Partner Violence and Unintended Pregnancy: Time to Make the Connections
By Elizabeth Miller MD PhD and Jay Silverman PhD
Originally posted at RH Reality Check blog on Feb. 8, 2010
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 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 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.”
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.” 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.
Around the time I was conceived, my mother finally worked up the courage to leave. She told my father she wanted a divorce. My father, who prescribed all her medication, withheld her contraception and raped her, thinking that another child would turn her around."
April 16th, 2010 at 11:33 pm
I would like to comment that in my own personal experience, I can answer the questions regarding 1. the prevalence of reproductive coercions broader population span and 2. which behavior precedes the other; violence or unintended pregnancy.
1. I was seeing my Gyno regularly and was both insured as well as regularly seeing my Dr.’s (Dentist, General/Family, Endocrinologist, OBGYN, and Optometrist). However I was slowly and gradually manipulated in one way or another into financially supporting my ex- and ended up going without insurance nor routinely going to my Dr. because I couldn’t financially afford it and although I know their are many options out there for me to seek out either free or discounted medical care, I am from an up-bringing that we just consult with our physician and work out a payment plan, because your life is too precious to entrust your medical to just anyone and we had had previous experience with incompetent physicians, so that caused a lot of worry when considering anyone else in treatment.
2. The manipulation was so well crafted that it wasn’t until my unintentional pregnancy that I realized what an irresponsible mistake I had made and where my part played into it. Although I was never fully aware of the reproductive coercion up to this point, until long after our relationship had ended and I was trying to recover from the post-traumatic stress of events that occurred within our relationship. It was after my unintended pregnancy and my reaction to it; terminated in a state of I guess one could say self-preservation, because I did not want to do it, but I was so distraught at the reality of all the potentially distracting and non-sensical legal issues I would be put through, by a person who hasn’t exhibited anything but “dead-beat-dad” behavior. I considered all the options and each one was a fight with him, he wanted it his way and I felt like in the end, I loved my child and myself too much to be put through the ringer of disrespect and unfulfilled responsibilities from him. I felt it was not right and he was going to fight me on the adoption issue too and culturally speaking I felt like I was going to be limiting my chances in life by being “damaged property.” It hurts now to know that I was not as informed about abortions as I thought I was. They seemed to be safe and I was told by a friend that had had one between her own children and felt reassured that I wouldn’t suffer any long-term physical consequences.
That’s when the intimate partner abuse started in conjunction with the blatant contraception sabotage. In my defense I could possibly take blame for the pregnancy, but I learned my lesson and I practiced diligent abstinence in the face of his reproductive coercions, regarding contraceptive and that’s usually when it would escalate to the verbal and/or physical abuse.
I just wanted to share this with you and hope it helps your studies, because in the aftermath of all this I’ve gone through, I want to be able to hold him legally accountable for making me what I see know as “damaged goods” I have no idea what my future fertility will hold until I get there and it’s sad that one can be so brutally victimized and yet the law has no legal action that I am aware of (as of yet) to prosecute men who go around and just “spread their seed” so to speak. And it wasn’t until our break-up that I learned of and came to realize that I am not the only one he’s done this to. I am just one in a number and it’s morally wrong. I feel people should be held accountable for these types of irresponsible behaviors, because if for nothing less, I feel like he probably doesn’t even know any better and his lack of education on this matter perpetuates the negative associates to what & how government assistance is meant to used for. I also feel like it victimizes women and perpetuates the whole domestic violence issue and maybe prosecuting people for Reproductive Coercion could at least provide them with resources and efforts to get help to overcome their own obstacles and provide a proactive concept in personal growth.