Public Health Issue:
Due to the physical, economic, and emotional implications of pregnancy, many women either do not wish to ever become pregnant or wish to become pregnant only at a specified point in their life. In medical and public health-related discourse, pregnancies are often divided into categories reflecting the mother’s desire to become pregnant at the time of conception. Intended pregnancies are defined as occurring “about the right time or later than desired, the latter a reflection of infertility or difficulty of conception” while unintended pregnancies are divided into subcategories of mistimed (“occurring earlier than desired”) and unwanted (“occurring when a woman wanted no more children or no children at all”) (Aztlan-James, McLemore, & Taylor, 2017, p. 407). Populations and communities across the nation and the world are impacted by unintended pregnancy at different rates, often reflecting and contributing to discrimination, oppression, and unequal power dynamics. As such, despite a common narrative which places blame for unintended pregnancy squarely on young women, power imbalances at both the societal and interpersonal levels play a crucial role in shaping risk for unintended pregnancy.
Approximately 45% of pregnancies in the US are unintended, and such pregnancies are associated with adverse health outcomes for both the mother and infant. While the mother is put at greater risk for negative mental and physical health outcomes, she is also less likely to initiate adequate and timely prenatal care, is less likely to breastfeed, and is more likely to drink or smoke during pregnancy. Between 2008 and 2011, the prevalence of unintended pregnancy declined 25% among some of the groups most severely affected- including Hispanic women, women aged 15-17, those living between 100% and 199% of the federal poverty level, those who did not have a high school education, those who are cohabiting with their partners. The exact reasons for these declines are not known, but may be related to a change in the desire for pregnancy among women and a change in type and frequency of contraceptive use. For example, long-acting reversible contraception options (LARCs), such as IUDs, increased in prevalence from 4% to 12% between 2008 and 2012. Despite this progress, women who are Black, Hispanic, multiracial, or below the federal poverty level are still at a greater risk for unintended pregnancy in the United States (Finer & Zolna, 2016; Holliday et al., 2017).
Unintended Pregnancy: Risk Factors
The major risk factor for unintended pregnancy is inconsistent contraceptive use, and the social determinants of health which influence such use may be examined through the socio-ecological model. At the individual level, contraceptive choice/adherence, age, insurance type, and past sexual experiences are all associated with consistency and type of contraceptive use (Holliday et al., 2017). Socio-economic status (SES) also plays an important role given that women living at a lower SES are more likely to use condoms than hormonal methods of birth control compared to women from more economically advantaged backgrounds. Additionally, religion plays a unique role in sexual risk because religiosity is associated with delayed initiation of sexual activity, but also with decreased consistency of contraceptive use once a woman becomes sexually active (Kusunoki, Barber, Gatny, & Melendez, 2018). The importance of these individual risk factors (namely, contraceptive use and adherence) has created a powerful narrative which places a woman as the sole actress in managing her sexual activity as well as her risk for unintended pregnancy. However, despite this dominant narrative, these individual-level factors themselves are further influenced by the social and interpersonal distributions of power and the ways in which this balance (or lack thereof) manifests in a woman’s life.
Power Imbalances: Societal
At the societal level, discrimination plays a crucial role in risk for unintended pregnancy. According to Holliday et al., “women who experience moderate to high levels of social discrimination are more likely to have [an unintended pregnancy, and] racial discrimination is significantly associated with an increase in risk-taking, including risky sexual behaviors (e.g., unprotected sex, transactional sex, and concurrent sex partners)” (Holliday et al., 2017, p. 829). This reflects power-related processes of oppression and historical lack of power and privilege among these groups of women.
This history of oppression can be observed in the context of “gendered racial project[s]”, which Barcellos describes as “the [ways] in which race and gender interact to structure social meanings, experiences, and inequities in ways that are so entrenched they often go unremarked” (Barcelos, 2018, p. 254). Barcelos argues that such projects both obscure and reinforce inequities under the guise of ‘colorblindness’. She cites the example of an intervention in an unnamed city targeting high birth rates among young Puerto Rican women, and criticizes the creation of a deterministic and homogeneous ‘Latino culture narrative’ as well as the ways in which an ideology of colorblindness was used to justify the “uncritical promotion of LARCs…” which were presented as race-neutral despite the history of “forced and coerced contraception aimed at low-income, racialized young women” (Barcelos, 2018, p. 260). Although there is a need for public health interventions targeting unintended pregnancy, it is crucial to address the historical oppression of women of color when creating such interventions in order to avoid perpetuating the racism and sexism which have plagued past public health projects. Furthermore, only by addressing the systematic oppression and power imbalances experienced by women of marginalized identities can the public health community work to address the upstream causes of high rates of unintended pregnancy in a culturally relevant manner.
Power Imbalances: Interpersonal
At the interpersonal level, the influence of male partners plays a crucial role in a woman’s risk for unintended pregnancy, which is also a reflection of power dynamics and historical oppression. Some relationship characteristics such as age and length of relationship are associated with contraceptive use (or lack thereof). For example, young women with older partners are less likely to use contraception, especially condoms. Additionally, condom use decreases and hormonal birth control use increases as relationships become more serious and sex becomes more frequent (Kusunoki et al., 2018).
Interpersonal influences on contraceptive use also include intimate partner violence (IPV), which has long been associated with unintended pregnancy risk. IPV can take a variety of forms including mental, physical, and sexual abuse. Based on data regarding physical IPV in Michigan, Kusunoli et al. found that “approximately one-third of women experienced some form of violence by an intimate partner in their lifetime, with over 70% of women’s violent experiences first occurring before age 25” (Kusunoki et al., 2018, p. 1016). Physical IPV has been found to be “a dynamic and strong predictor of contraceptive use, method type, and consistency of condom use” (Kusunoki et al., 2018, p. 1016). Kusunoli et al. found that a history of physical violence in a current relationship was associated with less condom use and more reliance on withdrawal. They also found that dual method use (using both a condom and hormonal birth control) and condom use (for women who primarily relied on condoms for birth control) were particularly low when women had recently experienced physical violence and in women with a history of violence in prior relationships (Kusunoki et al., 2018).
Another manifestation of abuse which overlaps with IPV is reproductive coercion, which involves “pregnancy coercion (e.g., using threats to promote a pregnancy) and active manipulation of condoms and hormonal contraception to promote a pregnancy (e.g., breaking condoms on purpose, flushing birth control pills down the toilet)” (Holliday et al., 2017, p. 829). Reproductive coercion is very common, especially among women at family planning clinics and women of color (Holliday et al., 2017). In a cross-sectional survey of women at family planning clinics in Northern California, Miller et al. found that pregnancy coercion and birth control sabotage were experienced by 1 in 5 and 1 in 7 women, respectively. IPV and reproductive coercion often overlap, so it is crucial that providers are able to recognize the signs of abuse and refer women to appropriate violence-support services. The high prevalence of reproductive coercion also points to the importance of ‘invisible’ forms of birth control such as the injection and IUD, in order to protect women who are abusive relationships from unintended pregnancy (Miller et al., 2010).
It has been proposed that women in abusive relationships are less likely to use contraceptives due to “compromised decision-making regarding, or limited ability to enact, contraceptive use and family planning, including fear of condom negotiation” (Miller et al., 2010, p. 316). Thus, “women’s lack of control over her reproductive health…[is] a critical mechanism underlying abused women’s elevated risk for unintended pregnancy” (Miller et al., 2010, p. 316). This lack of control reflects both historical and modern power-related processes such as oppression and unequal power dynamics.
Conclusion:
Despite a common narrative that women should be in complete control over their reproductive health, unintended pregnancy is a complex public health issue which is deeply rooted in oppression and power imbalances. While contraceptive use and adherence are crucial factors in understanding differential rates of unintended pregnancy, these factors themselves are shaped by the lived experiences of women and are based in the power dynamics that women experience. Such power dynamics can be seen at the societal level in systematic oppression and institutional bias, and is evident in the tragic history of racially motivated sterilization campaigns. Power imbalances are also evident at the interpersonal level with respect to the relationship between a woman and her sexual partner(s). In order for the field of public health to address unintended pregnancy, it is crucial to examine the issue from a social justice perspective and to critique the existing norms and structures which have created severe power imbalances with dramatic downstream consequences on health outcomes.
References
Aztlan-James, E. A., McLemore, M., & Taylor, D. (2017). Multiple Unintended Pregnancies in U.S. Women: A Systematic Review. Women’s Health Issues, 27(4), 407–413. https://doi.org/10.1016/j.whi.2017.02.002
Barcelos, C. (2018). Culture, Contraception, and Colorblindess: Youth Sexual Health Promotion as a Gendered Racial Project. Gender & Society, 32(2), 252–273. https://doi.org/10.1177/0891243217745314
Finer, L. B., & Zolna, M. R. (2016). Declines in Unintended Pregnancy in the United States, 2008–2011. New England Journal of Medicine, 374(9), 843–852. https://doi.org/10.1056/NEJMsa1506575
Holliday, C. N., McCauley, H. L., Silverman, J. G., Ricci, E., Decker, M. R., Tancredi, D. J., … Miller, E. (2017). Racial/Ethnic Differences in Women’s Experiences of Reproductive Coercion, Intimate Partner Violence, and Unintended Pregnancy. Journal of Women’s Health, 26(8), 828–835. https://doi.org/10.1089/jwh.2016.5996
Kusunoki, Y., Barber, J. S., Gatny, H. H., & Melendez, R. (2018). Physical Intimate Partner Violence and Contraceptive Behaviors Among Young Women. Journal of Women’s Health, 27(8), 1016–1025. https://doi.org/10.1089/jwh.2016.6246
Miller, E., Decker, M. R., McCauley, H. L., Tancredi, D. J., Levenson, R. R., Waldman, J., … Silverman, J. G. (2010). Pregnancy coercion, intimate partner violence and unintended pregnancy. Contraception, 81(4), 316–322. https://doi.org/10.1016/j.contraception.2009.12.004