Screening for intimate partner violence by health care providers. Barriers and interventions.

INTRODUCTION: Routine screening for intimate partner violence (IPV) is endorsed by numerous health professional organizations. Screening rates in health care settings, however, remain low. In this article, we present a review of studies focusing on provider-specific barriers to screening for IPV and interventions designed to increase IPV screening in clinical settings. METHODS: A review of published studies containing original research with a primary focus on screening for IPV by health professionals was completed. RESULTS: Twelve studies identifying barriers to IPV screening as perceived by health care providers yielded similar lists; top provider-related barriers included lack of provider education regarding IPV, lack of time, and lack of effective interventions. Patient-related factors (e.g., patient nondisclosure, fear of offending the patient) were also frequently mentioned. Twelve additional studies evaluating interventions designed to increase IPV screening by providers revealed that interventions limited to education of providers had no significant effect on screening or identification rates. However, most interventions that incorporated strategies in addition to education (e.g., providing specific screening questions) were associated with significant increases in identification rates. CONCLUSION: Barriers to screening for IPV are documented to be similar among health care providers across diverse specialties and settings. Interventions designed to overcome these barriers and increase IPV-screening rates in health care settings are likely to be more effective if they include strategies in addition to provider education.

Violence and reproductive health: current knowledge and future research directions.

OBJECTIVES: Despite the scope of violence against women and its importance for reproductive health, very few scientific data about the relationship between violence and reproductive health issues are available. METHODS: The current knowledge base for several issues specific to violence and reproductive health, including association of violence with pregnancy, pregnancy intention, contraception use, pregnancy terminations, and pregnancy outcomes, are reviewed and suggestions are provided for future research. RESULTS: Despite the limitations of current research and some inconclusive results, the existing research base clearly documents several important points: (1) violence occurs commonly during pregnancy (an estimated 4%-8% of pregnancies): (2) violence is associated with unintended pregnancies and may be related to inconsistent contraceptive use; and (3) the research is inconclusive about the relationship between violence and pregnancy outcomes. CONCLUSIONS: Improved knowledge of the risk factors for violence is critical for effective intervention design and implementation. Four areas that need improvement for development of new research studies examining violence and reproductive-related issues include (1) broadening of study populations, (2) refining data collection methodologies, (3) obtaining additional information about violence and other factors, and (4) developing and evaluating screening and intervention programs. The research and health care communities should act collaboratively to improve our understanding of why violence against women occurs, how it specifically affects reproductive health status, and what prevention strategies may be effective.

Unintended pregnancy among adult women exposed to abuse or household dysfunction during their childhood.

CONTEXT: Studies have identified childhood sexual and physical abuse as a risk factor for adolescent pregnancy but the relationship between exposure to childhood abuse and unintended pregnancy in adulthood has, to our knowledge, not been studied. OBJECTIVE: To assess whether unintended pregnancy during adulthood is associated with exposure to psychological, physical, or sexual abuse or household dysfunction during childhood. DESIGN AND SETTING: Analysis of data from the Adverse Childhood Experiences Study, a survey mailed to members of a large health maintenance organization who visited a clinic in San Diego, Calif, between August and November 1995 and January and March 1996. The survey had a 63.4% response rate among the target population for this study. PARTICIPANTS: A total of 1193 women aged 20 to 50 years whose first pregnancy occurred at or after age 20 years. MAIN OUTCOME MEASURE: Risk of unintended first pregnancy by type of abuse (psychological, physical, or sexual abuse; peer sexual assault) and type of household dysfunction (physical abuse of mother by her partner, substance abuse by a household member, mental illness of a household member). RESULTS: More than 45% of the women reported that their first pregnancy was unintended, and 65.8% reported exposure to 2 or more types of childhood abuse or household dysfunction. After adjustment for confounders (marital status at first pregnancy and age at first pregnancy), the strongest associations between childhood experiences and unintended first pregnancy included frequent psychological abuse (risk ratio [RR], 1.4; 95% confidence interval [CI], 1.2-1.6), frequent physical abuse of the mother by her partner (RR, 1.4; 95% CI, 1.1-1.7), and frequent physical abuse (RR, 1.5; 95% CI, 1.2-1.8). Women who experienced 4 or more types of abuse during their childhood were 1.5 times (95% CI, 1.2-1.8) more likely to have an unintended first pregnancy during adulthood than women who did not experience any abuse. CONCLUSIONS: This study indicates that there may be a dose-response association between exposure to childhood abuse or household dysfunction and unintended first pregnancy in adulthood. Additional research is needed to fully understand the causal pathway of this association.

Live births resulting from unintended pregnancies: is there variation among states? The PRAMS Working Group.

CONTEXT: States need data on live births resulting from unintended pregnancies in order to assess the need for family planning services; however, many states do not collect such data. Some states may use extrapolated rates from other states. METHODS: Pregnancy Risk Assessment Monitoring System (PRAMS) data were assessed to explore the feasibility of extrapolating data on the percentage of live births resulting from unintended pregnancies from states that collect these data to states that do not. Data on women who had live births between 1993 and 1995 were examined for eight states: Alabama, Florida, Georgia, Michigan, New York (excluding New York City), Oklahoma, South Carolina and West Virginia. Logistic regression was used to determine state variation in the odds of delivering a live birth resulting from an unintended pregnancy after adjustment for maternal race, marital status, age, education, previous live birth and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). RESULTS: The percentage of live births resulting from unintended pregnancy ranged from 33% in New York to 49% in Alabama, Georgia and South Carolina. Compared with women in Alabama, women in Oklahoma were more likely to deliver a live birth resulting from an unintended pregnancy (odds ratio of 1.2, confidence interval of 1.1-1.3) and women in New York State were less likely (odds ratio of 0.7, confidence interval of 0.6-0.8) to have such a birth. However, unmarried white women in New York had lower odds of having a live birth resulting from an unintended pregnancy and married black women in Michigan had higher odds of having a live birth resulting from unintended pregnancy than their counterparts in Alabama. Although the percentages varied, in all eight states women who were black, were unmarried, were younger than 20 years of age, had less than 12 years of education or had more than one child had higher percentages of live births resulting from unintended pregnancy than women with other demographic characteristics. CONCLUSIONS: Data on which women have the greatest risk of delivering a live birth resulting from an unintended pregnancy may be extrapolated from one state to another, but the rate of such births may overestimate or underestimate the problem from one state to another.

Treatment for lactation suppression: little progress in one hundred years.

Our goal was to characterize the postpartum symptoms experienced by women who do not breast-feed and to review data on the efficacy of nonpharmacologic methods of lactation suppression. The placebo arms of randomized clinical trials of pharmacologic methods for lactation suppression were used to characterize postpartum symptoms. A subset of the placebo arms was reviewed to assess current strategies for treatment of symptoms associated with lactation suppression. Studies of nonpharmacologic methods of lactation suppression were also reviewed to assess efficacy. Engorgement and breast pain may encompass most of the first postpartum week. Up to one third of women who do not breast-feed and who use a brassiere or binder, ice packs, or analgesics may experience severe breast pain. Specific studies of nonpharmacologic methods of lactation suppression were limited and inconclusive. Available data suggest that many women using currently recommended strategies for treatment of symptoms may nevertheless experience engorgement or pain for most of the first postpartum week.

The decline in US teen pregnancy rates, 1990-1995.

OBJECTIVES: Estimate pregnancy, abortion, and birth rates for 1990 to 1995 for all teens, sexually experienced teens, and sexually active teens. DESISN: Retrospective analysis of national data on pregnancies, abortions, and births. Participants. US women aged 15 to 19 years. OUTCOME MEASURES: Annual pregnancy, abortion, and birth rates for 1990 to 1995 for women aged 15 to 19 years, with and without adjustments for sexual experience (ever had intercourse), and sexual activity (had intercourse within last 3 months). RESULTS: Approximately 40% of women aged 15 to 19 years were sexually active in 1995. Teen pregnancy rates were constant from 1990 to 1991. From 1991 to 1995, the annual pregnancy rate for women aged 15 to 19 years decreased by 13% to 83.6 per 1000. The percentage of teen pregnancies that ended in induced abortions decreased yearly; thus, the abortion rate decreased more than the birth rate (21% vs 9%). From 1988 to 1995, the proportion of sexually experienced teens decreased nonsignificantly. CONCLUSIONS: After a 9% rise from 1985 to 1990, teen pregnancy rates reached a turning point in 1991 and are now declining. Physicians should counsel their adolescent patients about responsible sexual behavior, including abstinence and proper use of regular and emergency contraception.

Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.

BACKGROUND: The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. METHODS: A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. RESULTS: More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. CONCLUSIONS: We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

Violence during pregnancy: measurement issues.

OBJECTIVES: Standardized quantitative methods are needed to study occurrence and timing of violence in relation to pregnancy and to study the context in which pregnancy-related violence occurs. METHODS: Data from three published studies of prevalence of violence during pregnancy are used to illustrate ways to measure the association of violence in relation to pregnancy. RESULTS: Four patterns of violence in relation to pregnancy are identified, and related research issues are discussed. Also, 2 population-based surveys that address the suggestions presented here are discussed. CONCLUSIONS: Better measurement of the association between violence and pregnancy will facilitate development of data-based prevention and intervention programs.

Live births resulting from unintended pregnancies: an evaluation of synthetic state-based estimates.

OBJECTIVES: Most states lack information on the proportion of live births resulting from unintended pregnancies. We evaluated a potential solution to the lack of data, a synthetic state-based estimate of the percentage of live births resulting from unintended pregnancies for the state of Georgia. METHODS: We constructed the synthetic estimate by standardizing the 1995 National Survey of Family Growth data by the race, marital status, and age distribution of Georgia residents ages 15-44 years who delivered a live birth during 1990-1994. Two surveys conducted in Georgia during the same period that collected information on unintended pregnancies were used for comparison: the Georgia Women's Health Survey (GWHS) and the Georgia Pregnancy Risk Assessment Monitoring System (PRAMS). RESULTS: The synthetic estimate (35.2%, 95% CI = 33.5%-36.7%) was not statistically different from the GWHS estimate (39.6%, 95% CI = 35.7%-43.5%), but was significantly lower than the Georgia PRAMS estimate (49.0%, 95% CI = 45.5%-52.5%). When we stratified by race, marital status, and age, the synthetic and GWHS estimates were statistically similar except for married females and females ages 25-34 years, for whom the synthetic estimates were lower. For all groups of females, the synthetic estimates were statistically lower than the Georgia PRAMS estimates. CONCLUSIONS: The synthetic estimate can be a useful method for states that need to know the overall magnitude of the percentage of live births resulting from unintended pregnancy for purposes such as program planning.

Violence and adverse pregnancy outcomes: a review of the literature and directions for future research.

INTRODUCTION: Violence during pregnancy has been estimated to affect between 0.9% and 20.1% of pregnant women in the United States. This article presents a review of the research on the potential association between violence during pregnancy and adverse outcomes, explores mechanisms by which violence might influence pregnancy outcomes, and suggests directions for future research aimed at the development of successful interventions. METHODS: A review of the literature pertaining to violence during pregnancy and adverse pregnancy outcomes, trauma, and stress during pregnancy was completed. RESULTS: Overall, no pregnancy outcome was consistently found to be associated with violence during pregnancy. The trauma literature offers insight about the effects that injuries caused by physical violence might have on pregnancy outcomes. Information from the stress literature investigates potential mechanisms through which physical violence could indirectly affect pregnancy outcomes. The trauma and stress literature offers methodologic approaches that could be employed in future research on violence during pregnancy and pregnancy outcomes. CONCLUSIONS: This review lays the groundwork for the development of a future research agenda to investigate the association between violence during pregnancy and adverse outcomes. Future research should include quantitative and qualitative approaches, and investigation into the mechanisms and antecedents of how violence during pregnancy may lead to adverse outcomes. Only with such information can successful interventions to limit violence and its potential effects during pregnancy be implemented.

Comparison of two question sequences for assessing pregnancy intentions.

Unintended pregnancies can have serious health, social, and economic consequences. Such pregnancies may be unwanted (a baby is not wanted at any time) or mistimed, yet wanted (a baby is wanted eventually). Intended pregnancies are those conceived when desired. Reproductive health survey respondents' understanding of these concepts and validity of survey results may be affected by question order and wording. Using a randomized crossover design, National Survey of Family Growth (NSFG) and Demographic and Health Survey (DHS) intendedness questions were asked in a 1993 survey of Arizona women aged 18-44 years. Of 2,352 ever-pregnant respondents, 25% gave discordant responses to DHS and NSFG questions about the most recent pregnancy. Age, marital status, household income, education, parity, time since pregnancy, and outcome of pregnancy were significantly predictive of discordant responses. DHS and NSFG questions yielded similar prevalence estimates of intendedness and wantedness; but young, unmarried respondents gave more "mistimed" responses on whichever question was asked later. Classifying pregnancies as intended, mistimed, or unwanted may be a problem for women who have not decided on lifetime reproductive preferences. Approaches to improving survey validity include addressing ambivalence, clarifying the definition of "unwanted," and, for young, unmarried women, not attempting to classify unintended pregnancies as mistimed or unwanted.

Pregnant women's perspectives on intendedness of pregnancy.

PIP: This study examined whether intendedness is a valued characteristic of pregnancy and what factors influence women to risk unintended (unwanted or mistimed) pregnancy. Study participants were 24-34 weeks pregnant, White or Black, aged 18-30, and receiving prenatal care from a publicly funded clinic in North Carolina. Information gathered from 8 focus group sessions (14-15 participants each) revealed that: 1) the concept of a planned pregnancy had no meaning to many of the women; 2) religious beliefs helped people accept unintended pregnancy; 3) planning for pregnancy is a stressful concept because of potential disappointment; 4) unprotected intercourse without pregnancy leads to assumptions of infertility; 5) attitudes of male partners, friends, and family members influence women to risk pregnancy; 6) women adapt to unintended pregnancy very readily; 7) there are no uniform situational risks for unintended pregnancy; and 8) unintended pregnancies are more advantageous than not for some women. These results question the assumption that intendedness of pregnancy is preferred among low-income women or that the pregnancies are "subintended." While interventions to increase intendedness focus on access to contraception, study participants reported no barriers to access as a reason for conception. Health educators should consider the ramifications of teaching that pregnancy can result from a single act of unprotected intercourse without also teaching that pregnancy can occur after several acts of unprotected intercourse. These findings suggest hypotheses that should be explored with further research.^ieng

Prevalence of violence against pregnant women.

OBJECTIVES: To summarize the methods and findings of studies examining the prevalence of violence against pregnant women and to synthesize these findings by comparing study characteristics for studies with similar and dissimilar results. DATA SOURCES: MEDLINE, POPLINE, Psychological Abstracts, and Sociological Abstracts databases were searched for all articles pertaining to violence during pregnancy for the period 1963 through August 1995. STUDY SELECTION: Thirteen studies were selected on the basis of specific criteria: a sample with initially unknown violence status; a clear statement of research question(s), with focus on measuring the prevalence of violence; descriptions of the sample, data source, and data collection methods; and data from the United States or another developed country. DATA EXTRACTION: Relevant data were extracted to compare studies by study description, methods, and results. DATA SYNTHESIS: Evidence from the studies we reviewed indicates that the prevalence of violence during pregnancy ranges from 0.9% to 20.1%. Measures of violence, populations sampled, and study methods varied considerably across studies, and these factors may affect prevalence estimates. Studies that asked about violence more than once during detailed in-person interviews or asked later in pregnancy (during the third trimester) reported higher prevalence rates (7.4%-20.1%). The lowest estimate was reported by women who attended a private clinic and responded to a self-administered questionnaire provided to them by a person who was not a health care provider. CONCLUSIONS: Violence may be a more common problem for pregnant women than some conditions for which they are routinely screened and evaluated. Future research that more accurately measures physical violence during pregnancy would contribute to more effective design and implementation of prevention and intervention strategies.

Pregnancy, abortion, and birth rates among US adolescents--1980, 1985, and 1990.

OBJECTIVE: To analyze pregnancy, abortion, and birth rates among US adolescent girls in 1980, 1985, and 1990. DESIGN: Retrospective analysis of trends in data on pregnancies, abortions, and births. POPULATION: US adolescent girls aged 13 to 19 years. MAIN OUTCOME MEASURES: Pregnancy, abortion, and birth rates (with and without adjustment for sexual experience) among teenaged girls aged 15 to 19 years and girls under 15 years. RESULTS: Although pregnancy rates among all teenaged girls 15 to 19 years old remained fairly stable from 1980 to 1985, they increased by 9% during the last half of the decade, totaling 95.9 pregnancies per 1000 teenaged girls 15 to 19 years old by 1990. Because rates of sexual experience increased even faster, pregnancy rates among sexually experienced teens aged 15 to 19 actually declined between 1980 and 1990 by approximately 8%. Abortion rates among these teens remained stable during the 1980s, with 35.8 and 36.0 abortions per 1000 in 1980 and 1990, respectively. As with overall pregnancy rates, abortion rates among these sexually experienced teenaged girls declined during the 1980s. Between 1980 and 1985, birth rates among teenaged girls aged 15 to 19 years declined by 4%, but they increased by 18% during the latter half of the decade, totaling 59.9 births per 1000 in 1990. Among these sexually experienced teenagers, birth rates also declined between 1980 and 1985 and then increased over the next 5 years. In 1990, pregnancies and abortions among girls younger than 15 years accounted for only 3% of all adolescent pregnancies and abortions. However, the number of births among these younger adolescents increased by 15% over the decade. In that age group, trends in pregnancy, abortion and birth rates over the decade were similar to those for older teens. However, during the late 1980s, the abortion rate declined and the pregnancy rate remained stable, resulting in a 26% increase in the birth rate. CONCLUSIONS: Despite efforts to reduce adolescent pregnancy in the United States, pregnancy and birth rates for that group continue to be the highest among developed countries. Considering that 95% of adolescent pregnancies are unintended, increased efforts to prevent these pregnancies are warranted.

Surveillance for pregnancy and birth rates among teenagers, by state--United States, 1980 and 1990.

PROBLEM/CONDITION: In the United States in 1990, there were an estimated 1 million pregnancies and 521,826 births among women ages 15-19 years. Rates of teenage pregnancy and birth rates by state in 1990 exceeded those in most developed countries. An estimated 95% of teenage pregnancies are unintended (i.e., they occur sooner than desired or are not wanted at any time). REPORTING PERIOD COVERED: This report summarizes and reviews surveillance data for pregnancies, abortions, and births among women ages 15-19, 15-17, and 18-19 years reported by CDC for 1980 and 1990. DESCRIPTION OF SYSTEM: Data for births and abortions were reported to state health departments and other health agencies and sent to CDC. The data from each state included the total number of births and abortions by age and race/ethnicity. RESULTS: Data in this report indicate that pregnancy rates by state among U.S. teenagers ages 15-19 years have changed little since 1980. Moreover, many states have reported increases in birth rates that are probably related to concurrent decreases in abortion rates. Pregnancy rates range from 25 to 75 per 1,000 for 15- to 17-year-olds and from 92 to 165 per 1,000 for 18- to 19-year-olds. INTERPRETATION: States with low rates of teenage pregnancy or birth may have developed and used prevention strategies directed at the needs of both younger and older teenagers; these programs may serve as models for other states where birth rates have remained high or have increased since 1980. ACTIONS TAKEN: CDC will continue to conduct surveillance of and analyze data for pregnancies, abortions, and births among teenagers to monitor progress toward national goals and to assist in targeting program efforts for reducing teenage pregnancy.

Pregnancy and birth rates among sexually experienced US teenagers--1974, 1980, and 1983.

We examined pregnancy rates and birth rates among United States teenagers aged 15 to 19 years in 1974, 1980, and 1983. Pregnancy rate refers to live births plus induced abortions per 1000 women; birth rate refers to live births per 1000 women. We present these rates for all teens aged 15 to 19 years and for teens aged 15 to 19 years who were sexually experienced. Data sources included National Center for Health Statistics birth records, Centers for Disease Control abortion surveillance reports, and Bureau of the Census population estimates. Sexual experience estimates came from national surveys of adolescent sexual behavior. Between 1974 and 1980, the pregnancy rate among all teens increased; the pregnancy rate among sexually experienced teens declined. From 1980 to 1983, the pregnancy rate declined among all teens and among sexually experienced teens. Birth rates among US teenagers (all teens and sexually experienced teens) declined between 1974 and 1983. Whereas the decline in the birth rate from 1974 to 1980 was primarily due to increased use of abortion, the decline from 1980 to 1983 related to the decrease in teenage pregnancies.

Contraceptive use in Georgia: estimation by telephone survey.

Because household surveys are expensive and time consuming, determination of state or local family planning needs is based on national household survey estimates of contraceptive use rather than state-specific estimates. In June 1982, the University of Georgia Survey Research Center invited the Georgia Department of Human Resources (DHR) to add questions to a Statewide Omnibus Telephone Survey to obtain information on contraceptive use, source of contraception, and reasons for not using contraception. The survey used two-stage random digit dialing to select 1,737 households. From these households, we have complete information on 332 women aged 18 to 44. The definition of contraception included use by either the respondent or partner. Fifty-six percent of female respondents were using contraception; oral contraceptives (22%) and contraceptive sterilization (21%) were the primary methods used. Private sources provided 78% of nonpermanent contraceptive methods. The majority of women not using contraception reported a noncontraceptive sterilization or infertility (31%) or were pregnant, desiring a pregnancy, or not sexually active (29%). The advantages of this method over household surveys are rapid turnaround of data and relatively low cost.

Legal abortion in Georgia, 1980.

PIP: According to data reported to the Georgia Department of Human Resources (DHR), the number of induced abortions performedin Georgia in 1980 decreased for the 1st time since 1968 when the state legalized abortion. To verify this reported decrease, the DHR data were compared with statistics obtained by the Alan Guttmacher Institute in a 1980 survey of abortion providers in Georgia. Since the AGI contacts providers directly, its statistics are considered a more accurate reflection of abortions performed. According to the DHR, the number of abortions dropped from 36,579 in 1979 to 33,288 in 1980, a 9% decrease, and the abortion rate fell from 26.6/1000 women ages 15-44 years to 23.9/1000. AGI data indicated a drop from 38,760 abortions in 1979 to 37,890 in 1980, a 2% decrease. Since both sources noted a similar trend despite differences in data collection methods, the 1980 decline in abortion procedures in Georgia is considered to represent a true decline rather than s statistical artifact. The sociodemographic characteristics of women obtaining abortions in Georgia in 1980 were also analyzed on the basis of DHR data. Although the number of abortions in Georgia performed on Georgia residents increased 2.5% from 1979-80 to 90.7%, the abortion ratio for residents decreased from 367.7 to 327.4 abortions/1000 live births. There was little change in the age, race, or marital status distribution of women receiving abortions. The ratio for white women was 317 abortions/1000 live births and that for blacks was 342/1000. The abortion ratio for unmarried women (1166/1000) was 13 times that for married women (88/1000). The number of repeat abortions decreased form 34% in 1979 to 29% in 1980. Moreover, 93% of women obtaining abortions did so in the 1st 12 weeks of gestation compared with 89% in 1979. The percentage of abortions performed in clinics increased from 66.5% in 1979 to 75.3% in 1980, with suction curettage accounting for 85% of all abortions in the 1st 12 weeks of gestation. Further analysis ruled out the possibility that the decreased abortion rate was caused by an increase in the number of births, declining numbers of abortion providers, changes in public funding for abortion, or an increase in the number of Georgia residents obtaining out of stat abortions.^ieng