Research Article, J Womens Health Issue Care Vol: 12 Issue: 4

The Impact of Reproductive Coercion on Reproductive Health and Outcomes among Women in Low and Middle-Income Countries: A Qualitative Evidence Synthesis

Jote Markos Cafo^1*, Desallegn Wirtu¹, Taka Girma² and Tahir Hasen¹

¹Department of Nursing, Wallaga University, Nekemte, Ethiopia

²Department of Public Health, Ambo University, Ambo, Ethiopia

*Corresponding Author:

Jote Markos Cafo
Department of Nursing,
Wallaga University,
Nekemte,
Ethiopia;
E-mail: lammiicaffoo@gmail.com

Received: 19 June, 2023; Manuscript No: JWHIC-23-103088;
Editor assigned: 22 June, 2023; PreQC No: JWHIC-23-103088 (PQ);
Reviewed: 06 July, 2023; QC No: JWHIC-23-103088;
Revised: 04 August, 2023; Manuscript No: JWHIC-23-103088 (R);
Published: 01 September, 2023; DOI: 10.4172/2325-9795.1000462

Citation: Cafo JM, Wirtu D, Girma T, Hasen T (2023) The Impact of Reproductive Coercion on Reproductive Health and Outcomes among Women in Low and Middle-Income Countries: A Qualitative Evidence Synthesis. J Womens Health Issue Care 12:5.

Abstract

Keywords: Reproductive coercion, Contraceptive sabotage, Pregnancy promotion, Reproductive outcomes

Introduction

Reproductive Coercion (RC) is the behaviour that restricts a person's ability to make decisions about their reproductive health in their desired way. A woman's autonomy in making reproductive decisions is being interfered with by this behaviour [1]. This can take the form of forced pregnancy, birth control sabotage (such as ripping off a condom or damaging it), ripping off a patch or throwing away oral contraceptives. Any behaviour that purposefully restricts another person's reproductive options is considered RC. Forcing someone to carry on or end a pregnancy, sabotaging contraception by removing or damaging condoms or throwing away oral contraceptives are just a few of the behaviours that the perpetrator exhibits. In order to maintain power and control in the relationship, RC is frequently a partner's demand to enforce their own reproductive intentions through physical, psychological, sexual and other means. These violent acts frequently make it difficult for women to exercise their autonomy and right to reproduction.

Reproductive coercion is subtype of intimate partner violence and it may explain the linkage between intimate partner violence and poor sexual and reproductive health outcomes. However, reproductive coercion can happen independent of physical and sexual violence forms. RC has been shown to be independently associated with risk for unintended pregnancy beyond the risk associated with intimate partner violence.

As evidenced from the systematic review by Grace and Anderson in the USA, RC affects women experiencing other forms of intimate partner violence, women of low socioeconomic status and women who are Latina, African American or multiracial. Reproductive coercion has been measured almost exclusively through the Reproductive Coercion Scale (RCS) developed and refined in the United States among clinic based adolescents and corroborated with adult samples.

The search question based on SPICE was what are the experiences of mothers with reproductive coercion and its effects on reproductive health outcome in low and middle-income countries? The aim of this qualitative evidence synthesis is to synthesise qualitative research evidences on reproductive age women’s experiences regarding reproductive coercion and its effects on reproductive health outcomes of the women.

Materials and Methods

This review was conducted in accordance with the cochrane Effective Practice and Organization of Care (EPOC) for qualitative evidence synthesis and follows the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). The review also follows a priori protocol of EPOC.

Search strategy

An initial limited search of PubMed was undertaken, followed by analysis of the text words contained in the title and abstract of the index terms used to describe the articles. The initial search informed the development of a search strategy which was tailored for each information source. For search of researches, databases including, MEDLINE (PubMed), APA PsycINFO, CINAHL and Web of Science for published researches and sources of grey literatures included core.ac.uk and Google Scholar. Search from different databases was depicted in appendix.

Selection criteria

Inclusion criteria included; human primary studies, English language, low and middle-income countries. Primary studies with a qualitative study design that focused on reproductive coercion and reproductive health outcome in low and middle income countries, studies of reproductive coercion and abuse perpetrated by an intimate partner, family members or in-law will be eligible for inclusion. Titles and abstracts and full texts will be screened by independent reviewers. Studies that only explored intimate partner or sexual violence were excluded. Following the search, all identified citations were collated and uploaded into Endnote v7 and duplicates removed. Titles and abstracts were screened by two independent reviewers (JM and TG) for assessment against the inclusion criteria for the review [2]. The full texts of selected studies were retrieved and assessed in detail against the inclusion criteria. Full-text studies that did not meet the inclusion criteria were excluded and reasons of exclusion are provided. Any disagreements that arose between the reviewers were resolved through discussion, and third reviewer was not needed.

Criteria for considering studies for this synthesis

Types of studies: We included primary studies with a qualitative study designs like ethnography, phenomenology, grounded theory that used qualitative methods for data collection focus group discussions, observation, individual interviews and data analysis methods of thematic analysis, grounded theory. Mixed methods studies will be included if it is feasible to extract data that was both collected and analysed with qualitative methods. We will include both published and unpublished studies that used English language starting from 2000 to the search date of September, 2022.

Topic of interest: Reproductive coercion defined as contraceptive sabotage, pregnancy coercion and control of pregnancy outcomes according to Marie Stopes. Behaviours that constitute reproductive coercion and abuse includes sabotaging another’s contraception, controlling a pregnancy outcome (forcing someone to have a termination or continue a pregnancy), forcing or pressuring someone into pregnancy and forcing someone to have sterilisation procedure.

Types of participants and settings: Studies that focus on the experiences and perceptions of women who have encountered reproductive coercion from low and middle income countries was included.

Data collection and analysis

We extracted data from included studies using a form designed for this synthesis and assessed methodological limitations using Critical Appraisal Skills Programme (CASP). We have used Thomas and Harden’s thematic analysis approach to analyse and synthesise the evidence and the GRADE-CERQual approach to assess confidence in review findings. We report our qualitative evidence synthesis based on the cochrane Effective Practice and Organisation of Care (EPOC) template for qualitative evidence synthesis.

Selection of studies

Citations identified through database searches was compiled into endnote, where duplicates were removed, then uploaded to covidence, where further duplicates were removed. All titles and abstracts of the identified studies were assessed independently by two reviewers (JM, TG) to evaluate eligibility for inclusion. We retrieved the full text of potentially relevant records and assessed them independently by two authors (JM, TG) for inclusion eligibility [3]. Any conflicts were resolved through discussion with a third author (TH).

Data extraction

Data were extracted from the selected studies using a word template designed specifically for this review by two independent reviewers (JM and TG) and checked by a third reviewers TH. The template included information about the study setting, sample characteristics (population), objectives, design, data collection and analysis methods, qualitative findings, supporting quotations, conclusions as well as any relevant table. We have identified the key concepts from individual qualitative studies. The data extracted included specific details about the populations, context in which the studies were done, study methods and the phenomena of interest relevant to our review question.

Assessment of the methodological limitations in included studies

An adaptation of the CASP tool was used to assess methodological limitations for each included study. Methodological limitations were assessed according to the following domains: Aims, methodology, research design, recruitment strategy, data collection, author reflexivity, ethical considerations, data analysis, statement of findings and research contribution. Any disagreements that arose between the reviewers were resolved through discussion and third reviewer was not needed. The result of methodological critical appraisal are reported in narrative form.

Data synthesis

A thematic synthesis approach described by Thomas and Harden was used to analyse and synthesise the data. Thematic synthesis is used to analyse qualitative data by generating meaning from people’s perspectives and experiences. We used a three-stage approach to analysis. First we conducted free line-by-line coding of the findings in primary studies, then organised free codes into common themes and developed ‘descriptive’ themes [4]. Finally, these themes were constructed into ‘analytical themes’, which were then interpreted to generate wider concepts and hypotheses. We have used EPPI reviewer software for line to line coding. Qualitative analysis was conducted using NVivo 12.

Assessing confidence in the findings

The final synthesized findings were graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a summary of findings.

Results

Study inclusion: From our database search we have identified 255 and 2 thesis from grey literature database. After removing the duplicates, 183 studies were left for screening of titles and abstracts. Out of these 183 studies, 167 articles were excluded: 87 articles used quantitative methods, 56 were excluded since they were from developed countries and 24 were systematic reviews. Finally, there were 16 articles eligible for inclusion in the review.

Characteristics of included studies: For analysis of the individual findings we have used three steps of synthesis. The first step is line by line reading and coding of the findings, organizations of these codes and forming descriptive themes and finally developed the analytical themes which we have included in this report.

Characteristics of included studies: All the studies were published after 2000 except the 2 unpublished studies. All the included studies were from low and middle income countries. Eleven (17-28) of the sixteen studies used pure qualitative study design while five of the studies have used mixed method design (29-31) with clear part of qualitative studies [5]. All of the studies included were from low and middle income countries.

Confidence in the Evidence from Reviews of Qualitative research (CERQual) includes four components for assessing how much confidence to place in findings from qualitative evidence syntheses methodological limitations, coherence, adequacy of data and relevance (Table 1). There are four levels of confidence in a review finding in the CERQual approach. High confidence papers are that article which is highly likely that the review finding is a reasonable representation of the phenomenon of interest. Moderate confidence it is likely that the review finding is a reasonable representation of the phenomenon of interest. Papers that labelled as low confidence is possible that the review finding is a reasonable representation of the phenomenon of interest [6]. Very low confidence papers did not clear whether the review finding is a reasonable representation of the phenomenon of interest.

Table 1: Summary of qualitative findings, CERQual assessment for women’s experiences of reproductive coercion and its effects on reproductive health and outcomes in low and middle-income countries: A qualitative evidence synthesis, 2022.

Findings from these studies were organized into major themes that originated from the analysis.

Theme I: Types of reproductive coercion experienced by the women

Women involved in the studies have experienced different forms of reproductive coercion including forced sex without condom, pregnancy promotion (most women explain as male consciously doing to impregnate them) and removing condom during sex, refusing to provide money for birth control. Pregnancy promotion happens to all reproductive age women, young women of 15-24 years have experienced pressured to have the first child while other women 25-49 years reported RC related to having more children or male children [7]. Studies revealed different forms of sexual coercion within marriage includes deception, verbal threats to obtain sex, forced penetrative sex.

Theme II: Birth control sabotage

Male partners’ behaviour around contraceptive control was described by the respondents across different forms of sabotage from condom refusal or purposeful misuse to overt sabotage of women’s contraceptive efforts. Participants describes as male totally dislike using barrier methods as the male partners expressed displeasure or indignation. Because of that they use it incorrectly even if they decided to use it. As some respondents reported, their partner has monitored their ovulatory cycles and sabotaged the contraceptive so that the women can get impregnated. Partners interfered with condom durability by poking holes in the condom and by hiding or disposing contraception flushing the pills down to the toilet.

He used condoms when we first started and then he would fight with me over it and he would just stop using condoms completely and did not care. He got me pregnant on purpose and then he wanted me to get an abortion.

A 16 year old female with a physically and verbally abusive partner who was 6 years older, she left the relationship and continued the pregnancy. Deception by male partner is one of the methods of sabotaging contraception. Partners’ lying about taking medicine that made them sterile, lying about having operation or they claim that they were unable to have children. Some men forced a woman to have a tubal ligation which the women considered as significant breach of her right.

After I had two kids and two miscarriages, he decided that it was time for me to use birth control. When he said birth control I figured he was just talking the pills or maybe the shot. He decided to force me into having my tubes tied. And that’s always been heartbreak to me.

Theme III: Pregnancy pressure

Pregnancy pressure has two forms promoting pregnancy in which case the male partner wants his female partner to be impregnated. Abusive partners used a range of emotionally coercive behaviours such as harassment, pressure and bullying to promote pregnancies that were unwanted by women. The male partners used emotional manipulation including threatening to end the relationship if women did not get pregnant. Women also reported being forced to have sex against their will in order to promote pregnancy. One way of manipulative tactic used by men to undermine women’s contraceptive self-efficacy is to question woman’s ability to know whether she wanted a pregnancy or not [8]. Pregnancy promotion was happened by denying women’s agency to choose the contraceptive methods to be used.

After the woman became pregnant, the abusive male partners prevent women from getting abortion services using different tactics. The tactics they used were withholding the money to pay for an abortion, sabotaging appointments for abortions including coming to clinic and breaking things up, so that the women leave the clinic before getting the service and withholding transportation and hindering her to get to the clinic. There were also partners who have threatened the women as he can kill her if she had an abortion for the pregnancy that have happened without her will.

He really wanted the baby he wouldn’t let me have, he always said, “If I find out you have an abortion,” you know what I mean, “I’m gonna kill you,” and so I really was forced into having my son. I didn’t want to; I was 18. I was real scared; I didn’t wanna have a baby. I just got into college on a full scholarship, I just found out, I wanted to go to college and didn’t want to have a baby but I was really scared. I was scared of him.

The second form is forcing termination of pregnancy or promoting the termination through verbal or emotional pressure. Among women who wanted to have the child, some described experiencing pressure and coercion to terminate a pregnancy. Even when men had not used contraception by themselves to avoid an unintended pregnancy, there were situations in which men demanded abortions once their partners became pregnant [9]. The abusive male partner threats to kill the woman and the baby if she did not terminate the pregnancy, women were also emotionally coerced to terminate a pregnancy, threatening to end the relationship accusing women of infidelity. Mother-in-laws pressured the woman to become pregnant by on-going and persistent verbal pressure to become pregnant, as well as threats and physical violence as a reaction to women’s attempts to prevent pregnancy.

Theme IV: Reproductive coercion and its consequences on reproductive health of the women

Women expressed as they considered the main goal of their partner’s reproductive coercion was to control their lives and remove their independent decision-making abilities.

Reproductive coercion that occurred with physical violence or RC that has happened independently have ultimately led to unintended pregnancy which affected disabled women than nondisabled women. Women who were forced to have an abortion service experienced severe trauma and depressive symptoms. Women were forced to have sex when they were not like to have sex because of different reasons like feeling sick. However, their partners did not listen to them and had forced sex sometimes involving other types of violence like beating the wife. Some women believed that their ability to get pregnant was used as a mechanism of control by their partners. Not only being pregnant but also having children makes the women to need the partners which directly or indirectly affected their reproductive lives [10]. Even though they know as their partner is causing reproductive coercion against them, some women are unable to resist their partner because they want to continue their education and pursue their career goals. From our synthesis we have found that women affected by RC were likely to have neonates having birth weight of less than 2500 grams.

Theme V: Other health impacts of reproductive coercion

Women who were victims of RC were experienced different health consequences including anger, distress and trauma. High levels of depressive and anxiety symptoms was reported by women that were exposed to sexual coercion in their marriage.

Discussion

The aim of this qualitative evidence synthesis was to show qualitative evidences regarding reproductive coercion and its reproductive health outcomes. Women have shared their experiences regarding reproductive coercion by their intimate partners. Ranges of tactics for RC were identified by the participants within structural themes of pregnancy promotion, contraceptive sabotage and abortion services prohibition and forced abortion. Impact of reproductive coercion on women is twofold as expressed in impact of reproductive health like unintended pregnancy, sexually transmitted diseases, inability to access contraception and abortion services when required and non-reproductive health consequences including trauma and anger [11]. We also found that reproductive coercion of different types were identified in our synthesis including pregnancy promotion, deception, verbal threats to obtain sex, forced penetrative sex. Our synthesis expanded the understanding related to pregnancy promotion in which the younger women were forced to have their first child from her husband and from her mother in-law. In a similar manner the women older than 25 years of age were forced to have additional child or in most cases they were pressurized to have male child.

Consistent with research from other LMIC contexts descriptions of RC from this synthesis highlighted the roles of both male intimate partners and in-laws in perpetrating RC, especially in promotion of pregnancy.

RC is one cause of unintended pregnancy and restricted reproductive autonomy and may be linked to outcomes such as unsafe abortion and unplanned forced childbearing. From this synthesis we have identified serious breach of human right and limitation of the reproductive autonomy of women as some men forced a woman to have a tubal ligation which the women considered as significant breach of her right [12]. From our synthesis we have found that women affected by RC were likely to have neonates having birth weight of less than 2500 grams. The literatures of intimate partner violence have demonstrated association between exposure to IPV and poor birth outcomes including low birth weight and it is reasonable as the reproductive coercion and birth weight are related with the same mechanism [13-15].

Conclusion

Reproductive coercion is a hidden and emergent public health issue recently identified as a phenomenon. This qualitative evidence synthesis explored the experiences of women on reproductive coercion and its impacts on reproductive health and outcome. A wide range of behaviours in which male partners engage in their efforts to control pregnancy and pregnancy outcomes of their female partners were also identified. The synthesis found common patterns of the different manifestations of reproductive coercion caused commonly by their intimate partners and in some cases by their mother-in-laws. The common types of reproductive coercion identified included contraceptive sabotage, pregnancy promotion and forced sex. Unintended pregnancy and forced termination of pregnancy were the reproductive outcome commonly happening to the women because of reproductive coercions.

Implications

Reproductive control is a heretofore under-explored process that can lead to negative reproductive health outcomes (unintended pregnancy; rapid, repeat pregnancy; sexually transmitted infections; repeat abortion; and women’s inability to meet their fertility goals) among women who have experienced RC. Interventions crafted around mitigating reproductive coercion could take the form of targeted assessment and prevention strategies in clinical settings. Assessment would allow providers to identify which women may need to hide their contraceptive method from their partners as hidden methods of birth control have the potential of improving the reproductive health outcomes of women who are experiencing reproductive coercion. Providers should conduct prenatal care and abortion counselling in private and should ask questions about whether anyone is pressuring the woman either to terminate or to continue the pregnancy.

Strength and Limitations

Our study has both limitations and strengths. There are a number of key strengths to our review. The use of the cochrane systematic review methodology was strength of the study. Due to the relatively recent coining of ‘reproductive coercion’ as a unique phenomenon, a broad search strategy enabled us to capture experiences of behaviours defined under different terminology including reproductive control, contraceptive sabotage and pregnancy promotion. We have used many search engines to include as much as possible primary studies. However, our review is not free of limitations, is possible that due to evolving language and scope of what is understood as reproductive coercion, some key relevant studies may not have been included. Based on the languages of the review authors, we were only able to include studies published in English. Another limitation is that women’s use of covert contraception may not necessarily be due to their partner’s desire for pregnancy but a range of other factors. This includes male sexual pleasure and dislike of side effects including weight gain and increased and irregular bleeding.

Recommendations

As the phenomenon of reproductive coercion is relatively new and most of the qualitative researches were conducted in United States and other developed nations the researchers from developing world must give attention to it. The available studies are mostly quantitative and the sensitive issue may not address well using quantitative, so attention has to be given for qualitative studies. Further research on help seeking and appropriate interventions should be conducted to help inform practice and ensure that women experiencing reproductive coercion are detected and provided appropriate support and service referrals.

Based on the findings of our synthesis we recommend the health care system to include reproductive coercion assessment in maternal health care services like antenatal care services. Health professionals should ensure that best practice screening methods are used to increase detection and early intervention of reproductive coercion.

Acknowledgment

We thank Dr. Desallegn Wirtu who provided directions in screening titles and for data extraction in this project.

Author’s Information

Review author reflexivity. Our review team has expertise in public health, reproductive health and nursing. From the onset of the study, we believed that reproductive coercion is a form of violence against women and that can affect reproductive health and outcome of the women.

We had continuous conversations with each other exploring our views on reproductive coercion and the findings, while holding each other accountable to stay truthful to the research principles of honesty, rigour and transparency.

Author Contributions

Conceptualization: Jote Markos, Dessalegn Wirtu

Data curation: Jote Markos, Teka Girma

Formal analysis: Jote Markos, Dessalegn Wirtu, Teka Girma, Tahir Hasen

Methodology: Jote Markos, Dessalegn Wirtu

Supervision: Desalegn Wirtu

Visualization: Jote Markos

Writing: Jote Markos

Writing: Jote Markos, Teka Girma

Funding

The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing Interests

None declared.

Patient and Public Involvement

Patients and/or the public were not involved in the design or conduct or reporting or dissemination plans of this research.

Patient Consent Publication

Not applicable.

 

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