Original research articleRecent reproductive coercion and unintended pregnancy among female family planning clients☆,☆☆,★
Introduction
Unintended pregnancy is common in the United States [1], disproportionately affects younger women [2] and is associated with intimate partner physical and sexual violence (IPV) [3], [4], [5], [6], [7], [8]. One in three women experience IPV, and similar to unintended pregnancy, younger women aged 15 to 24 years experience the highest rates [9], [10]. In reproductive health clinics, the prevalence of IPV among female clients ranges from 40% to 53% [11], [12], [13], [14], [15], [16].
Mechanisms linking IPV with unintended pregnancy include women's compromised sexual decision making [17], [18], limited ability to enact contraceptive use [8], [17], [19], [20], inconsistent condom use [18], [19], [21], [22] and fear of condom negotiation [19], [21]. Reproductive coercion (RC) by male partners also contributes to increased risk for unintended pregnancy through contraceptive sabotage (active interference with contraceptive methods) and pregnancy pressure (threats to promote a pregnancy) [13], [23], [24], [25], [26]. National data demonstrate that approximately 9% of (or 10.3 million) US women report ever-experiencing RC [9]. Estimates are higher among family planning clients, with recent evidence documenting a lifetime RC prevalence of 25% [13].
As noted in recent clinical guidelines, health professionals caring for women who are experiencing RC are able to offer contraceptive methods less vulnerable to partner influence (such as intrauterine contraception and implant) while providing women with information about IPV and strategies to increase their safety [27]. Thus, knowing if RC occurring around the time of a clinical encounter increases risk for unintended pregnancy is critical to guide reproductive health providers on whether to assess for RC in addition to physical and sexual violence during routine reproductive health visits [27].
This study hypothesized that RC occurring in the past 3 months (pregnancy-promoting behaviors specifically) would be associated with recent unintended pregnancy, independent of the influence of IPV. Knowing whether physical and sexual partner violence (given its consistent and robust associations with unintended pregnancy in past literature) and RC (an aspect of control within relationships distinct from physical and sexual IPV) separately confer significant, independent risk for unintended pregnancy is needed to guide screening recommendations.
As pregnancy intention is complex and not easily characterized by a single dichotomous category (intended vs. unintended) [28], pregnancy intention was assessed using a set of items that asked about planning and timing in addition to desire for a pregnancy. This allowed for a more precise discrimination of unintended pregnancy risk among those experiencing recent RC and lifetime IPV (separately and in combination).
Section snippets
Materials and methods
The current study was conducted via a survey of English and Spanish-speaking females aged 16–29 years at 24 family planning clinics in Western Pennsylvania from October 2011 to November 2012 (baseline data for a randomized controlled trial testing a brief RC intervention). Upon arrival to a clinic, females seeking care at these family planning clinics were approached by research staff about the study. Interested, age-eligible women were escorted to a private area in the clinic for consent and
Sample characteristics
Of the 3980 age-eligible female clients approached, 3682 agreed to complete the survey (participation rate 93%). Primary reasons for nonparticipation were lack of time and plans to move away in the near future (these individuals were ineligible based on need for follow-up surveys for the intervention study). Participants and nonparticipants did not differ significantly by age or ethnicity. Final sample size was determined by outcomes of interest for this analysis (i.e., unintended pregnancy);
Discussion
This study is the first to document a robust and independent association of recent RC with unintended pregnancy in the past year, even in the absence of exposure to IPV. Prior research by this investigative team has shown associations of lifetime exposure to RC with unintended pregnancy occurring in the context of any IPV [13]. The finding that RC occurring around the time of a clinical encounter is associated with increased risk for unintended pregnancy, independent of physical or sexual
Acknowledgments
We gratefully acknowledge the staff of Planned Parenthood of Western Pennsylvania and Adagio Health as well as the multiple domestic violence and sexual assault victim advocates in Western Pennsylvania for their continued support of this study. Rebecca Levenson, Senior Policy Analyst for Futures Without Violence, served as a coinvestigator on this study and contributed to the research design and writing of this manuscript. Sam Ciaravino, Hillary Darville, Jill Etienne, Tarrah Herman, Angela
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Cited by (0)
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Funding: Funding for this study is from the National Institute of Child Health and Human Development (R01HD064407; to Miller and Silverman).
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Conflict of interest: None of the authors have any financial interests to disclose.
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Clinical Trials Number: NCT01459458.