Considering abortion made her feel guilty. Her boyfriend made it worse: “What kind of human being are you?” he taunted.
Elizabeth Miller, director of adolescent and young adult medicine at the UPMC Children’s Hospital of Pittsburgh, was the first to identify and study this form of domestic abuse she called reproductive coercion — when a man or a woman tries to overrule a partner’s choice about a pregnancy.
Not to be confused with rape, the sexual relationship is consensual, and there may be no physical abuse. Reproductive coercion, Miller says, is about domination and power. “Everything from ‘Honey, we’re going to have beautiful babies together,’ to yanking out IUDs,” she says. The intent could be to make it harder for a partner to leave the relationship or simply a way to exert control. The means could be birth control sabotage, taking control of the pregnancy outcome, or lying about one’s fertility.
Yet, Miller says, “If someone isn’t hitting them, victims may hesitate to recognize pregnancy control as a form of abuse.” And most do not seek help.
“I never told anyone what happened,” the Los Angeles woman recounts. “I thought he had the right to do that; he was my boyfriend.” Like many others in this situation, she grew up in a family where abuse was normalized, plus she was financially dependent on her partner.
“I don’t think I’ll ever get over it,” she says today, asking not to be identified to protect her daughter. Still, she found the courage to leave her partner in 2012 before her daughter was born and went to live in a homeless shelter.
Miller’s first research on reproductive coercion was published in 2010 in the journal Contraception. She found that 1 in 4 women, ages 16 to 29, at family planning clinics had encountered it and further, that it was an important and overlooked factor in unintended pregnancies.
Miller was met with disbelief when the study came out. “This really happens?” she was asked. Contrary to prevailing notions of pregnant teens lacking contraceptive knowledge or being careless, researchers asking different questions found that men were flushing birth control pills down the toilet or forcing partners to get abortions.
Sometimes both partners use coercive tactics against each other.
R.M.M. (through a Spanish translator, she asked to be identified by initials only) was 18 when she moved to California from Mexico to wed in 2006. She desperately wanted children and her husband didn’t, insisting that she take birth control pills. R.M.M. stopped taking the pills secretly, however, and became pregnant. “I loved him and I thought that he would change when the baby was born.” But he remained indifferent during her pregnancy and after the baby arrived.
“He told me that if I got pregnant again, he would leave me and not help me or the baby financially,” she said. Afraid of being alone in a new country where she didn’t speak the language, R.M.M. went back to using birth control.
Studies since Miller’s suggest that reproductive coercion is a bigger problem for teens and the more vulnerable population seen at free or low-cost clinics than it is in the general population.
A 2019 study in Obstetrics & Gynecology found that 1 in 8 sexually active high school girls at eight California health centers had experienced reproductive coercion over a three-month period. The researchers identified them through a series of questions about their sexual activity during that time.
For instance, did anyone try to take birth control pills away from them? Say they would have a baby with someone else if they didn’t get pregnant? Broken a condom on purpose during sex?
“We’ve talked about [reproductive coercion] for a long time without having a name on it,” notes Karen Trister Grace, a nurse-midwife and researcher at Johns Hopkins School of Public Health.
Getting a handle on how often this happens is challenging because existing studies measure different samples, says Grace, who conducted a systematic review of the research on reproductive coercion.
A 2019 study in BMJ examining nine differently collected reports of reproductive coercion between 2010 and 2017 found that one-quarter of women and teen girls receiving sexual and reproductive health services said they experienced it.
Only a handful of studies include data on men. From 2010 to 2012, the National Intimate Partner and Sexual Violence Survey found that male respondents experienced reproductive coercion slightly more often than women at a 9.7 percent rate compared with 8.4 percent of women.
Men are more likely to report that a partner tried to entrap them through pregnancy against their wishes. Their partners lied about being infertile or using contraceptives, for example. Among women, men refusing to wear condoms was the most frequent coercion tactic.
Reproductive coercion is more prevalent for Black, multiracial, and Latina women, too. The reasons are systemic and structural rather than racial or cultural, says Virginia Duplessis, associate director of health at Futures Without Violence in San Francisco. “It’s about who has access to power and resources — health care, a car, a credit card.”
Both maternal and infant health outcomes suffer if a pregnancy is unwanted, Duplessis adds. Prenatal care may be neglected. The woman may drink or smoke more during pregnancy. The mother is at higher risk for mental health problems or she can contract a sexually transmitted infection if a man refuses to use condoms.
In 2013, the American College of Obstetricians and Gynecologists (ACOG) issued definitions and screening guidance for members on reproductive and sexual coercion.
Diane Horvath, a physician at a Baltimore OB/GYN clinic, screens all women at clinic appointments without their partners present. If an abortion is requested, for example, they are asked: “Whose decision is this? Is there anyone pressuring you to be here?” She looks for any nonverbal signs that a patient is reluctant to move forward, like not getting undressed.
A year ago, Horvath had a patient who confided she didn’t want an abortion but she was in a violent situation. Her partner was in the waiting room. Horvath and her team got her out the back door and to a shelter and started the process of getting her a restraining order. Asked if the patient would have had the abortion had she not probed, Horvath couldn’t say.
Horvath says reproductive coercion is underreported, and anecdotal accounts suggest that all forms of domestic violence have increased during the pandemic. Reproductive coercion, she says, “sets a trajectory for someone’s life.”
There is a strong association between reproductive coercion and physical violence, too. “Overall, health-care providers don’t do a good enough job [of screening]. We need to be doing it better,” Horvath maintains.
In addition to screening for reproductive coercion, ACOG recommends “harm-reduction” strategies. If a partner is forbidding birth control, for example, the physician can recommend an IUD where the string is hidden inside the cervix.
Rose Martinez’s health-care provider recommended Depo-Provera, a contraceptive injection, after her unwanted pregnancy. Only 18, Martinez wasn’t ready for a family but her husband wanted children and was furious, throwing out her birth control pills when he found them.
She was able to conceal the contraceptive injections from her husband for the next three years, but Depo-Provera is not recommended for longer than that. Martinez then turned to other forms of birth control that were less reliable. By the time she left him, she had experienced five unwanted pregnancies and had four children. The coercion was accompanied by physical violence as well at times.
Martinez and R.M.M. both credit the programs at Next Door Solutions to Domestic Violence in San Jose, Calif., for helping them understand they were being abused and for support that helped them move on. Both divorced now, they co-founded El Comite de Mujeres Fuertes (the Committee of Strong Women), an advisory group for Next Door Solutions serving women like them.
Preventing reproductive coercion is more effective than trying to undo the lifelong damage it causes, experts say. At Futures Without Violence, Duplessis assists in producing guides and training programs for women’s health providers to identify and counsel suspected victims. “Universal education about healthy relationships” is also needed, she says.
Now 31, the Los Angeles woman who was abused at 22 says she still feels judged and shamed by people who blame her for what happened. She entered the relationship, she says, but “it is not what I consented to.” That’s why she’s sharing her story now.
“So many people are unaware that [reproductive coercion] is a real thing,” she says. “I’m raising a girl, and I don’t want her ever to be in silence.”