About a decade ago, Elizabeth Miller remembers seeing a certain teenage girl at a hospital clinic for adolescents in Boston. The patient thought she might be pregnant and asked for a test. When it came out negative, Miller started asking the standard questions, inquiring as to whether her patient wanted to be pregnant (she didn't) and whether she was using contraceptives (she wasn't). So Miller explained all of the birth-control options and, as she describes it, "sent her on her merry way with a brown bag of condoms." It was, by most measures, a pretty routine appointment.
Except that, two weeks later, the same patient was back at the hospital, in the emergency room after her partner pushed her down the stairs. "That was the wake-up call where I started thinking there might be a relationship between the two situations," says Miller, now an assistant professor of pediatrics at University of California, Davis. "She was coming in for a pregnancy test, not wanting to be pregnant, and not wanting to use birth control. And now I'm wondering what's going on for her, knowing she was in a physically and sexually violent relationship. I started wondering whether I needed to be asking her about why [she isn't using birth control] at that visit."
This month, Miller published a study in the journal Contraception detailing "reproductive coercion," when the male partner pressures the other, through verbal threats, physical aggression, or birth-control sabotage, to become pregnant. According to Miller's research, about a third of women reporting partner violence experienced reproductive coercion, as did 15 percent of women who had never reported violence.
Overall, rates of reproductive coercion among family-planning-clinic patients are suprisingly high: about one in five women report their partner having attempted to coerce them into pregnancy. "What we're seeing is that, in the larger scheme of violence against women and girls, it is another way to maintain control," says Miller, who studied 1,300 female patients culled from five family-planning clinics in Northern California. "You have guys telling their partners, 'I can do this because I'm in control' or 'I want to know that I can have you forever.' " This may help explain previous findings of higher rates of unintended pregnancies in relationships with partner violence.
The women in Miller's study were between 16 to 29; Miller will publish a study later in 2010 that finds similar numbers in demographics of older women. That said, younger women may have a more difficult time dealing with reproductive coercion: they have less experience in relationships, and, if they are minors, less access to doctors' appointments and emergency contraception. Particularly for teenagers in relationships with older men, the age difference "may have profound implications for perceived and actual reproductive choices for young adult women," Miller wrote in a 2007 paper on the same subject. "Such factors may also lead to fewer adolescents reporting such reproductive control as abusive, forced, or coercive." Put another way, teenage girls are at greater risk of not recognizing reproductive coercion as problematic, and allowing it to continue.
The research is particularly relevant in light of new data, released Tuesday morning, showing an increase in the teen pregnancy rate for the first time since the 1990s. Prior to these new numbers, which come from the Guttmacher Institute, researchers had known that the teen birth rate was increasing but were unsure whether that uptick in live births meant an increase in pregnancies or a decrease in abortions. The new data points to the latter as the explanation, since both the birth rate and abortion rate for 15- to 19-year-olds increased between 2005 and 2006 (by 3 and 1 percent, respectively).
Reproductive coercion among adolescents could be an overlooked factor behind the United States's unusually high, and now increasing, teen-pregnancy rate. "I think [reproductive coercion] is underreported and not thought about as often as it should be," says Leslie Walker, chief of adolescent medicine at Seattle Children's Hospital, who is not affiliated with either the Guttmacher or Contraception study.
The boundary between reproductive coercion and relationship violence—and whether there is, in fact, a boundary at all—is a difficult issue for health-care providers to address. In some cases, it can fit a spectrum of other abusive behaviors, from threatening to physical violence, that create an imbalance in a relationship's power dynamic. "Just like violence, it's a power thing," says Walker, who has seen patients whose boyfriends monitor their periods to ensure they're not taking Depo-Provera contraceptive shots (which often cause women to skip their period). "The man is taking away a woman's power to decide she's not going to have a child. Still, the line is unclear. Miller, for example, would be hesitant to categorize reproductive coercion as a form of partner violence, since many states have laws mandating reporting of such incidents. "I'm not sure that a young woman telling me that her partner flushed her birth control down the toilet necessitates me reporting that to the authorities," says Miller. In these situations, Miller has two concerns: getting the teenager onto a birth control she can hide from her partner (possibly Depo-Prevera shots, which last three months and are administered at a doctor's office) and building a relationship with the patient to explore the possibility of ending the relationship." What we hear from domestic-violence survivors is they don't like being told they have to leave a relationship," says Miller. "So instead of saying, 'This is an abusive relationship,' our counseling is very much focused on having them explain how this affects their health."
While reproductive coercion is not necessarily an indicator of an abusive relationship, Miller says the possibility should at least be in the back of a clinician's mind as a possible scenario. "If you have a patient coming in and saying, 'I don't want to be pregnant,' " says Miller, "It really behooves clinicians to offer her methods where she can control the outcome, whether her partner agrees or not." It's an opportunity to reduce teen pregnancy that, up until now, may have gone mostly unnoticed.