March 31, 2011 — Summary of "A Family Planning Clinic Partner Violence Intervention To Reduce Risk Associated With Reproductive Coercion," Miller et al., Contraception, March 2011.
Women who visit family planning clinics report higher rates of intimate partner violence, or IPV, compared with their peers, pointing to a potential role for family planning clinics to provide intervention and serve as a bridge to aid women. Researchers led by Elizabeth Miller of the University of California-Davis Department of Pediatrics wrote that "unintended pregnancy, abortion and sexually transmitted infection are increasingly considered to be a result of male coercive behaviors related to sex and contraception." According to the researchers, "reproductive coercion" includes males pressuring their partners to become pregnant, sabotaging birth control and any manipulation that "results in women's compromised decision-making regarding, or limited ability to enact, the use of condom and other contraceptives."
Prior research shows that a clinic-based IPV assessment can be the first step to recognizing partner violence, and clinical interventions can facilitate awareness of reproductive coercion. Interventions may also help female victims overcome coercion and provide them with critical tools to reduce unintended pregnancy.
The study evaluated "family-planning-clinic-based intervention using a randomized controlled design, comparing changes in reports of reproductive coercion, IPV, awareness and utilization of IPV-related resources and relationship status among participants in intervention and control clinics," the researchers explained.
A team of community-based practitioners, IPV advocates and researchers developed the intervention, which was "an enhanced IPV screening" to educate clients about reproductive coercion and different forms of IPV, and how they can affect sexual health. Family planning counselors conducted the assessment based on responses to a question about why the patient was visiting the clinic. For example, if a patient sought to change her birth control method, the counselor would ask why she wanted to switch and about possible partner influences. If the counselor identified possible IPV or reproductive coercion, he or she would advise the patient on how to reduce the risk for IPV or reproductive coercion. The counselor also would direct the patient to local resources for help. Counselors also used a business-sized card designed specifically for the intervention to go over information with patients.
At control clinics, clients responded to two violence screening questions on an intake form: "Have you ever been hit, kicked, slapped or choked by your current or former partner?" and "Have you ever been forced to have sex against your will?"
Four free-standing urban family planning clinics were randomized into control and intervention arms. The researchers conducted a baseline survey and follow-up questionnaire at 12 to 24 weeks later. Participants were recruited between October 2008 and May 2009 and all follow-up surveys were completed by October 2009. All English- and Spanish-speaking women between ages 16 and 29 who were seeking care at a participating family planning clinic were eligible. Clinic staff referred 1,337 eligible female clients to research assistants, and 1,207 agreed to complete the baseline survey. About 75% of the women who agreed to participate completed the follow-up survey.
The researchers collected demographic information, including age, ethnicity, education level, nativity and relationship status, from participants. Intimate relationships were defined as "your sexual or dating relationships." Researchers used a series of four questions to assess pregnancy coercion. They assessed birth control sabotage with five questions.
Researchers also measured awareness and use of IPV services asking participants whether they were aware of eight local and national IPV and sexual assault resources and whether they had used the services in the prior three months. Finally, researchers asked participants about changes in their relationships between the baseline and follow-up survey and if the reason for the change was prompted by a feeling of being unsafe.
Seventy-six percent of all respondents were ages 24 or younger, and more than 75% identified themselves as non-white. The researchers noted that the four participating clinics served predominately minority patients; intervention clinics had more Hispanic patients, while control clinics had more African-American patients. About one-third of respondents described their current relationship status as single or dating more than one person.
At the baseline survey, 11% of participants at the intervention clinics reported birth control sabotage, compared with 7% at control clinics. Twenty-one percent of intervention clinic participants reported recent IPV compared with 14% of control clinic clients. Women who reported having experienced IPV in a relationship at the baseline survey had a 71% reduction in the odds for pregnancy coercion at the follow-up. Awareness and use of services increased among both groups at the follow-up survey, when more women in the intervention group also reported having stopped dating or going out with someone in the past three months.
"Exposure to this brief and sustainable intervention to reduce male partner reproductive coercion was associated with a large reduction in pregnancy coercion among women who had recently experienced IPV," the researchers wrote.
The study suggests that "intervention exposure was also associated with leaving a relationship because it was unhealthy or because the woman felt unsafe, perhaps partially explaining the observed reduction in reproductive coercion experiences." There was no significant difference between intervention and control participants in terms of awareness of services and utilization of services on follow-up. The study suggested the "utility of intervention that educates women about reproductive coercion and promotes harm reduction strategies," the researchers found. However, "[l]arger-scale and longer-term studies are necessary to assess the potential for this type of intervention to improve clinical outcomes, specifically unintended pregnancy," they added. The study's limitations included the small number of participants, the short follow-up interval, a lack of demographic variations and the fact that women who left relationships between the baseline and follow-up surveys were not asked if their actions were related to the intervention.
The researchers concluded that the "findings from this nonrepresentative sample from four family planning clinics in one Northern California region cannot be generalized to all family planning clinic clients. A larger cluster-randomized controlled trial with a greater number of clusters, more participants from geographically diverse clinics, and longer-term follow-up with assessment of clinical outcomes is needed."