identification of a history of abuse, using behavior-based
designed to reduce bias from the inquiry regarding questions, among women seeking abortion services al-
abuse as a factor in the decision. The open-ended lows providers the opportunity to provide information
question concerning the major factor in deciding on about safety and referral for counseling during the time
pregnancy termination preceded the direct abuse ques- women are interacting with abortion services.
tion. Several lined spaces intervened for answering the
open-ended question.
In this study, the finding that white women were References
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1006 Glander et al Domestic Violence and Abortion Obstetrics & Gynecology