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. Author manuscript; available in PMC: 2024 Sep 10.
Published in final edited form as: Violence Against Women. 2023 Feb 9;30(9):2075–2095. doi: 10.1177/10778012231153372

Contraceptive Use Among Women Experiencing Intimate Partner Violence and Reproductive Coercion: The Moderating Role of PTSD and Depression

Jessica L Zemlak 1,2, Lea Marineau 2, Tiara C Willie 3, Helena Addison 4, Gabrielle Edwards 2, Trace Kershaw 5, Kamila A Alexander 2,6
PMCID: PMC11384232  NIHMSID: NIHMS2007088  PMID: 36762382

Abstract

Women experiencing reproductive coercion (RC) report more unintended pregnancies and mental health symptoms that can influence contraceptive use patterns. We examined associations between RC and contraceptive use among intimate partner violence (IPV) exposed women aged 18–35 (N = 283). We tested depression, post-traumatic stress disorder (PTSD), and co-morbid depression and PTSD as effect modifiers. Though no association was found between RC and contraception, PTSD significantly modified this relationship. Among Black women (n = 112), those reporting RC and either PTSD or comorbid PTSD and depression were less likely to use partner-independent contraception compared to those reporting RC without mental health symptoms. PTSD could be a barrier to contraceptive choice among this population.

Keywords: reproductive coercion, contraception, intimate partner violence

Introduction

Reproductive coercion (RC), a form of intimate partner violence (IPV), is consequential to women’s sexual and reproductive health. RC includes behaviors by sexual partners such as contraceptive sabotage (partner interference with contraception), pregnancy coercion (pressure by male partners to become pregnant), and/or controlling the outcome of a pregnancy (pressure to terminate or not terminate a pregnancy) and has been linked to unintended pregnancies (Grace & Anderson, 2018; Katz et al., 2017; Samankasikorn et al., 2019). RC affects 8–39% of women and can be experienced by multiple genders and people of different sexualities (Basile et al., 2019; Grace & Anderson, 2018). RC can occur independent of physical violence or sexual violence, but more than one-third of women reporting physical or sexual IPV also report experiencing RC (Clark et al., 2014). Women who experience IPV have twice the odds of experiencing unintended pregnancy while women experiencing both RC and IPV have three times the odds of experiencing unintended pregnancy (Samankasikorn et al., 2019). Women experiencing IPV often use contraceptive methods that are less detectable by a male partner; however, the contraceptive choices of women experiencing RC are not well-documented. Given the significant relationships between RC, IPV, and unintended pregnancy, it is critically important for research to address the need for safe, accessible, and partner-independent contraception among women (Holliday et al., 2017).

The Relationship of RC and IPV With Contraception

Partner-independent methods such as injections (depot medroxyprogesterone), sterilization, or intrauterine devices, allow women to covertly maintain control of their fertility (Fanslow et al., 2008; McCloskey et al., 2017; Zemlak et al., 2021). Partner-independent methods for contraception may be optimal strategies for women experiencing RC. In particular, women experiencing RC report that men control contraceptive use by limiting women’s access to reproductive health services, throwing away pills, or intentionally removing or damaging condoms (Alexander et al., 2016). Thus, women experiencing RC might be less likely to use contraception during heterosexual vaginal sexual intercourse and have lower feelings of control over contraceptive decision-making (Katz et al., 2017). Lower feelings of control over contraceptive choices among women can lead to negative health behaviors and outcomes such as low self-esteem, substance use, and sexually transmitted infections, all of which are exacerbated when facing mental health symptoms (Barber et al., 2019; Basile et al., 2019; Holliday et al., 2017).

Experiences of RC and IPV, Mental Health Symptoms, and Contraception

Depression and PTSD are well-known mental health consequences of IPV and RC (Alexander et al., 2019; Grace, Perrin, et al., 2020; McCauley, Falb, et al., 2014). In particular, it is well-established that women experiencing depression often choose lower efficacy contraceptive methods (Hall et al., 2013, 2015). More recent studies have examined the prevalence of depression and PTSD symptomatology among women experiencing RC. For example, among a sample of young Black women, depression and PTSD symptoms were prevalent when reporting RC and IPV (Alexander et al., 2019). Despite this growing body of research, limited research has investigated the moderating role of women’s mental health symptoms on the association between RC and contraceptive choices; and examining this relationship among non-Latina Black women (hereafter, Black women) is particularly important due to long-standing disparities in rates of unintended pregnancy, RC, and IPV when compared to White women.

Structural Racism, Violence, and Contraception

Structural racism signifies the sanctioning of laws, rules, and practices by government and economic systems that underpin inequities in medical care (Bailey et al., 2021). Complex pathways derived from structural racism can help explain the racial health inequities among Black women. Some of these pathways include economic and social deprivation, such as racial residential segregation, social trauma, and health-harming responses to discrimination (Gee & Ford, 2011; Krieger, 2012, 2016). Black women are at elevated risk for unintended pregnancies due to structural causes such as barriers to healthcare, racism, and contraceptive access (Barber et al., 2019; Brandi et al., 2018; Prather et al., 2018). For example, historical medical practices such as forced or coerced sterilization of Black women, may engender distrust in the health care system (Prather et al., 2018). Partner-independent contraceptive methods such as intrauterine devices have a contentious history because Black women were more frequently advised to restrict childbearing and utilize intrauterine devices when compared to white women (Dehlendorf et al., 2010).

The wage and health inequities experienced by Black women can also exacerbate some of the challenges associated with unintended pregnancies (Prather et al., 2018; Samankasikorn et al., 2019). The ability to time, space, delay, and control the timing of pregnancies allows women to complete education, and earn higher wages, thereby decreasing the likelihood of living in poverty (Finer & Sonfield, 2013). Socioeconomic disparities related to structural racism also influence the overrepresentation of Black women in publicly funded clinics which might influence access to quality reproductive health care (Prather et al., 2018). The complexities surrounding partner-independent contraceptive use for Black women might create vulnerabilities to unintended pregnancy. Thus, examining the intersection of RC and contraceptive method use among this population is critical in order to inform comprehensive reproductive healthcare.

Study Aims and Hypotheses

The goal of the present study was to extend extant research by examining associations between RC and contraceptive method use among IPV-exposed women; and explore depression and PTSD symptoms as moderators. The present study focused on cis-gender women who can experience pregnancy, and therefore are more likely to have a contraceptive need. In this study among women with lifetime exposure to IPV, we aimed to: (a) test RC as a predictor of contraceptive method use (hypothesis: we predict that RC will be associated with more partner-independent contraceptive use) and (b) test depression, PTSD, and comorbid depression and PTSD as moderators of this relationship (hypothesis: RC will lead to less use of partner-independent contraceptive methods for women with mental health symptoms compared to women without mental health symptoms). We also examined these relationships in a subsample of Black women given the disproportionate RC and unintended pregnancy inequities that exist for this population.

Materials and Methods

Design

Data from two-parent studies, (Her PrEP Her Way; N = 186 and BMore Her PrEP Her Way N = 97) were merged and analyzed. Each parent study had distinct goals but shared similar measures allowing data to be merged and strengthening the statistical power of this analysis. The resultant multi-ethnic and multi-racial analytic sample (N = 283) included cisgender, non-pregnant women, aged 18–35 who reported lifetime experience(s) of IPV. We selected participants with lifetime exposure to IPV to examine how RC experiences are associated with contraceptive use in this population. Women with overlapping IPV and RC experiences are far more likely to experience unintended pregnancies; thus, understanding contraceptive use among these women is vital (Grace, Decker, et al., 2020).

Participants and Procedures

The first parent study, Her PrEP Her Way was a prospective cohort study designed to examine the impact of IPV on women’s attitudes, intentions, and uptake of pre-exposure prophylaxis (PrEP). We conducted a cross-sectional analysis of data from timepoint one of this study. Women were eligible for the study based on the following criteria: (a) between the ages of 18 and 35; (b) reported at least one of the sexual risk indicators for PrEP candidacy in the past 6 months according to the 2014 CDC clinical summary guidelines (i.e., unprotected sex with a male partner, HIV-positive sexual partner, recent STI, two or more sexual partners, transactional sex); (c) spoke English and/or Spanish; and (d) reside in the State of Connecticut. Participants were recruited online and throughout the community. Data were collected between August 2017 and April 2018. Surveys were conducted in safe, private locations or online. All study procedures were approved by the Yale University IRB. Women were given $25 to thank them for their participation.

The second parent study—BMore Her PrEP Her Way was a cross-sectional study designed to assess the social and economic determinants of long-acting reversible contraception and PrEP uptake among women experiencing IPV. Cisgender women were eligible for participation in this study if they were: (a) aged 18–35; (b) able to complete a survey in English or Spanish on a device (tablet); (c) HIV negative; (d) engaged in unprotected sex with a man in the previous 12 months; and (e) responded yes to at least one item indicating past-year IPV on the HARK questionnaire (Humiliation, Afraid, Rape, Kick). Women enrolled in this study all lived in the Baltimore metropolitan area. Data were collected between February 2018 and July 2019. Women meeting inclusion criteria provided informed consent and completed one computer-assisted 60- to 90-min survey. Trained female research assistants assessed women’s comfort and followed a trigger protocol if women reported experiencing distress during survey data collection. All study materials and procedures were approved by the Johns Hopkins School of Medicine IRB. Women were given a $35 gift card to thank them for their participation.

Measures

Lifetime IPV.

We included participants in this analytic sample if they answered “yes” to at least one-lifetime experience of physical, sexual, or psychological IPV. Women were asked to report each type of violence experienced with her current or most recent (within one year) main partner and current or most recent (within one year) other sexual partners. We also asked whether the violence behaviors occurred in her lifetime by asking participants the following question: “Have you EVER experienced (IPV Type) by someone you were dating or going with (not including current main or current other partner).”

We used the Revised Conflicts Tactics Scale-2 to measure lifetime experiences of physical violence (Cronbach’s alpha .96) (Straus Hambly SL. Boney-McCoy S., 1996). Lifetime experiences of sexual violence were assessed with the Sexual Experiences Survey (Johnson et al., 2017) (Cronbach’s alpha .86). Lifetime experiences of psychological maltreatment were assessed with the Psychological Maltreatment of Women-Short Form (Tolman, 1999) (Cronbach’s alpha .98). Women who endorsed physical or sexual violence one or more times or psychological violence rarely, occasionally, frequently, or very frequently were coded as experiencing lifetime violence. The rationale for inclusion of a lifetime measure of violence is reflective of the dynamic nature of contraceptive decision-making across a woman’s life course (Downey et al., 2017). Previous IPV exposure, even if not ongoing, might have an association with current contraceptive use.

Lifetime RC.

We assessed lifetime RC using Reproductive Coercion Scale, a five-item dichotomous scale (McCauley et al., 2017). Three questions on this scale assessed pregnancy coercion such as “Has [your partner] ever told you not to use birth control.” We asked two questions to assess condom manipulation, for example, “Has [your partner] ever taken off the condom while you were having sex.” Women who endorsed any item with “yes” were considered to have experienced lifetime RC. The Cronbach’s alpha was .83.

Contraceptive Method Use.

Participants were asked which contraceptive method(s) they used in the six months prior to taking the survey. Contraceptive options on the survey included lay language such as “The Shot (Depo)” to describe the injection as well as color pictures of each method. We categorized contraceptive methods into two categories: partner-independent and partner-dependent. Partner-independent methods included birth control pills, birth control patch, vaginal ring, injection, intrauterine device, implant, emergency contraception, and sterilization/tubal ligation. We defined partner-independent contraceptive methods as methods women could use covertly without their partner’s knowledge or consent and if the method did not have to be used during sexual intercourse. Partner-dependent methods met one of two criteria: (a) required partner cooperation for use such as condoms, withdrawal, rhythm method, abstinence, or vasectomy or (b) controlled by women but potentially influenced by male partners during sexual intercourse such as diaphragms, cervical caps, or sponges.

If women reported not using a contraceptive method, we placed them in the partner-dependent method category because their IPV exposure reflects a sexual relationship with imbalanced power. While we recognize women might choose not to use contraception, the dynamics of relationships with IPV might influence contraceptive decisions (Bergmann & Stockman, 2015). Women using more than one method were categorized according to the contraceptive with the highest efficacy (Hatcher et al., 2018).

Mental Health Symptoms

Post-Traumatic Stress Disorder (PTSD)

We used the 17-item self-report PCL-5 to assess symptoms of PTSD in the previous month (Weathers et al., 2013). A total symptom score of 17–85 can be obtained from responses ranging from “not at all” to “extremely.” A binary variable was created with a cut point of 31 or above to signify symptoms consistent with PTSD. The PCL measure had a Cronbach’s alpha score of .97.

Depression

We assessed depression symptoms using the Center for Epidemiologic Studies of Depression (CES-D) scale, a 20-item self-report measure of past week depressive symptoms on a 4-point scale ranging from “rarely/none of the time (less than 1 day)” to “most or all of the time (5–7 days).” A binary (yes/no) indicator with a standard cut-off of ≥16 was created to indicate clinically significant depression symptoms (Radloff, 1977). Cronbach’s alpha measure of reliability was .84.

Covariates

We identified covariates in our final models from the contraceptive method use literature (Alexander et al., 2019; Bergmann & Stockman, 2015; Grace, Perrin, et al., 2020; Grace & Anderson, 2018; Maxwell et al., 2018). Income was dichotomized at the mean of greater or less than $25,000 annual household income per year. Education was dichotomized to some college/college graduate or high school/GED/less than high school. Number of pregnancies was dichotomized at the mean as two or more pregnancies or zero to one. Race/ethnicity is a categorical variable including non-Latina Black, non-Latina White, Latina, and non-Latina another racial group. We refer to women as Black but, in our survey, when we asked about race we included identification as Black or African American. Our analytic reference group is Black women. Respondents who endorsed “Non-Latina other Racial Group” identified as Asian, American Indian, Alaskan Native, or more than one race.

Analytic Plan

We used descriptive statistics among our full sample (N = 283) to examine sample characteristics related to lifetime experiences of RC. To test associations between participant characteristics and contraceptive method use, odds ratios and 95% confidence intervals were calculated using logistic regression. We created bivariate models (not shown) to consider variables that might confound associations as well as relevant variables from extant research (Alexander et al., 2019; Nathanson et al., 2012). We tested the association between lifetime experiences of RC and partner-independent contraception use through unadjusted and adjusted logistic regression models. We examined moderating effects by separately adding product terms (RC × PTSD, RC × depression, RC × comorbid PTSD & depression) to the final multivariable logistic regression model. Statistical significance was set at 0.05 for product terms. Among variables found to be moderators in the multivariable logistic regression models that included product terms, we stratified the sample by the moderating variable to determine the effect of lifetime experiences of RC on partner-independent contraception use in the presence and absence of the moderating variable. An unadjusted logistic regression model was used to perform the stratified analyses, allowing us to determine how the stratum-specific estimates differed. We performed a separate analysis among women in our sample who identified as Black (n = 112), using unadjusted and adjusted regression models as well as including product terms (RC × PTSD, RC × depression, RC × comorbid PTSD & depression) to the final multivariable logistic model.

Results

The distribution of demographic variables, mental health symptoms, other health variables, and contraceptive method use are reported in Table 1. Women’s mean age was 25.48 years (SD = 5.12). The majority of women in the sample self-identified as Non-Latina Black (39.6%) and Non-Latina White (33.2%). Latinas were 19.1% of the sample. There were no differences in age, education, sexual behavior, having children, having a medical provider, employment status, annual income, or contraceptive method use between women with lifetime RC experiences and women who never experienced RC. Women with lifetime RC experiences were less likely to report non-Latina White race and more likely to report non-Latina Black race and to report being Latina (39.8% vs. 24.6%, 45.9% vs. 34.8%, 23% vs 16.1%, respectively, P = .26). Women with lifetime experiences of RC were also more likely to report two or more sexual partners in the past 6 months (56.6% vs. 34.8%, P < .001), being pregnant one or more times without wanting to be (59% vs. 31.7%, P < .001), PTSD symptoms (55.3% vs. 27.8%, P < .001), depression symptoms (70.2% vs. 56%, P = .02), and comorbid PTSD and depression symptoms (50% vs. 22.1%, P < .001) than women who never experienced RC.

Table 1.

Demographic Characteristics of IPV Exposed Reproductive Aged Women (N = 283)

Total N = 283 Ever experienced RC (N = 122) Never experienced RC (N = 161) χ2/t-test
Sociodemographics
Age mean (SD) 25.48 (5.12) 26.09 (5.33) 25.01 (4.92) 0.083
Race 0.026
 Non-Latina White 94 (33.2%) 30 (24.6%) 64 (39.8%)
 Non-Latina Black 112 (39.6%) 56 (45.9%) 56 (34.8%)
 Non-Latina Other 23 (8.1%) 8 (6.6%) 15 (9.3%)
 Latina 54 (19.1%) 28 (23%) 26 (16.1%)
Education 0.138
 High school, GED, or less 109 (38.5%) 53 (43.4%) 56 (34.8%)
 Some college through graduate school 174 (61.5%) 69 (56.6%) l05 (65.2%)
Sexual history
Sexual behavior 0.163
 Men only 189 (66.8%) 76 (62.3%) 113 (70.2%)
 Women, mostly women, men and women, mostly men 94 (33.2%) 46 (37.7%) 48 (29.8%)
Number of sexual partners in past 6 months 0.001
 0–1 186 (65.7%) 67 (54.9%) 119 (73.9%)
 2 or more 97 (34.3%) 55 (45.1%) 42 (26.1%)
Relationship status <0.001
 Single 85 (30%) 50 (41%) 35 (21.7%)
 Married or dating 1 person 175 (61.8%) 58 (47.5%) 117 (72.7%)
 Dating more than 1 person 23 (8.1%) 14 (ll.5%) 9 (5.6%)
Health
Number of lifetime pregnancies <0.001
 0–1 158 (55.8%) 53 (43.4%) 105 (65.2%)
 2 or more 125 (44.2%) 69 (56.6%) 56 (34.8%)
Number of times pregnant and didn’t want to be <0.001
 Zero 160 (56.5%) 50 (41%) 110 (68.3%)
1 or more 123 (43.5%) 72 (59%) 51 (31.7%)
Has children 132 (46.6%) 65 (53.3%) 67 (41.6%) 0.051
Has medical provider 218 (83.2%) 94 (81.7%) l24 (84.4%) 0.278
Has health insurance 237 (90.1%) l03 (89.6%) l34 (90.5%) 0.031
Mental health
 PTSD (PCL score > = 31) 103 (39.9%) 63 (55.3%) 40 (27.8%) <0.001
 Depression (CES-D score > = 16) 159 (62.4%) 80 (70.2%) 79 (56%) 0.02
87 (34.5%) 56 (50%) 31 (22.1%) <0.001
 Comorbid PTSD and Depression
Socioeconomics
Employment status 0.828
 Full time or part time 151 (53.4%) 66 (54.1%) 85(52.8%)
 Unemployed 132 (46.6%) 56 (45.9%) 76 (47.2%)
Annual income 0.221
 Less than $25,000 141 (51.3%) 65 (55.6%) 76 (48.1%)
 $25,000 or more 134 (48.7%) 52 (44.4%) 83 (51.9%)
Contraceptive method use 0.115
 Partner-independent method 166 (59.5%) 65 (54.2%) 101 (63.5%)
 Partner-dependent method 113 (40.5%) 55 (45.8%) 58 (36.5%)
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Bold values are P ≤ 0.05.

Among our sample of women with lifetime IPV experiences, 73% reported physical violence, 41% reported sexual violence, and 98% reported psychological maltreatment. Among those reporting lifetime physical IPV, 49% reported experiencing RC with 37% experiencing contraceptive sabotage and 35% experiencing pregnancy coercion.

Most women (82%) in the sample reported using at least one contraceptive method in the previous 6 months. Nearly 60% of women used partner-independent contraception, most often combined oral contraceptive pills (25%) followed by the IUD (12%). Forty percent of women used partner-dependent contraception, most often male condoms (38%). Bivariate regressions (not shown) among the full sample revealed lower number of lifetime pregnancies (OR 0.56, 95% CI [0.34, 0.89]), lower annual income (OR 1.46, 95% CI [1.01, 2.37]), and less past 30-day PTSD symptoms (OR 0.53, 95% CI [0.32, 0.88]) were associated with partner-independent contraceptive methods.

The results of regression analyses are reported in Table 2. The associations between lifetime RC experience and the use of partner-independent contraception were not statistically significant in the unadjusted (Model 1) or adjusted (Model 2) models (Model 1: OR 0.679, 95% CI [0.42, 1.10]; Model 2: aOR 0.813, 95% CI [0.49, 1.36]).

Table 2.

Regression Analysis for Testing Moderation Effects of Mental Health Symptoms on RC and Partner-Independent Contraception among Full Sample of IPV Exposed Reproductive Aged Women

Variables Model 1
 Model 2
 Model 3
 Model 4
 Model 5
OR (95% CI) P AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P
Lifetime experiences of RC 0.679 [0.419, 1.100] .1 16 0.813 [0.487, 1.357] .428 2.143 [0.980, 4.685] .056 0.978 [0.385, 2.483] .962 1.447 [0.701, 2.984] .317
Annual household income greater than $25,000 – – 1.193 [0.661, 2.155] .558 1.111 [0.592, 2.086] .742 1.083 [0.577, 2.032] .804 1.035 [0.549, 1.949] .915
Education (some college) – – 1.114 [0.617, 2.011] .721 1.377 [0.733, 2.588] .32 1.326 [0.706, 2.491] .38 1.332 [0.707, 2.509] .375
Race – –
 Non-Latina Black – – Reference Reference Reference – Reference –
 Non-Latina White – – 1.395 [0.733, 2.654] .31 1.800 [0.895, 3.619] .099 1.449 [0.727, 2.888] .292 1.583 [0.785, 3.189] .199
 Latina 1.068 [0.523, 2.181] .857 1.258 [0.583, 2.715] .559 1.000 [0.476, 2.104] 1 1.134 [0.532, 2.417] .744
 Non-Latina Other 2.293 [0.820, 6.417] .1 14 2.416 [0.822, 7.096] .109 2.428 [0.793, 7.430] .12 2.553 [0.828, 7.870] .103
Two or more pregnancies – – 0.656 [0.388, 1.109] .1 15 0.621 [0.353, 1.093] .099 0.558 [0.319, 0.975] .041 0.615 [0.350, 1.081] .091
PTSD (PCL-5 score > = 31) – – – 1.188 [0.533, 2.647] .674
RC × PTSD – – – 0.204 [0.063, 0.665] .008
Depression (CES-D score ≥ 16) – – – 0.706 [0.337, 1.480] .357
RC × depression – – – 0.928 [0.296, 2.908] .898
Comorbid depression and PTSD 0.897 [0.380, 2.119] .804
RC × comorbid depression and PTSD 0.419 [0.128, 1.373] .151
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Model 1: unadjusted model; Model 2: adjusted for annual household income, education, race, number of lifetime pregnancies; Model 3: augments Model 2 by the inclusion of the interaction term RC × PTSD; Model 4: augments Model 3 by the inclusion of the interaction term RC × Depression; Model 5: augments Model 3 by the inclusion of the interaction term RC × Comorbid Depression and PTSD.

Bold values are P ≤ 0.05.

A moderation analysis was conducted to evaluate if the association of lifetime experiences of RC on contraceptive method use differed when clinically significant PTSD, depression, or comorbid PTSD and depression were present. In Table 2, Models 3, 4, and 5 augmented Model 2 by adding interaction terms (RC × PTSD, RC × depression, RC × comorbid PTSD & depression). We found that clinically significant PTSD moderated the relationship between RC and partner-independent contraception (Model 3; aOR 0.204, 95% CI [0.063, 0.665]). Depression (Model 4) and comorbid PTSD and depression (Model 5) were not found to be moderators (aOR 0.929, 95% CI [0.296, 2.908]; aOR 0.419 respectively, 95% CI [0.128, 1.373], respectively).

Analyses stratified by clinically significant PTSD scores, using unadjusted logistic regression models, among women who reported PTSD are reported in Table 3. We found lifetime experiences of RC were related to decreased odds of using partner-independent contraception (OR 0.405, 95% CI [0.18, 0.92]).

Table 3.

Exploring PTSD as a Modifier Among IPV Exposed Women Using Partner-Independent Contraception

Effect
Modifier Exposure Partner-independent contraception
No PTSD No RC 1
No PTSD RC 1.524 (0.741, 3.134)
PTSD No RC 1
PTSD RC 0.405 (0.179, 0.918)
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Bold values are P ≤ 0.05.

We performed a separate analysis to examine the relationship between lifetime experiences of RC and odds of partner-independent contraception use among Black women in the sample (n = 112). These results are reported in Table 4 and include unadjusted, adjusted, and moderation analyses. Similar to the full sample analyses, associations between lifetime experiences of RC and partner-independent contraception use did not reach statistical significance in the unadjusted (Model 1) or adjusted (Model 2) models (Model 1: OR 0.806, 95% CI [0.381, 1.707]; Model 2: 0.929, 95% CI [0.422, 2.044]). PTSD (Model 3) and comorbid PTSD and depression (Model 5) were found to moderate the relationship between RC and partner-independent contraception use among Black women (aOR 0.122, 95% CI [0.021, 0.699]; aOR 0.111, 95% CI [0.019, 0.657], respectively). Depression was not found to be a moderator (Model 4) (aOR 0.413, 95% CI [0.062, 2.732]).

Table 4.

Regression Sub-Analysis for Testing Moderation Effects of Mental Health Symptoms on RC and Partner-Independent Contraception of IPV Exposed Non-Latina Black Women

Model 1
 Model 2
 Model 3
 Model 4
 Model 5
Variables OR (95% CI) P AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P AOR (95% CI) P
Lifetime experiences of RC 0.806 [0.381, 1.707] .574 0.929 [0.422, 2.044] .855 2.863 [0.901, 9.101] .075 1.905 [0.393, 9.232] .424 2.698 [0.856, 8.504] .09
Annual household income greater than $25,000 – – 2.303 [0.796, 6.663] .124 1.682 [0.538, 5.257] .371 1.802 [0.588, 5.519] .303 1.854 [0.588, 5.849] .292
Education (some college) – – 0.686 [0.279, 1.686] .412 1.215 [0.447, 3.297] .703 0.861 [0.322, 2.306] .767 0.953 [0.351, 2.588] .924
Two or more pregnancies – – 1.034 [0.466, 2.293] .935 0.963 [0.398, 2.332] .933 0.764 [0.323, 1.808] .54 0.997 [0.407, 2.444] .994
PTSD (PCL score ≥31) – – – – 1.705 [0.500, 5.817] .394 – – – –
RC × PTSD – – – – 0.122 [0.021, 0.699] .018 – – – –
Depression (CES-D score ≤ 16) – – – – – – 0.750 [0.211, 2.665] .657 – –
RC × depression – – – – – – 0.413 [0.062, 2.732] .359 –
Comorbid depression and PTSD – – – – – – – – 2.099 [0.570, 7.724] .265
RC × comorbid depression and PTSD 0.111 [0.019, 0.657] .015
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Model 1: unadjusted model; Model 2: adjusted for annual household income, education, and number of lifetime pregnancies; Model 3: augments Model 2 by the inclusion of the interaction term RC × PTSD; Model 4: augments Model 2 by the inclusion of the interaction term RC × depression; Model 5: augments Model 2 by inclusion of the interaction term RC × comorbid depression and PTSD.

Bold values are P < 0.05.

Discussion

We examined relationships between RC and contraceptive method use among young women with lifetime IPV experiences, extending current knowledge about the consequences of RC on health behaviors. While there are previously well-documented relationships between experiences of IPV and/or RC reproductive and mental health morbidities (Alexander et al., 2019; Hall et al., 2013; McCauley et al., 2014; Stidham Hall et al., 2013) our research adds to the current body of literature by providing information about contraceptive method use among IPV exposed women experiencing RC. We also add knowledge to the emerging body of literature examining the consequences of trauma-related mental health morbidities on contraceptive use in this population at high risk for unintended pregnancy (Alexander et al., 2012).

Most participants in our sample used some form of contraception in the previous six months. Like previous studies among IPV-exposed women, participants in our study were more likely to use partner-independent contraception compared to women in the general population (Fanslow et al., 2008; McCloskey et al., 2017) Partner-independent contraceptive methods may be sought by women experiencing violence because they can be obtained and used without their partner’s knowledge; allowing women to maintain control over their fertility (Alexander et al., 2019; Nathanson et al., 2012). However, our results showed no overall significant relationship between RC and the use of independent contraceptive methods.

Prevalence of mental health symptoms among women in our sample were aligned with previous research (Nathanson et al., 2012). We found the relationship between RC and partner-independent contraception was moderated by PTSD for the full sample, and PTSD and comorbid PTSD and depression for Black women. While there is an established association between depression and use of lower efficacy contraceptive methods,(Hall et al., 2013; Stidham Hall et al., 2013) to our knowledge this is the first study to examine the associations between PTSD and contraceptive method type. The decreased use of partner-independent methods for women with PTSD and Black women with comorbid PTSD and depression shows that RC may be particularly impactful for those with mental health issues. Clinicians providing reproductive health services to IPV exposed women experiencing RC might consider comprehensive mental health symptom assessments inclusive of PTSD.

There is minimal research that explores differences between depression and PTSD regarding health-related behaviors. There is evidence that PTSD and depressive symptoms have effects on help-seeking behaviors among IPV-exposed women. IPV-exposed women with PTSD or depressive symptoms have less help-seeking behaviors with their health care providers (Stevens et al., 2017). Future studies examining associations between PTSD symptoms and contraceptive use among IPV- and RC-exposed women is warranted.

Among women experiencing IPV, mental health needs often go unmet because of barriers to healthcare related to affordability and accessibility. Additionally, a partner’s controlling behaviors and/or a woman’s feelings of shame and fear, can hinder help-seeking behaviors (Grace, 2016). Women experiencing IPV in conjunction with symptoms of PTSD and depression can have decreased self-efficacy when communicating with reproductive healthcare providers, creating barriers to using effective and partner-independent contraceptive methods (Stevens et al., 2017).

While we did not examine sequential pathways between PTSD and depression and contraceptive use, some research reveals a potential sequence of PTSD symptoms preceding depression (Ginzburg et al., 2010). Additional research, including longitudinal studies among women experiencing IPV and RC could examine the nature of symptom presentations as sequential and episodic or cyclical and persistent. This has implications for clinical care recommendations when caring for women experiencing trauma who need to preserve their reproductive autonomy using effective contraceptives. For example, if clinicians could anticipate that women presenting with symptoms of PTSD might evolve to depressive or comorbid symptoms, contraceptive counseling strategies could be modified accordingly to include close monitoring and interprofessional care coordination (Alvarez et al., 2017; Miller & Silverman, 2010).

Co-morbid depression and PTSD affected 31% of our multi-racial full study sample and 42% of Black women included in our sub-analysis sample. However, we found co-morbid depression and PTSD was only statistically significant moderator between RC and partner-independent contraceptive method use in our sub-analysis of Black women. Thus, this mental health co-morbidity on contraceptive method use is another potential mechanism for experiencing unintended pregnancy among Black women experiencing violence. Co-morbidity as a separate mental health state requires further research to determine its impact on contraceptive use specifically and health behaviors among women generally.

Historical and contemporary injustices against Black women such as coercive and abusive healthcare practices underpin reproductive health inequities. Forced sterilization as well as state policies to use implants for public benefits or to avoid incarceration shape Black women’s contraceptive use (Brandi et al., 2018). Additionally, health care providers use selective IPV screening methods that could be influenced by racial bias, rather than universally screening all women in their practice (Alvarez et al., 2017). Black women also report contraceptive coercion by healthcare providers to use longer-acting, partner-independent methods (Prather et al., 2018). Other structural barriers to contraceptive access that disproportionately affect Black women include the geographic locations of pharmacies with fewer and less efficacious contraceptive options available (Barber et al., 2019).

Thus, Black women experiencing RC and IPV may have limited contraceptive access influenced by unique structural vulnerabilities enacted by both political institutions and healthcare systems (Prather et al., 2018). These macro-level experiences of gendered racism, therefore, illustrate that multiple oppressions—that of being a woman and racially identifying as Black (among many other social positions) can underpin psychological distress and mental health morbidities (Thomas et al., 2008).

Limitations

These findings should be considered within the context of some limitations. The data from this research are cross-sectional; therefore, we were unable to assess temporality or causality of the associations between lifetime experiences of RC, past 6-month contraceptive method use, and mental health symptoms. However, prior research supports the relationship between IPV experiences and contraceptive method use behaviors (McCloskey et al., 2017; Zemlak et al., 2021). We explored mental health as a moderator versus a mediator in our analysis. In this study, we were interested in how associations between lifetime RC experience and contraceptive method use might differ with current clinically significant mental health symptoms. We did not assess for pregnancy intention in our sample. Therefore, it is possible that some of the women in our sample were not using contraception with the intention of becoming pregnant. Additionally, we recognize that the Conflict Tactics Scale-2 as a measure of physical violence is not inclusive of all behaviors that comprise IPV experiences. The limitations of the CTS-2 are well-documented, but we necessarily accounted for our desires to minimize participant burdens as well as the decades-long body of literature that has used it as a valid measure of IPV experiences (Jones et al., 2017). We were unable to determine if responses to mental health symptoms were associated with life-time trauma or contraceptive use behaviors women reported. For example, there remains a possibility that women could have experienced trauma unrelated to interpersonal dynamics that influenced their current depression and/or PTSD symptoms. It is also possible that cumulative trauma or childhood trauma could have an impact on mental health symptoms, impacting our results, but examining this was beyond the scope of the current study (Lang et al., 2008). The sample included women from urban areas in the Northeast and Mid-Atlantic regions of the United States, limiting generalizability to rural communities or other geographic regions. Our sample included cis-gender women who have sex with men, so our study is generalizable only to this group of women. Finally, research participants self-reported these data. Social desirability and social stigmas from their life experiences might have influenced responses. For example, mental health stigma may have caused some women to underreport symptoms of PTSD and/or depression.

Practice Recommendations

Using a lens of intersectionality to understand how Black women’s experiences of gendered racism can affect contraceptive use, based on our findings, we suggest provision of contraceptives should emphasize autonomy over fertility and integrate mental health services into reproductive healthcare as potential strategies to address reproductive inequities among Black women (Lewis et al., 2017; Moody & Lewis, 2019). Additionally, healthcare provider education about sociohistorical aspects of reproductive oppression and trauma experienced by Black women in the U.S. is paramount to comprehensive reproductive healthcare.

Health care providers can identify and provide holistic, harm-reduction-focused care services for women experiencing both RC and IPV.

The American College of Obstetricians and Gynecologists recommends health care providers screen for RC and IPV at discrete points of reproductive care: (a) when women establish care; (b) during annual wellness exams; and (c) during the first prenatal visit and each trimester of pregnancy including the postpartum visit (Committee Opinion No. 554: Reproductive and Sexual Coercion, 2013). These guidelines join other health professionals and government organizations in supporting universal screening practices that identify women experiencing IPV and RC. Using these guidelines, reproductive health providers can build trust and engage in safety planning with women while also meeting family planning goals. However, there is high variability in screening practices, particularly among women marginalized by structural vulnerabilities that constrain reproductive autonomy.

Conclusion

Supporting the reproductive autonomy of women experiencing RC and IPV is imperative. RC is a pervasive experience among women experiencing IPV that can lead to unintended pregnancies. While access to partner-dependent contraceptive methods are important option for women wishing to prevent pregnancy, women experiencing RC and IPV might benefit from greater access to partner-independent methods. Access can be impeded by accompanying trauma-related mental health symptoms that might go undetected. These research findings provide foundational data to inform future trauma-informed interventions designed to improve access to high-efficacy contraceptives among women experiencing RC and IPV.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Johns Hopkins Population Center and the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD) via R24HD042854. Dr. Alexander was supported by the NICHD Office of Women’s Health via K12HD085845. Funding for this research was also provided by the Yale University Center for Interdisciplinary Research on AIDS and the National Institute of Mental Health (NIMH) via P30-MH062294 and F31-MH113508. TCW was supported by the National Institute on Minority Health and Health Disparities (NIMHD) via K01MD015005. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Biographies

Jessica L. Zemlak began her work on this research while a doctoral candidate at Johns Hopkins University School of Nursing. She is currently an Assistant Professor at Marquette University College of Nursing. Dr. Zemlak’s program of research focuses on the physical and mental well-being of marginalized women. She has worked clinically as a Family and Psychiatric Nurse Practitioner among underserved communities in Milwaukee, WI.

Lea A. Marineau is a Ph.D. candidate at the Johns Hopkins University School of Nursing. Her research is focused on further understanding multi-level factors associated with recurrent violent injury. She has worked as an adult nurse practitioner in various settings caring for people from underserved communities, including a large trauma center in Baltimore, MD.

Tiara C. Willie is an Assistant Professor of Mental Health at the Johns Hopkins Bloomberg School of Public Health. Her research examines the etiology and health consequences of gender-based violence among populations at-risk or currently experiencing violence with an emphasis on HIV prevention.

Helena Addison is a PhD Candidate at the University of Pennsylvania School of Nursing, a Penn Presidential PhD Fellow, 2021 – 2023 Jonas Scholar, and a fellow in the SAMHSA Minority Fellowship Program at the ANA. Her research interests include mental health outcomes and health-seeking behaviors among individuals who have experienced trauma and various manifestations of structural racism, including incarceration. Her overall career goal is to engage in innovative and interdisciplinary research that propels scientific knowledge to promote mental health in disenfranchised populations, and more broadly, promote health equity and social justice.

Gabrielle Ann Edwards is a staff nurse in the Medical Intensive Care Unit at Christiana Care in Newark, DE.

Trace Kershaw is Professor and Chair of the Social and Behavioral Sciences Department at the Yales School of Public Health.

Kamila A. Alexander is an Associate Professor at Johns Hopkins School of Nursing. Her research focuses on prevention of sexual health outcome disparities and the complex roles that structural determinants such as intimate partner violence, societal gender expectations, and social networks play in the experience of intimate human relationships.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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