Racial Differences in Pregnancy Intention,Reproductive Coercion,and Partner Violence among Family Planning Clients: A Qualitative Exploration

Background

Unintended pregnancy (UIP) is a persistent public health concern in the United States disproportionately experienced by racial/ethnic minorities and women of low socioeconomic status. UIP often occurs with experiences of reproductive coercion (RC) and intimate partner violence (IPV). The purpose of the study was to qualitatively describe and compare contexts for UIP risk between low-income Black and White women with histories of IPV/RC.

Pregnancy coercion, intimate partner violence and unintended pregnancy

Background

Reproductive control including pregnancy coercion (coercion by male partners to become pregnant) and birth control sabotage (partner interference with contraception) may be associated with partner violence and risk for unintended pregnancy among young adult females utilizing family planning clinic services.

Study Design

A cross-sectional survey was administered to females ages 16-29 years seeking care in five family planning clinics in Northern California (N=1278).

Results

Fifty-three percent of respondents reported physical or sexual partner violence, 19% reported experiencing pregnancy coercion and 15% reported birth control sabotage. One third of respondents reporting partner violence (35%) also reported reproductive control. Both pregnancy coercion and birth control sabotage were associated with unintended pregnancy (AOR 1.83, 95% CI 1.36-2.46, and AOR 1.58, 95% CI 1.14-2.20, respectively). In analyses stratified by partner violence exposure, associations of reproductive control with unintended pregnancy persisted only among women with a history of partner violence.

Conclusions

Pregnancy coercion and birth control sabotage are common among young women utilizing family planning clinics, and in the context of partner violence, are associated with increased risk for unintended pregnancy.     

Recent reproductive coercion and unintended pregnancy among female family planning clients

Objective

Reproductive coercion (RC) — birth control sabotage and coercion by male partners to become pregnant and to control the outcome of a pregnancy — has been associated with a history of both intimate partner physical and sexual violence (IPV) and unintended pregnancy among females utilizing reproductive health services. The temporal nature of associations of RC and unintended pregnancy (distinct from the impact of IPV), however, has remained less clear.

Study Design

A survey was administered to females aged 16–29 years seeking care in 24 rural and urban family planning clinics in Pennsylvania (n= 3539).

Results

Five percent of respondents reported RC in the past 3 months, and 12% reported an unintended pregnancy in the past year. Among those who reported recent RC, 21% reported past-year unintended pregnancy. Compared to women exposed to neither condition, exposure to recent RC increased the odds of past-year unintended pregnancy, both in the absence of a history of IPV [adjusted odds ratio (AOR) 1.79, 1.06–2.03] and in combination with a history of IPV (AOR 2.00, 1.15–3.48); history of IPV without recent RC was also associated with unintended pregnancy (AOR 1.80, 1.42–2.26).

Conclusions

Findings indicate the temporal proximity of the association of RC and unintended pregnancy, with recent RC related to past-year unintended pregnancy, both independently and in combination with a history of IPV. Recent RC is relatively prevalent among young women using family planning clinics and is associated with increased risk for past-year unintended pregnancy even in the absence of IPV.

Implications

Recent RC and a history of IPV are prevalent among female family planning clients, particularly younger women, and these experiences are each associated with unintended pregnancy. Pregnancy prevention counseling should include not only assessment for physical and sexual partner violence but also specific inquiry about RC.     

Race and Reproductive Coercion: A Qualitative Assessment

BackgroundUnintended pregnancy is common and disproportionately occurs among low-income and African-American (AA) women. Male partners may influence women's risk of unintended pregnancy through reproductive coercion, although studies have not assessed whether racial differences in reproductive coercion impact AA women's disparate risk for unintended pregnancy. We sought to describe women's experiences with pregnancy-promoting behaviors by male partners and explore differences in such experiences by race.MethodsSemistructured interviews were conducted with low-income, AA and White women aged 18 to 45 years recruited from reproductive health clinics in Western Pennsylvania to explore contextual factors that shape women's contraceptive behaviors. Narratives were analyzed using content analysis and the constant comparison method.FindingsAmong the 66 participants (36 AA and 30 White), 25 (38%) described experiences with male partner reproductive coercion. Narratives provided accounts of contraceptive sabotage, verbal pressure to promote pregnancy and specific pregnancy outcomes, and potential motives behind these behaviors. AA women in the sample reported experiences of reproductive coercion more often than White women (53% and 20%, respectively). AA women were also more likely than White women to attribute a current or prior pregnancy to reproductive coercion. AA women identified relationship transiency and impending incarceration as potential motivations for men to secure a connection with a female partner via pregnancy.ConclusionsOur findings suggest that reproductive coercion may be a factor contributing to disparities in unintended pregnancy. More research, including population-level studies, is needed to determine the impact of reproductive coercion on unintended pregnancy and to understand the social and structural factors associated with pregnancy-promoting behaviors.     

A family planning clinic partner violence intervention to reduce risk associated with reproductive coercion

Background

This study examined the efficacy of a family-planning-clinic-based intervention to address intimate partner violence (IPV) and reproductive coercion.

Study Design

Four free-standing urban family planning clinics in Northern California were randomized to intervention (trained family planning counselors) or standard of care. English-speaking and Spanish-speaking females ages 16–29 years (N=906) completed audio computer-assisted surveys prior to a clinic visit and 12–24 weeks later (75% retention rate). Analyses included assessment of intervention effects on recent IPV, awareness of IPV services and reproductive coercion.

Results

Among women reporting past-3-months IPV at baseline, there was a 71% reduction in the odds of pregnancy coercion among participants in intervention clinics compared to participants in the control clinics that provided standard of care. Women in the intervention arm were more likely to report ending a relationship because the relationship was unhealthy or because they felt unsafe regardless of IPV status (adjusted odds ratio=1.63; 95% confidence interval=1.01–2.63).

Conclusions

Results of this pilot study suggest that this intervention may reduce the risk for reproductive coercion from abusive male partners among family planning clients and support such women to leave unsafe relationships.     

Exposure to Partner,Family, and Community Violence: Gang-Affiliated Latina Women and Risk of Unintended Pregnancy

While teen pregnancy rates appear to be declining in the USA overall, the rate of decline among young Latinas has been less than other ethnic groups. Among the myriad factors associated with elevated pregnancy rates, for Latina girls living in the inner city, exposure to gang and community violence may be a critical context for increased pregnancy risk. This study explores the relationship between gang involvement and reproductive health, and the pathways through which childhood, family, and relationship violence exposure may lead to unintended pregnancy. Interviews of 20 young adult Latinas with known gang involvement in Los Angeles County were audiotaped, transcribed, and coded for key themes related to violence exposure and reproductive health. Limited access to reproductive health care compounded by male partner sexual and pregnancy coercion, as well as physical and sexual violence, emerged in the interviews. Exposures to interparental domestic violence, childhood physical and sexual abuse, and gang violence were prominent and closely associated with unhealthy and abusive intimate relationships. Adverse childhood experiences and exposure to partner, family, and community violence impact the reproductive lives and choices of young Latina women in gangs. These findings may guide targeted pregnancy prevention efforts among urban gang-affiliated Latinas as well as encourage the integration of sexual violence prevention and reproductive health promotion within gang violence intervention programs.     

Community level effects of gender inequality on intimate partner violence and unintended pregnancy in Colombia: testing the feminist perspective

Violence against women, especially by intimate partners, is a serious public health problem that is associated with physical, reproductive, and mental health consequences. The effect of intimate partner violence on women's ability to control their fertility and the mechanisms through which these phenomena are related merit further investigation. Building on findings from a previous analysis in which a statistically significant relationship between intimate partner violence and unintended pregnancy in Colombia was found, this analysis examines the effect of gender inequality on this association using data from the 2000 Colombian Demographic and Health Survey. Specifically, the objective of this analysis is to explore whether gender inequality (as measured by women's autonomy, women's status, male patriarchal control, and intimate partner violence) in municipalities partially explains the association between intimate partner violence and unintended pregnancy in Colombia. Results of logistic regression analysis with multi-level data show that living in a municipality with high rates of male patriarchal control significantly increased women's odds of having an unintended pregnancy by almost four times. Also, living in a municipality with high rates of intimate partner violence increased one's odds of unintended pregnancy by more than 2.5 times, and non-abused women living in municipalities with high rates of intimate partner violence were at a significantly increased risk of unintended pregnancy. In addition, abused women living in a municipality with high personal female decision-making autonomy had more than a fourfold increased risk of having an unintended pregnancy. These findings demonstrate the need for reproductive health programs to target areas at particularly high risk for unintended pregnancy by reducing intimate partner violence and gender inequality.     

Associations of intimate partner violence with unintended pregnancy and pre-pregnancy contraceptive use in South Asia

ObjectiveTo assess associations of intimate partner violence (IPV) with pregnancy intendedness and pre-pregnancy contraceptive use among pregnant women in South Asia.Study designCross-sectional analyses were conducted using the most recent Demographic and Health Surveys from Bangladesh, India and Nepal for married, pregnant women aged 15–49 years who responded to IPV assessments specific to current marriage (N= 4738). Adjusted logistic and multinomial regression analyses were conducted with pooled data to assess associations of IPV ever (sexual only, physical only, sexual plus physical or none) with the outcomes of pregnancy intendedness (wanted, mistimed or unwanted) and pre-pregnancy contraceptive use (no, traditional or modern) for the current pregnancy.ResultsIPV was not associated with a mistimed or unwanted pregnancy. Sexual IPV was associated with pre-pregnancy modern contraceptive use (aOR=2.32, 95% CI=1.24, 4.36); sexual plus physical IPV was associated with pre-pregnancy traditional contraceptive use (aOR=1.85, 95% CI=1.12, 3.07). Post hoc analysis of reasons for pre-pregnancy contraceptive discontinuation revealed that women with a history of IPV, particularly sexual IPV, had higher prevalence of contraceptive failure (sexual only, 37.3%; sexual plus physical, 30.9%; physical only, 22.6%; no IPV, 13.6%).ConclusionPregnant women who experienced sexual IPV from husbands were more likely to use contraceptives pre-pregnancy but had no reduced risk unintended pregnancy, possibly due to higher rates of pre-pregnancy contraceptive failure among those with this history. These findings suggest that victims of sexual IPV are able to acquire and use family planning services but require more support to sustain effective contraceptive use.ImplicationsFamily planning services are reaching women affected by sexual IPV, and programs should be sensitive to this concern and the heightened vulnerability to contraceptive failure these women face. Long-acting reversible contraception could be beneficial by allowing women to have greater reproductive control in situations of compromised sexual autonomy.     

The Role of Intimate Partners in Women's Reasons for Seeking Abortion

PurposeThe literature on partners and abortion focuses on intimate partner violence (IPV) and risk for abortion, and partners' control of women's abortion decisions. This paper examines how partners figure in women's abortion decisions, and identifies factors associated with identifying partner as a reason (PAR) for abortion.MethodsBaseline data were used from the Turnaway Study, a longitudinal study among women (n = 954) seeking abortion at 30 U.S. facilities between 2008 and 2010. Mixed methods were used. Data were analyzed using thematic coding and logistic regression.FindingsNearly one third of women reported PAR for abortion. Three most common partner-related reasons were poor relationships, partners unable/unwilling to support a baby, and partner characteristics that made them undesirable to have a baby with. Eight percent who mentioned PAR identified having abusive partners as a reason for abortion. One woman in this subgroup reported being pressured by her partner to seek abortion, whereas others in this subgroup sought abortion to end abusive relationships or to avoid bringing children into abusive relationships. Factors associated with identifying PAR for seeking abortion included race, education, partner's pregnancy intentions, relationship with man involved in the pregnancy, and experience of IPV.ConclusionWomen make decisions to terminate pregnancies considering the quality of the relationship with and potential support they will receive from the man involved. Even women who report IPV, who may be vulnerable to coercion, report their motivation for the abortion is to end an abusive relationship, rather than coercion into abortion.     

How does intimate partner violence affect condom and oral contraceptive Use in the United States?: A systematic review of the literature

IntroductionIntimate partner violence (IPV) is estimated to affect 25% of adult women in the United States alone. IPV directly impacts women’s ability to use contraception, resulting in many of unintended pregnancies and STIs. This review examines the relationship between IPV and condom and oral contraceptive use within the United States at two levels: the female victim’s perspective on barriers to condom and oral contraceptive use, in conjunction with experiencing IPV (Aim 1) and the male perpetrator’s perspective regarding condom and oral contraceptive use (Aim 2).Study DesignWe systematically reviewed and synthesized all publications meeting the study criteria published since 1997. We aimed to categorize the results by emerging themes related to each study aim.ResultsWe identified 42 studies that met our inclusion criteria. We found 37 studies that addressed Aim 1. Within this we identified three themes: violence resulting in reduced condom or oral contraceptive use (n= 15); condom or oral contraceptive use negotiation (n= 15); which we further categorized as IPV due to condom or oral contraceptive request, perceived violence (or fear) of IPV resulting in decreased condom or oral contraceptive use, and sexual relationship power imbalances decreasing the ability to use condoms or oral contraceptives; and reproductive coercion (n= 7). We found 5 studies that addressed Aim 2. Most studies were cross-sectional, limiting the ability to determine causality between IPV and condom or oral contraceptive use; however, most studies did find a positive relationship between IPV and decreased condom or oral contraceptive use.ConclusionsQuantitative, qualitative, and mixed methods research has demonstrated the linkages between female IPV victimization/male IPV perpetration and condom or oral contraceptive use. However, additional qualitative and longitudinal research is needed to improve the understanding of dynamics in relationships with IPV and determine causality between IPV, intermediate variables (e.g., contraceptive use negotiation, sexual relationship power dynamics, reproductive coercion), and condom and oral contraceptive use. Assessing the relationship between IPV and reproductive coercion may elucidate barriers to contraceptive use as well as opportunities for interventions to increase contraceptive use (such as forms of contraception with less partner influence) and reduce IPV and reproductive coercion.     

Risk factors for intimate partner violence initiation and persistence among high psychosocial risk Asian and Pacific Islander women in intact relationships

PurposeThe present study identifies risk factors for intimate partner violence (IPV) initiation and persistence over three years in a high psychosocial risk Asian American and Pacific Islander (AAPI) sample of women with children living in Hawaii.MethodsWe included 378 women in a 3-year relationship with the same partner who reported IPV experiences at baseline and 3 years later. Baseline risk factors included characteristics of each woman, her partner, and their relationship. Bivariate and multivariate regression models were conducted to assess the influence of risk factors on the likelihood of experiencing IPV initiation and persistence.FindingsOf women who experienced no physical violence at baseline, 43% reported IPV initiation. Of women who did experience physical violence at baseline, 57% reported IPV persistence. Being unemployed and reporting poor mental health at baseline are important risk factors for experiencing IPV initiation. Reporting frequent physical violence at baseline increases the likelihood of experiencing IPV persistence. Asian women were significantly less likely to report IPV persistence than other groups of women.ConclusionsOur study indicates that among a high psychosocial risk sample of AAPI women there are different risk factors for IPV initiation and persistence. Future prevention and screening efforts may need to focus on these risk factors.     

Partner violence victimization and unintended pregnancy in Latina and Asian American women: Analysis using structural equation modeling

Intimate partner violence (IPV) is a pervasive public health problem in the U.S., affecting nearly one in every three women over their lifetimes. Using structural equation modeling, we evaluated the association between IPV and unintended pregnancy, mediated by condom use and perceived spousal/partner support among Latina and Asian women. Data came from the 2002–2003 National Latino and Asian American Study (NLAAS). The analysis was restricted to married or cohabiting female respondents aged 18+ years (n = 1,595). Dependent variables included unintended pregnancy, condom use, and perceived partner support. Independent variables included physical abuse or threats by current partner and primary decision-maker. Weighted least squares was used to fit path models to data comprising dichotomous and ordinal variables. More than 13% of women reported IPV during their relationship with their partner/spouse. Abused women were twice as likely as non-abused women to have had an unintended pregnancy. This association was partially mediated by perceived partner support. Condom use had a positive, but non-significant association with unintended pregnancy, and IPV had a negative, but non-significant association with condom use. Results highlight the importance of IPV screening for minority women. Efforts to combine family planning and violence prevention services may help reduce unintended pregnancy.     

Unwanted pregnancy,pregnancy loss,and other risk factors for intimate partner violence in the Democratic Republic of the Congo

The Democratic Republic of the Congo (DRC) has one of the highest rates of violence against women in the world; however, few studies have focused on this issue. In this study, we assessed the interrelationship among intimate partner violence (IPV), unintended pregnancy, pregnancy loss, and other sociodemographic factors in the DRC. Our analyses were based on data from the DRC demographic and health survey, conducted from November 2013 to February 2014. We constructed generalized estimating equation models to analyze the data from a sample of 5,120 married women. Our results showed that having a husband or partner who exhibited controlling behaviors, women who justified wife-beating, having a mother who had experienced IPV, and having a husband or partner who consumed alcohol were positively associated with IPV, whereas decision-making autonomy among women was negatively associated with IPV. In the community, the proportion of women who had experienced IPV and that of those who had completed secondary or higher education were positively and negatively associated with any IPV type, respectively. In addition, emotional IPV and any IPV type were positively associated with pregnancy loss. Our results indicate the necessity of implementing programs targeting gender equality at both individual and community levels.     

Male reproductive control of women who have experienced intimate partner violence in the United States

Women who have experienced intimate partner violence (IPV) are consistently found to have poor sexual and reproductive health when compared to non-abused women, but the mechanisms through which such associations occur are inadequately defined. Through face-to-face, semi-structured in-depth interviews, we gathered full reproductive histories of 71 women aged 18–49 with a history of IPV recruited from a family planning clinic, an abortion clinic and a domestic violence shelter in the United States. A phenomenon which emerged among 53 respondents (74%) was male reproductive control which encompasses pregnancy-promoting behaviors as well as control and abuse during pregnancy in an attempt to influence the pregnancy outcome. Pregnancy promotion involves male partner attempts to impregnate a woman including verbal threats about getting her pregnant, unprotected forced sex, and contraceptive sabotage. Once pregnant, male partners resort to behaviors that threaten a woman if she does not do what he desires with the pregnancy. Reproductive control was present in violent as well as non-violent relationships. By assessing for male reproductive control among women seeking reproductive health services, including antenatal care, health care providers may be able to provide education, care, and counseling to help women protect their reproductive health and physical safety.     

Intimate Partner Violence Among Economically Disadvantaged Young Adult Women: Associations With Adolescent Risk-Taking and Pregnancy Experiences

CONTEXT: Intimate partner violence negatively impacts the health of substantial proportions of young women in economically disadvantaged communities, where sexual initiation, aggressive behaviors, unintended pregnancies and childbearing are common among adolescents. It is therefore important to assess how adolescent risk behaviors and pregnancy experiences are linked to such violence during young adulthood.
METHODS: Data from 526 participants in the Reach for Health Longitudinal Study who were surveyed during middle school (in 1995–1996 and 1996–1997) and at ages 22–25 (in 2005–2007) provided information on adolescent risk behaviors and pregnancy experiences, as well as experiences of intimate partner violence during young adulthood. Bivariate and multivariate analyses were conducted to identify correlates of intimate partner violence involvement.
RESULTS: As young adults, 29% of women reported having been victims of intimate partner violence in the past 12 months; 21% reported having perpetrated such violence. In multivariate analyses, victimization and perpetration in the last year are positively associated with aggressive behavior in middle school (odds ratios, 1.9 and 2.5, respectively), lifetime number of sex partners (1.3 for both) and having a history of unintended pregnancy or pregnancy problems (1.3 for both). Perpetration also is associated with early sexual initiation (0.5) and living with a partner (1.8).
CONCLUSIONS: It is important to consider women's pregnancy histories in programs aimed at preventing the adverse outcomes of relationship violence and in screening for partner violence in sexual and reproductive health services. Early intervention may help women develop the skills needed for resolving conflicts with peers and partners.     

Sexual Orientation Disparities in Experiences of Male-Perpetrated Intimate Partner Violence: A Focus on the Preconception and Perinatal Period

IntroductionCompared with their heterosexual counterparts, sexual minority women (SMW), especially those with male partners, are at increased risk for intimate partner violence (IPV). IPV has been linked to a variety of adverse maternal, infant, and child health outcomes. However, to date, no research has examined SMW's experiences of IPV in the context of pregnancy. This study explored whether SMW were more likely than exclusively heterosexual women with only male sexual partners (WSM) to report a variety of forms of IPV perpetrated by their male partner before or during pregnancy.MethodsData are from the National Longitudinal Study of Adolescent to Adult Health (Add Health). Our sample size ranged from 10,081 to 10,328 pregnancies, matched with their male pregnancy partner, reported by 3,828 to 3,873 women.ResultsLogistic regression results indicated that compared with heterosexual-WSM, mostly heterosexual women and heterosexual-women who have sex with women (WSW) were more likely to report any IPV, mostly heterosexual women were more likely to report an IPV-related injury, and heterosexual-WSW were more likely to report sexual assault.ConclusionsResults suggest that mostly heterosexual and heterosexual-WSW are at increased risk of experiencing multiple forms of IPV with their male pregnancy partners, highlighting the need for additional screening and prevention efforts to reduce IPV and its negative sequelae.     

Intimate Partner Violence,Depression, PTSD,and Use of Mental Health Resources Among Ethnically Diverse Black Women

This study examined exposure to violence and risk for lethality in intimate partner relationships as factors related to co-occurring MH problems and use of mental health (MH) resources among women of African descent. Black women with intimate partner violence (IPV) experiences (n?=?431) were recruited from primary care, prenatal or family planning clinics in the United States and the U.S. Virgin Islands. Severity of IPV was significantly associated with co-occurring MH problems, but was not associated with the use of MH resources among African-American women. Risk for lethality and co-occurring problems were also not significantly related to the use of resources. African Caribbean women with severe physical abuse experiences were significantly less likely to use resources. In contrast, severity of physical abuse was positively associated with the use of resources among Black women with mixed ethnicity. Severe IPV experiences are risk factors for co-occurring MH problems, which in turn, increases the need for MH services. However, Black women may not seek help for MH problems. Thus, social work practitioners in health care settings must thoroughly assess women for their IPV experiences and develop tailored treatment plans that address their abuse histories and MH needs.     

Prevalence and Associated Factors of Intimate Partner Violence Among Pregnant Women Attending Kisumu District Hospital, Kenya

To determine prevalence and factors associated with intimate partner violence (IPV) among pregnant women seeking antenatal care. This was a cross-sectional study conducted at Kisumu District Hospital, Kenya amongst randomly selected pregnant women. A structured questionnaire was used to collect data. Participants self-reported about their own IPV experience (lifetime, 12 months prior to and during index pregnancy) and associated risk factors. Data were analyzed using Epi-info. The mean age of the 300 participants was 23.7 years. One hundred and ten (37 %) of them experienced at least one form of IPV during pregnancy. Psychological violence was the most common (29 %), followed by sexual (12 %), and then physical (10 %). Women who experienced IPV during pregnancy were more likely to have witnessed maternal abuse in childhood (aOR 2.27, 95 % CI = 1.05–4.89), been in a polygamous union (aOR 2.48, 95 % CI = 1.06–5.8), been multiparous (aOR 1.94, 95 % CI = 1.01–3.32) or had a partner who drank alcohol (aOR 2.32, 95 % CI = 1.21–4.45). Having a partner who attained tertiary education was protective against IPV (aOR 0.37, 95 % CI = 0.16–0.83). We found no association between HIV status and IPV. IPV is common among women seeking antenatal care at Kisumu District Hospital. Health care providers should be alerted to the possibility of IPV during pregnancy in women who witnessed maternal abuse in childhood, are multiparous, polygamous, have a partner who drinks alcohol or has low level education. Screening for IPV, support and referral is urgently needed to help reduce the burden experienced by pregnant women and their unborn babies.     

Intimate Partner Violence and HIV Risks: A Longitudinal Study of Men on Methadone

Whereas research has suggested that drug-involved men are at disproportionately high risk of engaging in transmission risk behaviors for HIV and of perpetrating intimate partner violence (IPV) against women, only a few cross-sectional studies have examined the relationship between IPV and HIV/sexually transmitted infection (STI) transmission risks among heterosexual, drug-involved men. This study builds on previous cross-sectional research by using a longitudinal design to examine the temporal relationships between perpetration of IPV and different HIV/STI transmission risks among a random sample of 356 men on methadone assessed at baseline (wave 1), 6 months (wave 2), and 12 months (wave 3). The findings indicate that (1) perpetration of IPV in the past 6 months at wave 1 was associated with having more than one intimate partner, buying sex, and sexual coercion at subsequent waves and that (2) noncondom use, injecting drugs, and sexual coercion at wave 1 were associated with subsequent IPV. The temporal relationships between perpetration of IPV and HIV risks found in this study underscore the need for HIV prevention interventions targeting men on methadone to consider IPV and HIV risks as cooccurring problems.