We have known for many years that violence and abuse are more closely associated with unintended pregnancy than with pregnancies that are intended. Forced sex, fear of violence if she refuses sex, and difficulties negotiating contraception and condom use in the context of an abusive relationship all contribute to increased risk for unintended pregnancy as well as for sexually transmitted infections including HIV. Newer research now also points to the influences of male control of contraception and pregnancy pressure on unintended pregnancy.
We are lead researchers of a new study, which appeared in Contraception online [16]in late January. The research report, “Pregnancy coercion, intimate partner violence and unintended pregnancy,” highlights a phenomenon we labeled reproductive coercion to describe explicit male behaviors to promote pregnancy. Particularly for women with a history of partner violence, these behaviors are significantly linked with unintended pregnancy.
Such reproductive coercion takes many forms, but frequently involves a male partner’s direct interference with a woman’s use of contraception (‘birth control sabotage’). It includes removing condoms during sex to get her pregnant, intentional breaking of condoms, and preventing her from taking birth control pills.2,3
In addition, a male partner may utilize threats and coercion to pressure a woman to get pregnant (‘pregnancy coercion’), such as telling her not to use contraception and threatening to leave her if she doesn’t get pregnant.
Our previous qualitative research has pointed to a range of reasons that a man might engage in such behaviors including wanting to leave a legacy, desiring to keep a woman connected to him in some way, as well as need for control in the relationship. Clearly, much more research with men and boys needs to be done to understand male involvement in unintended pregnancies and how to positively engage men and boys in discussions of healthy relationships.
Our new study included English- and Spanish-speaking women ages 16 to 29 who sought health care at five reproductive health clinics in California. The reasons the women sought care included annual physical exams, contraception, pregnancy testing, and testing for sexually transmitted infections.
Participants completed a confidential computerized survey (with questions read to them via headphones) before their clinic visit; the clinic providers did not see the responses. More than half of the respondents (53 percent) reported experiencing physical or sexual violence from a male partner, or someone they were dating or going out with some time in their lives. A quarter (25 percent) reported that they had ever experienced ‘reproductive coercion,’ with 19 percent reporting pregnancy coercion and 15 percent reporting birth control sabotage. Women who reported experiencing both partner violence and reproductive coercion experienced a 100 percent increase in their risk for unintended pregnancy.
Unintended pregnancy is clearly a complex phenomenon. It can be caused by a number of factors including: a mismatch of intentions and behaviors for both males and females (i.e., not wanting to get pregnant, while not using contraception or a condom, often called ‘contraceptive and pregnancy ambivalence’); limited access to contraception; lack of knowledge about the range of contraceptive options; stigma associated with asking a partner to use a condom; as well as substance use such as alcohol accompanying intercourse.
Our study adds another important piece to this puzzle: Male partners interfering with women’s reproductive autonomy. Moreover, the effect of male partner reproductive coercion on unintended pregnancy is likely to be greater in the context of partner violence, given the clear threat of violence if she tries to resist her partner’s wishes.
There are many unanswered questions around the interrelationship between reproductive coercion, partner violence, and unintended pregnancy. Our study provides preliminary findings indicating a significant connection, but it was limited to lower income women seeking care in a particular type of family planning clinic in a particular region. We need to know the prevalence of reproductive coercion when women are seeking gynecologic care in other settings such as hospitals or primary care clinics, as well as how prevalent this is across the general population.How often does reproductive coercion occur in the absence of partner violence? Does partner violence precede effective attempts to control a woman’s pregnancy and the outcomes of that pregnancy? Or do men’s coercive behaviors regarding contraception and reproductive outcomes precede physical and sexual violence in the relationship? How do men recognize and understand reproductive coercion? And, perhaps most critically, why do men engage in such controlling behaviors, and what strategies will successfully engage men and boys in preventing partner violence and reproductive coercion?
Beyond answering such research questions, we need to identify effective strategies to increase awareness about reproductive coercion among both men and women. Women may perceive reproductive coercion and physical violence in a relationship as distinct issues, and may need support and information to connect the dots between this range of behaviors and their reproductive health needs. If family planning practitioners pay attention to and address reproductive coercion, they may be more successful at identifying clients at risk both for unintended pregnancy and for harm from partner violence.
Further, such identification is likely to improve the efficacy of family planning services, because knowledge of reproductive coercion can inform counseling about contraceptive adherence and choices (women at risk can be offered methods that are not easily detected by male partners and are not reliant on male partner consent). This knowledge that a woman is experiencing reproductive coercion can trigger more intensive use of prevention strategies that can reduce unintended pregnancies, including among adolescents, and promote a woman’s safety.
It also would be wise to consider incorporating efforts to reduce reproductive coercion into comprehensive sexuality education and pregnancy prevention programs. Making discussions of healthy relationships the foundation of sexuality education would be a good start. Then incorporating discussions of abusive behaviors and partner violence into curricula that discuss contraceptive negotiation would be particularly helpful in increasing a woman’s success at contraceptive negotiation and enhancing her reproductive autonomy. Prevention programs that engage men and boys in reducing unintended pregnancies should also offer opportunities to discuss masculinities, gender equity, and reproductive justice.
Finally, vehicles like the currently authorized Violence Against Women Act’s Health Provision could assist in supporting needed health research and innovations in practice related to intimate partner violence and reproductive coercion, including efforts to promote healthy relationships. We should encourage professional health care provider organizations to recognize and develop relevant standards and competencies. For instance, family planning standards can be updated to address issues of partner violence and reproductive coercion.
Many people were stunned and alarmed by the Guttmacher Institute’s January report [17] on teen pregnancy rates in the United States. It noted a three percent increase in pregnancies among 15- to 19-year-olds from 2005 to 2006—the first increase in some 15 years. While teens and young women report the highest rate of unintended pregnancies, many adult women experience unintended pregnancies as well. Experts have been telling us for years that almost half of pregnancies in the United States are unintended (i.e., mistimed, unplanned, and/or unwanted).
The causes and mechanisms that underlie unintended pregnancy are numerous and complex, but one thing is clear. If we are serious about reducing unplanned pregnancies in this country, we must bridge the gap between efforts to reduce violence against women and girls and efforts to reduce unintended pregnancy. We need innovative programs for both young men and women that address both partner violence and healthy relationships.
1. Miller, E., M. R. Decker, et al. (2010 Epub ahead of print). "Pregnancy Coercion, Intimate Partner Violence, and Unintended Pregnancy." Contraception.
2. Center for Impact Research. (2000). "Domestic Violence & Birth Control Sabotage: A Report from the Teen Parent Project." [18]
3. Miller, E., M. R. Decker, et al. (2007). "Male Partner Pregnancy-Promoting Behaviors and Adolescent Partner Violence: Findings from a Qualitative Study with Adolescent Females." [19] Ambulatory Pediatrics 7(5): 360-366.
4. Finer, L. B. and S. K. Henshaw (2006). "Disparities in rates of unintended pregnancy in the United States, 1994 and 2001." Perspectives on Sexual & Reproductive Health 38(2): 90-96.