Obstetrics & Gynecology:
Abortion Disclosure and the Association With Domestic Violence
Woo, Junda MD; Fine, Paul MD; Goetzl, Laura MD, MPH
From the Department of Obstetrics and Gynecology, Baylor College of Medicine; and Planned Parenthood of Houston and Southeast Texas, Houston, Texas.
The authors thank Tae-Chin Yu, MD, Buffalo, New York, who substantially assisted with a pilot study in 2002.
Reprints are not available. Address correspondence to: Junda Woo, MD, Department of Obstetrics and Gynecology, Baylor College of Medicine, 6550 Fannin Street, Suite 977A, Houston, Texas 77030; e-mail: firstname.lastname@example.org.
Received November 17, 2004. Received in revised form January 27, 2005. Accepted February 3, 2005.
OBJECTIVE: To estimate the rate at which women disclose abortion to their partners and examine the association between domestic violence and partner disclosure.
METHODS: A cross-sectional cohort study was performed on women presenting for elective termination of pregnancy to a single clinic in Houston, Texas. Subjects were offered an anonymous, self-administered questionnaire. The 15-question survey addressed disclosure of abortion to the partner, reasons for nondisclosure if applicable, and physical and sexual abuse using a modified Abuse Assessment Screen.
RESULTS: Of 960 patients, 85.2% completed the survey, for a final sample size of 818. Overall, 139 (17.2%) of subjects chose not to disclose the abortions to their partners, and 14% of patients reported abuse within the past year. Physical or sexual abuse or both was twice as common among nondisclosers (23.7% compared with 12.0%, P = .001). Among nondisclosers, 63 (45.3%) said the relationship with the partner had no future, 52 (37.4%) did not feel obliged to notify their partners, 29 (20.9%) said the partner would oppose the abortion, and 11 (7.9%) said disclosure would result in physical harm.
CONCLUSION: In this urban, racially and socioeconomically diverse population, 17.2% of women concealed pregnancy terminations from their partners. Although relationship instability and personal choice were cited as the most frequent reasons for nondisclosure, the rate of domestic abuse was twice as high in this group and may have adversely affected open communication. Of greatest concern, a subset of nondisclosers reported the direct fear of personal harm as the primary reason for nondisclosure.
LEVEL OF EVIDENCE: III
Domestic violence is more common among women choosing pregnancy termination than in the general population.1–4 Studies using detailed screening and one-on-one interviews of abortion patients report abuse rates of 14–22% within the year and cumulative lifetime rates of 27–31%.2–5 Similar studies using self-administered questionnaires report lifetime domestic violence rates of 7–40%.1,5 Abuse may be more common among women who exclude their partners from the decision to terminate an unwanted pregnancy. In examining the prevalence of domestic violence among 486 women at a single urban abortion clinic, Glander et al1 found that 65% of nonabused women and 43% of abused women had involved their partners in their choice. However, that study was not designed to compare disclosers and nondisclosers, and we are unaware of any such research. In surveys, a majority of the general population believes that a woman's partner should be involved in decision-making about abortion.6–11 Rates of disclosure reflect this belief and have been estimated at 75–86% in studies mostly from the 1970s.1,12–19 The current investigation was designed to estimate how often women disclose abortion to their partners and examine any association between domestic violence and nondisclosure. A secondary objective was to address reasons for nondisclosure.
MATERIALS AND METHODS
Between March 2004 and July 2004, a self-administered anonymous questionnaire was offered to all patients seeking voluntary abortion at a single clinic within the Planned Parenthood of Houston and Southeast Texas network. The clinic offers surgical and medical abortion in the first trimester and surgical abortion in the second trimester. Patients who spoke neither English nor Spanish were excluded. The questionnaire was offered by a counselor, with a brief verbal introduction, to consecutive patients in a private counseling area. The partner was absent. To preserve anonymity, written consent was not obtained; consent was considered implied if the questionnaire was completed. The concept of implied consent was explained in the cover letter attached to the front of each survey. Patients were asked to read the cover letter and place the survey in a locked box, regardless of whether they completed the survey. Response rate was calculated by comparing the known number of surveys distributed with those completed and returned. Community resource and referral information for domestic abuse was made available to all women. The study was reviewed and approved by the Baylor College of Medicine Institutional Review Board (IRB # H-14689).
The questionnaire collected information on the patient's basic demographics, self-reported gestational age, disclosure of abortion to her partner, and reasons for nondisclosure if applicable (Table 2). Domestic violence history was elicited using the modified Abuse Assessment Screen, a standardized and validated screening tool.20 Screening questions (offered in both English and Spanish) were 1) Have you ever been emotionally or physically harmed by your partner or someone important to you? 2) Within the last year, have you been hit, slapped, kicked or otherwise physically hurt by someone? 3) Since you have been pregnant, have you been hit, slapped, kicked or otherwise physically hurt by someone? 4) Within the past year, has anyone forced you to have sexual activities? 5) Are you afraid of your partner or someone important to you? Women who answered “yes” to questions 2, 3, 4, or 5 or who reported that physical or sexual abuse influenced their decision about their abortion were defined as having been exposed to significant abuse. A second definition of abuse omitted subjects whose only criteria for abuse was an affirmative answer to question 5 (fear of partner). Seven reasons for nondisclosure were offered, and subjects were encouraged to write in additional reasons for nondisclosure.
A power analysis was performed based on an estimated baseline rate of recent domestic abuse of 10%. We calculated that a sample size of 815 patients would result in an 80% power to detect a 2-fold increased rate of domestic abuse (20%) in nondisclosers, assuming a 15% rate of nondisclosure. All tests were 2-tailed, and a P value of less than .05 was considered significant. Categorical variables were compared with the χ2 or Fisher exact test. Ordinal variables were compared using the Cochran-Armitage trend test.21,22 Continuous variables were analyzed using the Student t test. Statistical analysis was performed with the SPSS 12.0 (SPSS Inc., Chicago, IL).
A total of 960 surveys were distributed, and 818 were completed (85.2% response rate). Most of the 142 women who declined to complete the survey did not specify a reason. However, 17.7% agreed with the statement, “I'm concerned about my privacy.” Other choices and responses were: “I don't have time” (9.9%) and “I don't like thinking about domestic violence” (7.8%). No demographic information was available for nonresponders. Response rates to individual items in the abuse assessment ranged from 97.6% to 99.4% (Table 1).
Among respondents, 17.2% chose not to disclose the pregnancy terminations to their partners. When justification for nondisclosure was reported, 45.3% said the relationship with the partner had no future, 37.4% did not feel obliged to reveal the information to their partners, 20.9% said the partner would oppose the abortion, and 7.9% said disclosure would result in physical harm. Overall, 13.8% of patients reported significant abuse (including fear of partner) within the past year, and 2.8% reported abuse during the current pregnancy. These rates do not include a positive answer to question 1 (lifetime abuse).
Demographic variables were compared between disclosers and nondisclosers (Table 2).
Overall, subjects were young, with a mean age of approximately 25 years (range 13–45). Our population was ethnically and racially diverse, reflecting the overall composition of the Houston metropolitan area. There was no association between ethnicity, gestational age, or other demographic variables and abortion disclosure.
Physical or sexual abuse or both within the last year was twice as common among nondisclosers (23.7% compared with 12.0%, P = .001, Table 3). This pattern of increased recent abuse persisted after fear of the partner was excluded from the definition of abuse (23.0% compared with 11.5%, P = .001). The individual factors that were significantly associated with nondisclosure were history of physical or emotional abuse (which was not included as part of the formal definition of abuse), physical abuse within the last year, and fear of current partner.
This is the largest study to date on domestic violence among women seeking voluntary termination of pregnancy (based on a PubMed search from 1966 to 2005 encompassing all languages and using the keywords “abortion,” “unwanted pregnancy,” or “pregnancy termination” in combination with “domestic violence,” “abuse” or “intimate partner violence.”) Our primary finding was that 17.2% (14.6–19.8%) of patients in our sample did not disclose their abortions to their partners (Table 1). This rate is similar to the 14–25% rate reported in previous studies.11–19 Little prior research has focused on nondisclosers. Major et al18 showed that they demonstrate good psychological adjustment to the abortion, particularly when compared with women who discuss their choice with an unsupportive partner. Of note, 56.1% of nondisclosers had a tenuous relationship or no relationship with the father of the pregnancy, a finding consistent with prior studies that peripherally examined nondisclosers.15,17 Surveys suggest that people believe male involvement in decisions about unwanted pregnancy should vary according to the intimacy of the relationship.7,8 For example, 41% of 274 college students surveyed by Ryan and Dunn8 said slight or no male involvement was appropriate if the pregnancy resulted from a single encounter, but only 3% agreed with minimal male involvement between married couples.
Our second major finding was that recent physical abuse was twice as common among nondisclosers. Although relationship instability and personal choice were cited as the most frequent reasons for nondisclosure, the rate of domestic abuse was twice as high in this group and may have adversely affected open communication. Of greatest concern, a subset of nondisclosers reported the direct fear of personal harm as the primary reason for nondisclosure. Previous studies have suggested that domestic violence may be more common among abortion patients in general; sexual abuse can lead to pregnancy, and contraceptive adherence is more difficult in women with chaotic lives.2 Our data estimate the rate of recent abuse (abuse within the last year or while pregnant) among abortion clients at 13.8%. This rate is consistent with rates of 14–22% reported in previous studies.2–4
The primary strengths of our study are large sample size and a high response rate, allowing statistical power to detect the effect of abuse on the subset of patients who did not disclose their abortions. A second strength of our study was anonymous reporting that allowed patients to disclose personal and sensitive details freely. Despite these strengths, there are also several limitations. We used a convenience sample, and results may not be generalizable to the U.S. population. Our study population had a large number of Hispanic patients (40% compared with 20% nationally),23 and the proportion of patients seeking termination in the first trimester was slightly higher than expected (93% compared with 88% nationally).24 However, neither ethnicity nor gestational age were associated with the rate of abortion disclosure in our population. In addition, abuse may have been underreported in the absence of a one-on-one interview. In a 1991 study at the same Planned Parenthood clinic, 7.3% of patients reported domestic violence when surveyed, but 29.3% did after interviews by a nurse.5 The 25.5% of nonresponders who cited privacy concerns or discomfort with thinking about this issue may have represented undetected cases of abuse. Finally, the Spanish translation of the Abuse Assessment Screen has not been systematically validated.
Domestic violence is a pervasive health problem, particularly among abortion patients. Because some of these patients do not otherwise access health care services, universal screening for domestic violence by all abortion providers is recommended. In particular, physicians should have a high index of suspicion for domestic violence among patients who avoid disclosing the abortion to their partners.
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