Partner Violence and Unintended Pregnancy: Time to Make the Connections

Elizabeth Miller MD PhD and Jay Silverman PhD

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 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.

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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.

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