Materials and Methods

From January through May 2012 we administered a cross-sectional, anonymous survey approved by the institutional review board of Women and Infants Hospital of Rhode Island. We offered a 28-item, self-administered questionnaire to English-speaking women presenting for routine obstetrics and gynecology care at a large obstetrics and gynecology clinic. Women were excluded from the study if they were age <18 or >44 years, were non-English speaking, or presented for a surgical or subspecialty appointment. Women who self-identified as being unable to read English were also excluded from the study. A medical assistant escorted eligible women into an examination room alone, per usual clinic policy, and then gave them the paper-based questionnaire with written instructions for completion. A cover sheet attached to each survey clearly explained the voluntary nature of the study and emphasized that the decision to participate would not affect health care. Additionally, the cover sheet stated that the clinic providers would not be aware of who participated in the study. Each participant was given a resource card with contact information for local organizations serving abused women and for the study team. Each woman was asked to place her questionnaire in a sealed envelope in the examination room prior to her provider’s arrival regardless of whether or not she had chosen to complete the survey. After the visit, the medical assistant placed the sealed envelope in a locked collection box. Per institutional review board approval, informed consent was implied when patients voluntarily completed the survey.

To our knowledge, no validated questionnaires currently exist to assess reproductive coercion. Therefore, prior to beginning the main study, we conducted a pretest in which 14 women meeting the inclusion criteria described above were asked to complete a survey with questions assessing for reproductive coercion derived from the previously published study by Miller et al. Two study investigators (L.E.C. and V.G.) then queried these women in private about clarity and readability of all survey questions and solicited suggestions to improve understanding of the instrument.

We incorporated feedback from the pretest to create the final 28-question survey. The final survey included 10 demographic questions on age, relationship status, race and ethnicity, type of insurance, education level, pregnancy status, parity, and immigration status; 14 questions assessing reproductive coercion; 3 questions addressing intimate partner violence in relationships where reproductive coercion occurred, and 1 question asking respondents who had experienced reproductive coercion how their health care providers could have helped them navigate their situations. We further divided the questions assessing for reproductive coercion into questions addressing “pregnancy coercion” and “birth control sabotage.” The pregnancy coercion section employed the following 7 questions (questions 1-6 were derived from Miller et al ). Study participants were asked, “Has a husband, boyfriend, sexual partner, or someone you were dating ever: 1) told you not to use any birth control (like the pill, shot, ring, patch etc.); 2) said he would leave you if you did not get pregnant; 3) told you he would have a baby with someone else if you didn’t get pregnant; 4) hurt you physically because you did not agree to get pregnant; 5) tried to physically force you to become pregnant; 6) tried to pressure you with words, promises, or mean comments to become pregnant?” and 7) “Have you ever hidden birth control from a husband, boyfriend, sexual partner, or someone you were dating because you were afraid he would get upset with you for using it?” For each of these questions participants could check “yes,” “no,” “do not know,” or “decline to answer.” Pregnancy coercion was defined as a positive answer to any of the above items.

We assessed birth control sabotage was with 7 additional questions (questions 1-6 were derived from Miller et al ). Study participants were asked, “Has a husband, boyfriend, sexual partner, or someone you were dating ever: 1) taken off a condom while you were having sex so that you would get pregnant; 2) put holes in the condom so you would get pregnant; 3) broken a condom on purpose while you were having sex so you would get pregnant; 4) made you have sex without a condom so you would get pregnant; 5) taken off a condom after you agreed to use one; 6) taken your birth control (like pills) away from you so you would get pregnant; 7) kept you from going to the clinic to get birth control so you would get pregnant?” For each of these questions patients could check “yes,” “no,” “do not know,” or “decline to answer.” Birth control sabotage was defined as a positive answer to any of these questions. Reproductive coercion was defined as a positive answer to any of the 14 questions assessing pregnancy coercion and birth control sabotage. To obtain the most conservative estimate of reproductive coercion prevalence, we designated women who declined to answer or reported that they did not know if any of the above actions had occurred as not having experienced reproductive coercion.

If a woman answered in the affirmative to any of the 14 reproductive coercion questions listed above, she was directed within the survey to complete 3 additional questions assessing for intimate partner violence specifically in that relationship where reproductive coercion had occurred. The respondent was asked, “In that relationship, did your husband, boyfriend, sexual partner, or someone you were dating ever: 1) threaten or hurt you; 2) hit, kick, choke, or hurt you physically; 3) force you to do something sexually that you did not want to do?” These 3 questions are part of the intimate partner violence screening standard at our hospital (Women and Infants Hospital of Rhode Island) and are based on the Abuse Assessment Screen, a validated screening instrument. Intimate partner violence was defined as a positive answer to any of these questions. Additionally, respondents who answered affirmative to any of the 14 reproductive coercion questions were asked, “In that relationship, which of the following would have been helpful to you (check all that apply): 1) your doctor or health care provider asking you if your partner messed with your birth control; 2) your doctor or health care provider asking you if you partner pressured you to become pregnant; 3) your doctor or health care provider talking with you about ‘hidden’ types of birth control like the Depo shot or IUD?”

To be included in the final analysis, women had to answer at least 1 of the 14 reproductive coercion questions. Prior to beginning our study, we performed a sample size calculation that assumed a 19% prevalence of reproductive coercion based on the findings of Miller et al. We calculated needing 946 respondents to produce a 95% confidence interval (CI) for our estimated prevalence with a precision of ±2.5%. However, due to financial and time limitations, we ended recruitment after 641 respondents, which gave us a precision of ±3% for the 95% CI of our estimated prevalence. We calculated differences in demographic and reproductive characteristics between women identified as positive vs negative for reproductive coercion, pregnancy coercion, and birth control sabotage by employing Fisher exact test for categorical variables and t tests or Wilcoxon rank sum test for continuous variables. We used multiple logistic regression to estimate adjusted odds ratios and 95% CI for participant characteristics and reproductive coercion. Variables associated initially with reproductive coercion at P < .1 were included in the adjusted model. Similarly, we calculated differences in characteristics between women who screened positive for reproductive coercion and intimate partner violence vs positive for reproductive coercion only. All calculated P values were 2-sided and P < .05 was considered statistically significant. Analyses were performed using software (SAS, version 9.2; SAS Institute, Cary, NC).

Results

A total of 737 women were approached to participate in the study. Of these, 641 (87%) women completed at least 1 of the reproductive coercion questions. The average age of participants was 26 years ( Table 1 ). The study sample was diverse with 42% self-identified as being Latina, 16% as black, 27% as white, and 15% as another or mixed race. Twenty-eight percent reported being single or in a dating relationship, and 70% were married or in a committed relationship. Almost everyone reported ever being pregnant (94%) and over half (58%) were currently pregnant. Almost half of the sample (46%) had obtained an associates degree, attended some college, or received a 4-year college degree. The majority of women (74%) were covered under the Medicaid program. Because the survey was self-administered, missing data were present and ranged from 25% for gravidity and parity to 3% for relationship status.

As seen in Table 2 , 16% (95% CI, 13.2–18.9%) of women reported some form of reproductive coercion–pregnancy coercion, birth control sabotage, or both–within their lifetime. On univariable analysis, women who reported reproductive coercion compared with those who did not were more likely to be single or in a dating relationship ( P < .01); more likely to be black, multiracial, or “other” race ( P = .03); and more likely to be receiving free care from the hospital, have no insurance at all, or be unaware of their insurance status ( P = .05). Additionally, women who experienced reproductive coercion were less likely to report currently being pregnant ( P = .01). Findings were similar among the 11% of women who reported pregnancy coercion only (95% CI, 9.1–14.0%) and the 9% who reported birth control sabotage only (95% CI, 6.8–11.3%) (data not shown). In multiple logistic regression, after adjusting for relationship status, current pregnancy status, race and ethnicity, and insurance type, women who were single or in a dating relationship were 2 times more likely to report reproductive coercion than women in a committed relationship ( P < .01), and respondents uncertain of their relationship status were almost 6 times more likely to report reproductive coercion ( P < .01) ( Table 3 ). Additionally, those who were currently pregnant were less likely to report reproductive coercion ( P = .04).

Table 3

Demographic and reproductive characteristics associated with RC

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