Violence Against Women and Unintended Pregnancy: Building Connections
By Elizabeth Miller, MD, PhD
About ten years ago, while providing clinical care in a community-based clinic for adolescents affiliated with our teaching hospital, I saw a 15-year-old young woman who requested a pregnancy test. Her pregnancy test was negative. Did she want to be pregnant? No. Was she using birth control? No. Assuming that she didn’t know about all the ways to prevent pregnancy, I efficiently listed a menu of birth control options for her. Cursorily, I asked whether she felt safe in her relationship and whether her boyfriend was willing to use condoms. She shrugged, “Yeah, whatever.” I handed the young woman a brown bag full of condoms and encouraged her to return later, when she had decided what birth control method would work best for her. Two weeks later, I learned that she was in our hospital’s emergency room with a head injury resulting from having been pushed down the stairs by her boyfriend. She survived, but had a rocky course with depression and suicide attempts, further complicated by her mother’s blaming her for the situation: “You picked him, it’s your own fault.”
This was a profoundly destabilizing experience for me — a physician trained in feminist anthropology who had conducted research on gender-based violence, sex trafficking, and HIV. This event drove me to try to better understand intimate partner violence among adolescents and young adults, and to ponder what potential red flags I had missed during that young woman’s clinic visit.
Two decades of research has demonstrated that violence against women is common across the globe and is associated with a myriad of poor health outcomes. Intimate partner violence (also known as relationship violence) includes physical, sexual and emotional abuse occurring within intimate relationships. The World Health Organization’s (WHO) Multi-Country Study on Women’s Health and Domestic Violence (the largest cross-national study of intimate partner violence) has found that women’s lifetime prevalence of intimate partner violence ranges from 13% in urban Japan to 61% in rural Peru.1 Beyond the obvious physical injuries women suffer, the broader impact of relationship violence on the health of women is a major global health problem. Numerous studies in a wide variety of clinical and community samples (including emergency rooms, primary care clinics, substance disorder treatment programs, family planning and sexual health clinics, schools, shelters, and domestic violence programs) have documented the adverse health consequences that stem from relationship violence. These include physical injury, disability, depression, suicidality, unintended pregnancy, sexually transmitted infections (including HIV), and related poor reproductive and sexual health outcomes.2
Intimate partner violence is more often associated with unintended pregnancy than with intended pregnancy.3 Experts have been telling us for years that almost half of pregnancies in the United States are unintended (in other words, the pregnancy is mistimed, unplanned, and/or unwanted).4 Women ages 16-24 experience the highest rates of unintended pregnancy, as well as the highest rates of intimate partner violence.5 Forced sex, fear of violence if the woman 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. Understanding the associations between intimate partner violence and unintended pregnancy is critical to guide effective prevention and intervention efforts in both areas.
Recent studies have drawn attention to the influence that male control of contraception and pressuring their partner to become pregnant have on their partner’s “unintended” pregnancy.6 Such reproductive coercion takes many forms, but frequently involves male partners’ direct interference with a woman’s contraceptive use, known as “birth control sabotage.” Birth control sabotage behaviors include removing condoms during sex in order to get the woman pregnant, intentionally breaking condoms, and preventing the woman from taking birth control pills or using another contraceptive method. In addition, male partners may use threats and coercion to pressure a woman to get pregnant, known as “pregnancy coercion.” Pregnancy coercion behaviors include preventing the woman from using contraception and threatening to leave if the woman doesn’t get pregnant. Once a pregnancy is diagnosed, women report their male partners’ attempts to control the pregnancy outcomes, including preventing her from seeking an abortion or, conversely, forcing her to terminate the pregnancy. The Family Violence Prevention Fund’s website (www.KnowMoreSayMore.org) contains a number of first-person narratives from women who have experienced reproductive coercion, and provides specific examples and consequences of these behaviors.
In order to better understand the connections between such coercive behaviors and reproductive health outcomes, our research group (comprised of investigators from U.C. Davis School of Medicine, Harvard School of Public Health, Planned Parenthood Shasta-Diablo affiliate, and Family Violence Prevention Fund) conducted a study among English- and Spanish-speaking women ages 16 to 29 who sought health care at one of five reproductive health clinics in California.7 More than half of the respondents (53%) reported that they had experienced physical or sexual violence from a male partner (defined as someone they were dating or going out with). One-quarter (25%) reported that they had experienced reproductive coercion; almost one-fifth (19%) reported pregnancy coercion, and 15% reported birth control sabotage. Women who reported both partner violence and reproductive coercion had a two-fold increase in their risk for unintended pregnancy, compared to women without prior experiences of partner violence.
Unintended pregnancy is clearly a complex phenomenon, and one that is likely related to multiple inter-related factors. One factor that is commonly cited as driving unintended pregnancy is “ambivalence” related to pregnancy and/or contraception. Ambivalence is thought to result in a mismatch between intentions and behaviors for both males and females (i.e., not wanting to get pregnant but not using contraception). Studies on pregnancy and contraceptive ambivalence have not, however, considered the role of intimate partner violence in reproductive outcomes. Male partner’s interference with a woman’s reproductive autonomy adds a critical piece to the puzzle of unintended pregnancy, and underscores the tremendous impact that intimate partner violence and coercion have on women’s health. Moreover, the effect of male partner’s reproductive coercion on unintended pregnancy is likely to be greater in the context of partner violence, given the clear threat of violence if the woman attempts to resist her partner’s wishes.
In addition to exploring the role of intimate partner violence on women’s reproductive outcomes through research and evaluation, we must identify effective strategies to increase awareness about reproductive coercion among both men and women. Women may perceive reproductive coercion and intimate partner violence as distinct and separate phenomena, and may need support and information in order to connect the dots between this range of behaviors and their reproductive health needs.
What did I miss at that fateful clinic visit? When my client told me she didn’t want to be pregnant, yet was not using contraception, I should have asked, “Do you think your boyfriend wants you to get pregnant?” In addition, I should have followed up with questions about her fear of negotiating condom use, whether her partner had ever threatened her or attempted to control her behaviors, whether he had ever tried to hurt her physically, and whether he had ever made her do things sexually she didn’t want to do. Answers to those questions should have prompted me to help her identify the unhealthy aspects of the relationship, to counsel her about contraceptive options that her partner could not influence (such as longer acting contraceptives like the shot), and to provide more information on relationship violence, safety, and local resources.
Paying more attention to reproductive coercion may help clinicians be more successful at identifying clients who are at risk for both unintended pregnancy and harm from intimate partner violence. Identifying these women is likely to improve the clinical care we offer our patients, because knowing a woman has experienced reproductive coercion or intimate partner violence can guide counseling her about contraceptive adherence and choices. For example, women who are at risk can be offered contraceptive methods that are not easily detected or controlled by their male partners and do not rely on male partner’s consent. In public health, we refer to these as ‘harm reduction’ strategies. In straight clinical language, helping a woman prevent an unintended pregnancy within an already controlling and unhealthy relationship is something we clinicians can offer. As clinicians on the front-lines, in collaboration with our colleagues in domestic violence and sexual assault prevention, we are also in a place to connect women to violence-related services and counseling.
From a broader prevention perspective, we need to incorporate discussions about intimate partner violence and reproductive coercion into sexuality education and pregnancy prevention programs, and make healthy relationships the foundation of sexuality education. This would not only provide crucial information to young people but also offer an innovative approach to adolescent pregnancy prevention. Of course, prevention programs that engage men and boys in reducing unintended pregnancies should also offer opportunities to discuss masculinity, gender equity, and reproductive justice. If we are serious about reducing unintended pregnancies and improving women’s health, we must build more explicit connections between efforts to reduce violence against women and efforts to reduce unintended pregnancy. Innovative programs for young men and women that address partner violence, reproductive coercion, and healthy relationships are critically needed.
Dr. Elizabeth Miller, MD, PhD, is Assistant Professor in Pediatrics at the U.C. Davis School of Medicine. Trained in medical anthropology as well as Internal Medicine and Pediatrics, Dr. Miller’s research has included examination of gendered risk for HIV among women in Japan (victims of sex trafficking and other forms of gender-based violence), and dating violence and health risks among adolescents in the United States.
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