Reproductive Control Reported By Up To 25% Of Women

Becky McCall

January 08, 2019

Interference with women's reproductive autonomy, including controlling contraception as well as decisions over pregnancy and abortion, is reported by 1 in 4 women attending sexual health clinics, according to a recent literature review.

Reproductive control comprises a wide range of behaviours, from coercion to become pregnant to forced abortion of a wanted pregnancy. It may be perpetrated against women by intimate partners, the wider family, or as part of organised criminal activity including the pimp-prostitute relationship and sex trafficking.

One of the latest methods to be reported, from a study published in 2017, involves contraceptive sabotage where so-called 'stealthing' occurs. This is when a man deliberately interferes with the agreed use of contraception by surreptitiously removing a condom during sex.

Hidden Issue

The research was carried out by Prof Sam Rowlands, from Bournemouth University, an expert in community sexual and reproductive health, and Dr Susan Walker, a specialist in contraception and sexual health, from Anglia Ruskin University, Chelmsford. The study is published in this quarter's edition of BMJ Sexual & Reproductive Health.

"The key concern is that it can be a hidden issue unless clinicians are aware of reproductive control and looking out for it," stressed Prof Rowlands in an interview with Medscape News UK. "We call it reproductive control rather than coercion. It's about having control over much of that person's life, and in particular reproduction, which includes contraception, or access to health services, among other things."

In the paper, the authors stress that, “healthcare professionals need to ask specific questions about it [reproductive control]” and they add that, “screening for reproductive control should take place in maternity, sexual and reproductive health and abortion services and in general practice settings.”

Reproductive Control Wider Than Reproductive Coercion

The narrative review builds on prior reviews from 2010 and 2015 and updates the available evidence to 2017. It widens the spectrum of activities involved to include family pressure and criminal behaviour, sex trafficking, and exploitation.

Prof Rowlands emphasised that he and his co-author prefer the term 'reproductive control' to 'reproductive coercion', a term that was first described in the 2010 review. "Coercion tends to relate to using force whereas control is having an influence over someone's life, dominating a person, and often isolates a victim." The authors define reproductive control over women as external and exerted by others, not to be confused with methods of fertility control where women make their own decisions. Reproductive control of women by others comprises a wide range of behaviours, from persuasion to pressure such as emotional blackmail, societal or family expectations, through to threats of, or actual physical violence.

A Quarter of Women of Reproductive Age Report Reproductive Control

Up to a quarter of women of reproductive age attending sexual and reproductive health services reported having experienced reproductive control. A negative association was found between reproductive control and autonomous decision-making around contraception and sexual behaviour. 

Other findings of note include that younger women, and black and racial minority women in the US, were particularly vulnerable. In addition, in some cultures, the wider family, and older female relatives in particular, may have control over reproductive decision-making that is endorsed by their societies. "We found evidence of wider family including in-laws getting involved in reproductive control, particularly in Asian families living in South Asia. They were found to control women by proxy through their sons."

Reproductive control was found to decrease the odds of contraceptive use at last vaginal sex, and women who had recently experienced reproductive control were found to be more likely to request tests for pregnancy and sexually transmitted infections (STIs). They also sought emergency contraception more frequently.

Control could manifest as insistence on continuation of a pregnancy against the woman's wishes. Conversely, the review also found that induced (therapeutic) abortion may be coerced, or a woman may be assaulted with the intention of causing a miscarriage.

Sex trafficking was also found to be associated with reproductive control. "This control was related to the prevention of, or the forcing of women to have abortions," Prof Rowlands explained. "It relates to women made to prostitute themselves, and if they become pregnant, a controlling pimp might force them to have an abortion."

Reproductive control was more likely to occur in longer-term relationships than with casual partners, and it can happen without a woman really knowing about it, noted Prof Rowlands. "If they're in a first relationship they might not be aware of it being abnormal."

The authors write that women's reactions to reproductive control included capitulation, seeking contraceptive methods that can be used covertly, or ending the relationship.

Uncovering Reproductive Control in Clinical Consultations

The challenge for healthcare professionals is how to find out about reproductive control and manage the situation, the authors say: "There are educational packages available to help professionals deal with it, but the difficulty is that women can be so deep in a situation that they are unaware of what is happening, and if they are aware then they might not admit to it or try to escape for fear of violence or because children are involved."

There are now screening questions for the detection of reproductive control and interventions that can assist in reducing its risks. "Women attending health services with escorts should, at some stage, be seen alone so that these sensitive issues can be raised and, if necessary, explored," said Prof Rowlands.

The study did not look at the male perpetrators, but productive control has links to a patriarchal society, remarked Prof Rowlands. "It's complex and we know it isn't an easy thing to tackle. It's vital to see the woman on her own, without exception, because there can be a lot of pressure from accompanying relatives or friends, especially if the accompanying person is the one doing the controlling."

COI: Prof Rowlands has declared no relevant disclosures.

Published in this quarter's edition of BMJ Sexual & Reproductive Health.

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