Raise awareness on contraceptive sabotage

Birth control sabotage — in which a partner deliberately pokes holes in condoms, destroys birth control pills, or tampers with the efficacy of a method — is not uncommon. In one study of family planning clinic patients, 15% of women experiencing physical violence also reported birth control sabotage.1 In another study among adolescent mothers on public assistance who experienced recent intimate partner violence, 66% experienced birth control sabotage by a dating partner.2

The American College of Obstetricians and Gynecologists (ACOG) has just issued a committee opinion calling for clinicians to routinely screen teens and women for sexual and reproductive coercion at annual exams, new patient visits, prenatal visits, and postpartum checks.3

The publication was prompted by work with Futures without Violence, an organization that works to end violence against women and children, says Eve Espey, MD, MPH. Espey, associate dean of students and professor in the Department of Obstetrics and Gynecology at the University of New Mexico in Albuquerque and chairperson of ACOG’s Committee on Health Care for Underserved Women, which issued the opinion.

Sabotaging a woman’s contraceptive method, pressuring her to become pregnant unwillingly, or forcing her to end or continue a pregnancy against her will are examples of reproductive coercion.1 Repeated pressure to have sex, forcing sex without a condom, and intentionally exposing a partner to sexually transmitted infections are examples of sexual coercion.1

Data indicates that unintended pregnancy occurs more commonly in abusive relationships, which suggests that victimized women face compromised decision-making regarding contraceptive use and family planning, including condom use.4-7

The first quantitative examination of the relationship between intimate partner violence, reproductive coercion, and unintended pregnancy was designed by researchers from University of California, Davis, Harvard School of Public Health in Boston, Futures Without Violence and Planned Parenthood Shasta Pacific in Concord, CA.1

Conducted between August 2008 and March 2009 at five reproductive health clinics in California, the study involved about 1,300 women ages 16-29 who responded to a survey about experiences with relationships and pregnancy.

About one in five women said they experienced pregnancy coercion, and 15% said they experienced birth control sabotage. More than half of the respondents (53%) said they had experienced physical or sexual violence from an intimate partner. About 33% of the women who reported partner violence also noted pregnancy coercion or birth control sabotage.1

One of the outcomes of the 2010 study was the development of a small, easy-to-conceal, wallet-sized safety cards in English and Spanish, says Rebecca Levenson, MA, study co-author and senior policy analyst at Futures Without Violence. The cards, cobranded by ACOG, provide information to help women make the connection between unhealthy relationships and reproductive health concerns such as unintended pregnancies. The safety cards also include self-administered questions for intimate partner violence and reproductive and sexual coercion, harm-reduction and safety planning strategies, and information about how to get help and resources. (See the resource at the end of this article for ordering information.) The card also can be used by providers to help have a dialogue with patients regarding potential violence issues, says Levenson.

Question women about sexual and reproductive coercion and informing them of community resources to maintain their safety, as well as develop personal strategies to preserve reproductive autonomy, says Espey. These strategies include using birth control methods that are less apparent to partners, such as the copper-T intrauterine device (ParaGard IUD, Teva North America, North Wales, PA), says Espey. The copper IUD is particularly well-suited for this scenario, Espey says. Some partners count menstrual bleeding days, so the levonorgestrel IUD (Mirena, Bayer HealthCare Pharmaceuticals, Wayne, NJ) could alert a partner to a change in menstruation, she notes. For extra protection, an IUD string may be cut short into the endocervical canal so that it is not palpable by the partner and can’t be pulled out, says Espey. Provide emergency contraceptive pills and advise women to put them into a plain envelope.

Create a safe and supportive environment for assessing and responding to reproductive and sexual coercion, the committee opinion advises. Practices should have a written policy and provide training to clinicians and employees on intimate partner violence and reproductive and sexual coercion, how to offer referrals, and how to establish relationships with women’s shelters and state health department violence prevention programs. Be sure there are private spaces to interview women without interruption and where their conversations cannot be overheard. Place a clearly stated policy in the reception area to help the staff maintain the normal experience of seeing the patient alone without a friend or family member.

“We [ACOG] have presented together with Futures without Violence at the ACOG annual meeting for the last couple of years and plan another joint session this year to raise consciousness and help develop approaches to patients,” states Espey.

References

  1. Miller E, Decker MR, McCauley H, Tancredi DJ, et al. Pregnancy coercion, intimate partner violence, and unintended pregnancy. Contraception 2010; 81(4):316-322.
  2. Raphael J. Teens having babies: the unexplored role of domestic violence. Prev Res 2005; 12:15-17.
  3. Committee opinion no. 554: reproductive and sexual coercion. Obstet Gynecol 2013; 121(2 Pt 1):411-415.
  4. Cripe SM, Sanchez SE, Perales MT, et al. Association of intimate partner physical and sexual violence with unintended pregnancy among pregnant women in Peru. Int J Gynaecol Obstet 2008; 100:104-108.
  5. Gao W, Paterson J, Carter S, et al. Intimate partner violence and unplanned pregnancy in the Pacific Islands Families Study. Int J Gynaecol Obstet 2007; 100:109-115.
  6. Pallitto C, O’Campo P. The relationship between intimate partner violence and unintended pregnancy: analysis of a national sample from Colombia. Int Fam Plan Perspect 2004; 30:165-173.
  7. Silverman JG, Gupta J, Decker MR, et al. Intimate partner violence and unwanted pregnancy, miscarriage, induced abortion, and stillbirth among a national sample of Bangladeshi women. Int J Obstet Gynaecol 2007; 114:1,246-1,252.

Resources

  • The Reproductive Health Safety Card is available at the Futures Without Violence web site, www.futureswithoutviolence.org. Select “order Materials online,” “Health Care and Domestic Violence Materials,” “Patient Education Safety Cards,” then “Reproductive Health Safety Cards”. Providers can download the free file or place an order for 50-250 preprinted cards. The pre-printed cards are free, but a mailing charge is assessed.
  • Download a free PDF of Futures Without Violence’s guidebook, A guide to Addressing Intimate Partner Violence, Reproductive and Sexual Coercion. Follow the prompts as listed above to “Health Care and Domestic Violence Materials,” then select “Reproductive Health,” then the guideline’s title.