The link between violence, coercion and unintended pregnancy

Dr. Elizabeth Miller was working in a family planning clinic in Boston a decade ago when she treated a 15-year-old girl who came in for a pregnancy test. The test was negative, and after a brief conversation about birth control, Miller sent the young patient home with condoms for her partner to use in future sexual encounters.

Two weeks later, the same girl was admitted to a local hospital with a severe head injury. Her boyfriend had pushed her down a flight of stairs. Only then did Miller realize that the girl was in an abusive relationship that included sexual and reproductive coercion.

“I completely missed it,” Miller said Wednesday at the state Capitol.

Since that encounter, Miller has dedicated much of her time as a researcher documenting the extent of partner abuse and its links to sexually transmitted infection and unwanted pregnancy, especially among adolescents. She has also helped devise, and test, a set of simple interventions that she says have proven effective in helping women escape abusive relationships or at least take control of their own reproductive health.

“This is not a marginal phenomenon affecting a small number of women,” said Miller, a UC Davis professor.

Miller’s recently published research (in the journal Contraception) surveyed 900 women in four California family planning clinics.

Fifty-three percent of the women in the study reported having experienced physical or sexual abuse by a partner in their lifetime, and nearly 18 percent reported such violence in the past three months.

Nearly 26 percent of women reported an experience of reproductive coercion, 19 percent reported pregnancy coercion and 15 percent said a partner had sabotaged their birth control.

Pregnancy coercion is defined as threats or pressure to promote pregnancy, or when a partner controls the outcome of a pregnancy. Sexual coercion is defined as intentionally exposing a partner to a sexually transmitted infection, forcing condom non-use, threats or acts of violence related to sexually transmitted infection notification or threats or acts of violence if a woman does not agree to have sex when her partner wants it.

Earlier studies have found that adolescent girls in physically abuse relationships were 3.5 times more likely to become pregnant than non-abused girls, 2.8 times more likely to fear the perceived consequences of negotiating condom use than non-abused girls, and twice as likely to have a second pregnancy within 24 months of giving birth.

The most startling finding in Miller’s research was probably her examination of some simple intervention techniques that clinics can use at little or no cost and which proved to be highly effective.

The program begins with a handful of questions for the patient:

–Does my partner mess with my birth control?

–Does my partner refuse to use condoms when I ask?

–Does my partner make me have sex when I don’t want to?

–Does my partner tell me who I can talk to or where I can go?

Doctors are also encouraged to talk to their patients about birth control options — including some that are invisible or impossible for a partner to sabotage — and to ask their patients if they are worried about how their partner will react if they don’t do what the partner wants with the pregnancy.

Finally, doctors and clinic workers were instructed to refer their patients violence prevention counselors.

After these interventions were tried, Miller found a 71 percent reduction in the odds pregnancy coercion compared to a group of women who were not given this kind of help. Women receiving the intervention were 60 percent more likely to end a relationship because it felt unhealthy or unsafe.

Yali Barr, an independent health care consultant who specializes in family planning, said Miller’s research and other recent studies have shown that reproductive coercion and birth control sabotage are “much more common than we could have thought.”

And with the evidence showing that integrated intervention can dramatically reduce the scope of the problem, Barr said it is time to implement that strategy widely.

“It doesn’t have to cost any more,” she said, mindful of the state’s chronic budget crises.

Miller recently received funding to expand her study to 20 Northern California clinics and 3,000 women.

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