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  The causes of unplanned pregnancy
By Ann Furedi

The following paper was given as part of a day of discussion for staff and students at Kent University Women's Studies Centre held in the Autumn Term 1997. The day was about reproductive choice and was organised by Ellie Lee, a student at Kent University and Co-Ordinator of Pro-Choice Forum.

Introduction

Despite modern methods of family planning, and widespread information about how to use it, unplanned pregnancy is one of the most common medical problems faced by sexually active women under 45. Abortion, the most usual solution to the problem of unplanned pregnancy, is the most common operation among women in the fertile age range.

It is impossible to calculate precisely just how many pregnancies each year are accidental. When medical sociologist, Anne Fleissig, asked a number of women who had given birth six weeks previously about whether their pregnancy was planned, she found that 31 per cent of them were not. She concluded in a paper subsequently published in the British Medical Journal that almost a third of births could be the consequence of accidental pregnancies. If this were the case it would mean 310 000 accidental pregnancies in Britain every year.

In fact, this is likely to be a conservative estimate. Because Anne Fleissig conducted her research into the circumstances in which women's new babies were conceived, her sample did not include women who had conceived but ended the pregnancy by an abortion. When these unplanned pregnancies are considered as well, it suggests the real extent of accidental pregnancy is even higher, perhaps as high as 50 per cent of all conceptions.

Defining unplanned pregnancy

It is extremely difficult to draw a clear line between those pregnancies that are planned and those that are unplanned.

It is difficult to arrange a pregnancy to order. The average fertile couple trying for a child may take three or four months to conceive, and many couples go through a stage where they are not exactly planning to have a child now, but at the same time they are not exactly doing everything in their power to prevent it either. Women who use the contraceptive pill are often advised to switch to a barrier method of contraception, such as a diaphragm or condom, three months before they intend to start 'trying' for a child. Barrier methods are inherently less effective and if the couple has difficulty using them, and happens to be highly fertile it is quite possible that the pregnancy intended for three months hence arrives sooner than planned. Technically this scenario could also count as an "unplanned pregnancy".

Other similar situations may arise. For example what about the situation where one partner wants a child, but the other is reluctant? A woman may assert her maternal ambitions by frequently 'forgetting' to take her contraceptive pill thereby becoming pregnant 'accidentally on purpose'. She may always insist that she conceived unintentionally, never admitting that she took chances that she would not have taken had she been committed to avoiding pregnancy. Men can just as easily manipulate things so that risk situations occur. He may 'forget' to buy condoms, insist if they have sex he will withdraw before ejaculation and then get 'carried away', or he may deliberately engineer situations where unprotected sex is likely. Sometimes these manoeuvres are quite conscious and deliberate, at other times they are unconscious and not even recognised by the people who perpetrate them.

An 'accidentally on purpose' pregnancy may even be the consequence of a woman's insecurity about her own fertility. The frequent discussions about infertility in newspapers, women's magazines and on television may lead some women to doubt their own ability to have a child when the time is right. If a woman who has never had a child frequently reads about the sub-fertility problems of others, and takes to heart the statistic that one couple in six experiences fertility problems, she may well suffer all manner of doubts and fears about her reproductive future. She may not want a child now but in the recesses of her subconscious mind she may be desperate to discover if she can. She may even develop an irrational belief that she is subfertile and be cavalier as to her contraception as a consequence. This may also lead to an 'accidentally on purpose' pregnancy.

It is also possible for accidental pregnancies to be disguised as deliberate conceptions. A woman may be embarrassed to admit that a pregnancy is accidental in case she is thought to be stupid, or it confers some kind of stigma on her future child. Many other women feel genuinely ambivalent about their pregnancy and are quite honestly unsure whether it was intended or 'just happened'.

Women face a great many social pressures to have children, and these pressures influence the way we think and feel about our fertility. A woman who confides to a friend that she is pregnant may be so overwhelmed with congratulations - particularly if she is perceived to be in a stable, long-term relationship - that it may be difficult to admit the pregnancy was neither planned, nor whole-heartedly welcomed. To declare in such circumstances that the state of affairs is all a big mistake may require a degree of boldness beyond that which the couple can summon. Once the pregnancy has been redefined publicly as a 'happy event', it may well become redefined in this way in the minds of the expecting couple.

In many cases however, probably the vast majority of cases, there is no doubt at all about the accidental character of a pregnancy. Women become pregnant in circumstances where they have absolutely no desire to conceive and have done absolutely everything possible to prevent conception.

A modern risk for all of us

Despite modern contraception, better provision of sex education, and greater scientific knowledge about human reproduction, a number of factors combine to place women today at just as great a risk of unplanned pregnancy (if not a greater risk) than women of our mothers or grandmothers generations. We probably have sex more often, we may have a greater number of partners during our lives and our expectations of sex are different. Whereas for earlier generations sex was linked to marriage and motherhood, it is now regarded by most of society as a legitimate form of recreational, rather than mainly procreational, activity. The very notion of unplanned pregnancy rests on the assumption that it is possible to 'plan pregnancy'. Whereas previous generations, who had sex without effective modern contraceptives, constantly feared pregnancy, in contrast we expect to enjoy sex without consequences.

The more times a woman has sex, the greater her chances of falling pregnant. This simple fact means that we may risk accidental pregnancies more than previous generations simply because our active sex life extends over a longer period of time than that of our parents and grandparents. At one end we start to form sexual relationships at an earlier age, and at the other we expect to enjoy an active sex life until well beyond the menopause.

Young girls today mature faster physically and emotionally and it is hardly surprising that they explore their sexuality at a younger age. When sociologist Michael Schofield investigated the sexual behaviour of young people in the early 1960s, he found that just two per cent of girls and six per cent of boys claimed to have experienced full sexual intercourse. By 1990, almost a third (31 per cent) of 16 year olds and 70 per cent of 19 year olds were claiming to have had full sexual intercourse. This means that more young women are having sex at a time when their fertility is particularly high. It is also the time when they may find it most difficult to obtain access to family planning services and to negotiate the use of contraception with an equally young, and perhaps equally inexperienced partner. Young women may feel unable to seek advice about the more effective methods of contraception, such as the pill, because they are worried about parents finding out - perhaps by discovering a pill packet, or as a consequence of a doctor's breach of confidentiality.

However, it would be wrong to see unplanned pregnancy as a problem only for young women. Public attention focuses on teenage pregnancies partly because they are ideal subjects for the sensational media stories and partly because they are a particularly vulnerable social group, but older women are also at risk.

It is no longer expected that women in their twenties should be either married and preparing to embark on family life or on the lookout for a husband. The twenty-somethings of the 1990s are likely to be continuing their education, forging careers, or simply enjoying a break between leaving their parents family life and starting their own. Even if a couple settles into a stable heterosexual relationship and achieves a secure income and a decent home, it is still considered normal and appropriate for them to defer children until their late twenties or early thirties. And, all the time that they are deferring a deliberate pregnancy they are at risk of an accidental one.

Whilst previous generations may have assumed that any pregnancy was wanted and deliberate so long as the couple were married, married couples today may have other plans which do not include children at all. Society in general still assumes that 'normal' women will want children at some time in their lives, but an increasing number of couples are deciding that their priorities lie elsewhere and parenthood is not for them.

It is no longer assumed that a married, childless couple are infertile. Recent research suggests that as many as 10 per cent of women over the age of 40 are childless through choice, rather than through infertility . Although, if a couple wish to remain childless and they are fertile, they may face considerable problems, particularly as they may not be able to obtain some of the most effective methods of contraception. Doctors are sometimes reluctant to sterilise couples who have no children regarding it as likely that they will change their mind and want a family at some time in the future. And many doctors are loathe to insert IUDs into childless women as the procedure can be more painful.

It is easy to forget that unplanned pregnancies are not just a problem for those who wish to remain childless. They can be just as great a problem to couples who already have planned and wanted children. Another addition to the family may bring about emotional and financial pressures that are damaging to the couple and their existing children. A woman struggling to cope with young children may find that organising her own contraception is the one job that drops from her busy agenda.

Women are at particular risk of accidental pregnancy shortly after the birth of a planned child, when they may be preoccupied with mothering and not yet settled into a new contraceptive regime. Fertility can return within a few months of childbirth, particularly if the new mother is not breastfeeding.

Similarly, a surprise pregnancy can be a particular nightmare for a woman approaching her menopause. We expect our sex lives to continue until well into old age, and while a woman's fertility level starts to decline from her mid-thirties, women can and do get pregnant right up until their menopause. There are many reasons why an unplanned pregnancy at this stage in life can seem disastrous. A couple may resent the thought of having to embark on another round of child-raising just when they were organising some time for themselves. The woman may be distressed by the knowledge that the child will have a far greater statistical risk of a genetic disability. The couple may worry that they are just 'too old' to cope with the stresses and strains of baby-care. Yet as long as they are having sex they are at risk - and their risk may be increased if they have relied on the pill for contraception and the woman has now been advised to change, perhaps because she smokes, to a new and unfamiliar method.

An added difficulty for an older women with an unexpected pregnancy is that she may mistake the absence of her periods for the start of menopausal symptoms and not identify the problem for months.

In conclusion accidental pregnancy is a potential problem for all fertile women who are sexually active. We live in an age when it is accepted that pregnancies are no longer events that just happen either by the 'grace of God' or by 'acts of nature'. Our lives are organised to incorporate sex for enjoyment and emotional satisfaction and it is seen as quite normal that we should wish to suppress our fertility. We expect to plan pregnancy just as we expect to be able to plan other aspects of our lives. Unfortunately keeping our fertility in check is far easier to say than to do.

Why accidental pregnancies happen

Contraceptive failure

Contraceptive failure is a significant cause of accidental pregnancy. Anne Fleissig found that over two thirds (69 per cent) of the women in her study who had become unintentionally pregnant claimed to have been using a method of contraception at the time they conceived. Other research has shown similar results. A study of 769 women requesting abortion in the NHS, conducted by David Bromham, chair of the faculty of Family Planning and Reproductive Health care of the Royal College of Obstetrician and Gynaecologists found that 68 per cent had conceived as a result of a failure of contraceptive method. A previous study, published in the British Journal of Family Planning, found that of 1 020 women referred for abortions, a fifth claimed to have been using the pill, one of the methods commonly regarded as the most effective.

A working party report on unplanned pregnancy by the Royal College of Obstetricians and Gynaecologists acknowledges that contraceptives let couples down, but they also draw attention to the fact that just as contraceptives are fallible, so are their users.

The success of a contraceptive method depends on the effectiveness of the method in itself and our ability to use it properly. No method of contraception prevents pregnancy unless it is used in the manner in which the manufacturers intended.

There are significant differences in the way that contraceptives are used in many study conditions. The is a big difference between a situation where study participants know that they are part of a trial, and are highly motivated to use a particular contraceptive and have been carefully instructed as to what to do, and the circumstances in which contraceptive methods are used in everyday life. This may account for the difference between the very low failure rates for contraceptives which are quoted by some contraceptive research centres and the manufacturers responsible for their production, and the much higher failure rates that are indicated by some of the studies mentioned above. It is clearly shown by the different results obtained in two different studies of the effectiveness of methods of contraception.

The most widely quoted study of the failure rates of contraceptives is known as the Oxford Family Planning Study. It was conducted by Martin Vessey in collaboration with the Family Planning Association, and published in 1982 in the Lancet.

Vessey calculated the number of women out of 100 who would become pregnant if they used the following methods of contraception for one year. The results were as follows:

Combined pill 0.3
Diaphragm 1.9
Condom 3.6
Spermicide alone 11.9
Periodic abstinence (natural methods) 15.5

However, these results are starkly different from those obtained from a more recent study of contraceptive failure rates in the USA, published in 1992.

The authors of this, equally reputable study found that the percentage of women who became pregnant within a year despite having expressed the intention to avoid pregnancy for at least a year was as follows:

Combined pill 8
Diaphragm 16
Condom 15
Spermicide alone 25
Periodic abstinence (natural methods) 26

How can this vast difference be explained? David Paintin, former editor of the British Journal of Obstetrics and Gynaecology and current Chair of the reproductive health information charity, Birth Control Trust argues that the difference may be explained by the methods used to select the sample of people studied. In a recent paper he explains that the couples studied by Vessey were 'over 25 years old, were in a long term relationship, were living in better than average socio-economic status and were willing from the late 1960s onwards to return every six months to be interviewed by a research assistant.' Paintin believes that the US study may reflect more accurately the effectiveness of contraceptive methods when used by average couples in normal conditions.

Contraception is not always easy to fit into a normal lifestyle, and this is particularly true of those methods that are used at the time of sex itself. Positioning a diaphragm in the right place so that it covers the cervix, while easy enough most of the time, can be tricky once the user has enjoyed a bottle of wine and is feeling rushed.

Even methods that can be dealt with in a methodical and routine fashion throw up problems of their own. With a diaphragm or a condom it is possible to check that the method is in situ, but there are no similar checks to make sure the pill is having the required effect. Even if a woman is sufficiently informed to know that severe stomach upsets may interrupt the pill's action, how is she to judge whether the attack of diarrhoea she had was severe enough to make a difference?

Contraceptive failure can be devastating. If a woman has taken a risk and had unprotected sex then she knows there is a possibility that she may be unlucky. However, a contraceptive failure can leave her feeling completely out of control of her life.

A contraceptive failure can leave the couple who experiences it insecure about future sex. If it happened once, then surely it can happen again. If possible, it is important to identify exactly what went wrong. Sometimes there is no apparent explanation, but often a reason can be found and locating it restores some degree of control to the couple with the problem pregnancy. At least they can try to avoid a repeat performance.

Myths and misconceptions

Failure to use a contraceptive properly does not imply that either partner is stupid or careless. Doctors often fail to spend the required amount of time carefully instructing people how to use their chosen method most effectively. Embarrassment often prevents people asking the necessary questions. Few people feel completely at ease talking to their doctor about sex, and we are often reluctant to reveal our own ignorance and so we avoid raising questions or problems if we think we should know the answer. This leaves people hanging on to a myriad of myths and half-truths about sex and contraception which can put them at risk.

Research by Britain's largest manufacturer of contraceptive pills, Schering Health Care Ltd, shows that women retain all manner of misconceptions about how to take the pill, such as which are the most dangerous pills to miss and what to do if a pill is forgotten. Interviewers found that on average a woman on the pill forgets to take it eight times a year. Most of the women questioned knew they had to do something when a pill was missed, but very few knew what the something was. Only one pill-user in ten was aware that missing just one pill could place them at risk of pregnancy and fewer than half knew that diarrhoea or stomach upsets could lessen the effectiveness of their contraceptive.

A woman should be able to have her contraceptive queries answered by one of several people. General practitioners and practice nurses, family planning doctors, pharmacists and help-lines run by organisations like the Family Planning Association and Brook Advisory Centres have information for the asking. Most of us however find it hard to voluntarily expose our ignorance, and it is easy for a woman, busy with the stresses of everyday life to push her concerns out of her mind.

It is often the case that we are unaware of the gaps in our knowledge and we hold on to misinformation not realising it to be false. Fertility is an extremely complex mechanism and it is easy to understand why there are so many confusions about it.

Lack of knowledge about contraceptive use is often understood as a problem for young people just discovering sex. There are countless reports identifying the need for better sex education in schools and more support for parents to help the explain 'the facts of life'. However, in some ways, it can be easier for young people to obtain knowledge because once the barrier of bravado has been broken down it is easier for them to admit that they are sexually inexperienced and do not know all the answers. An older woman who has been brought up to believe that 'there are some things one just does not discuss' is unlikely to feel sufficiently confident to discuss with her doctor the side-effects caused by her pills and so may just stop taking them.

Barrier methods raise enough modern etiquette problems to fill a book of their own. At exactly what stage of sex play does a woman mention that she has to insert your diaphragm or that she wants her partner to wear a condom? Who is expected to carry the condoms?

The answers are, of course, available in all manner of leaflets, booklets and magazine articles. We are instructed to make our contraceptive and prophylactic intentions known as soon as 'intimate relations' become a possibility, women are to be seen as sensible, not sluts, if they prepare for sex and take the contraceptive initiative. But life is not so clear cut and endless surveys show that even though a growing number of people carry condoms they often remain in packet. Just because we know we should use contraception does not mean we do.

Contraceptive availability

Even if their intentions are good, it is not possible for a couple to use contraception if they cannot obtain their favoured contraceptive when they need to use it. Access to contraceptive advice and supplies remains a problem for many couples.

Condoms are the most easily available of the various methods. Over the last ten years it has become easier to get hold of condoms. Not only are they sold in chemists and supermarkets but a growing number of machines are appearing in public toilets and in pubs, bars and clubs and colleges and even some enlightened work-places. However, we are still a long way away from the openness demonstrated in France where condom machines are to be found on busy streets.

Contraceptives methods which are only available on prescription can pose more of a problem for women. Even the most conscientious pill-user is likely to have experienced that moment of panic when she realises that she has lost or used up the spare packet of pills that she would have sworn was safely tucked away in the bathroom cabinet.

In principle it should be easy to obtain a prescription for the pill, or to have a diaphragm or an IUD fitted as almost all General Practitioners provide a family planning service and there is a widespread network of family planning clinics. In practice it can be more difficult. Many Family Planning Clinics are open for fewer than two sessions a week, often at times that are extremely inconvenient for the women who wish to use them. A clinic that is open between 2pm and 4pm on a Thursday afternoon is little use to a working woman who is unable to 'pop out' for a couple of hours. A recent survey conducted by Brook Advisory Services found that 44 per cent of teenagers requesting contraceptive help from family planning clinics were unable to get an appointment within a week.

Young people have a particular need for an alternative source of contraceptives to their GP - especially in smaller towns and villages where the GP may know their family well. GPs are, of course bound by strict regulations concerning confidentiality, but a teenager trying to obtain the contraceptive pill without her parents knowledge may be terrified that even if the GP doesn't spill the beans she may run in to Auntie Maud or the next-door neighbour in the waiting room.

Over the last couple of years many health authorities have decided to orient family planning clinic sessions towards younger women in response to the massive amounts of publicity about teenage pregnancies. While this may have improved services for teenagers, it has sometimes been at the expense of running a decent service for older women as general clinics have been cut to allow special 'young persons' clinics to be set up.

Cost-cutting within the NHS may also mean that it is more difficult to get a particular chosen contraceptive method without paying for the 'privilege'. This affects a whole range of services. For example it is becoming increasing difficult to be sterilised without having to pay to have the operation privately. In some areas couples can expect to wait up to 18 months for a vasectomy operation, in others it is not available on the NHS at all and the waiting lists for female sterilisation operations is even longer. There is growing financial pressure on GPs and family planning clinics to prescribe the cheapest brands of contraceptive pill, despite the fact that they might be less-well tolerated by the woman for whom they are prescribed. The fewer problems a contraceptive method causes a woman, the more likely she is to use it effectively, and this particularly applies to the pill. The greater the number of side-effects suffered by a woman the less motivated she will be take it regularly. Over the last few years new formulations of hormones have been created which lessen the risk of the side-effects, like weight gain, headaches and break-through bleeding, suffered by some women. Unfortunately these newer, better pills are more expensive and as doctors are increasingly pressurised to cut their spending on drugs, there are suggestions that many are avoiding these newer brands.

Greater availability of emergency post-coital contraception could significantly dent the numbers of accidental pregnancies by providing a second chance for women who know they are at risk. There are two ways of preventing pregnancy after sex has taken place. One involves the insertion of an IUD, which can be removed when the woman has her next period, within five days of sex. The more common method involves two doses of a special pill. The two doses are taken 12 hours apart, but the first must be within 72 hours of sex.

The emergency contraceptive pill is available from most doctors and family planning clinics and from some Accident and Emergency departments of local hospitals. It is however significantly under-utilised because of the misconceptions that surround the way it should be used. For example, many women assume that if they have been advised by a doctor that they are unable to take the normal contraceptive pill they will be unable to use the Emergency pill. This is not the case as most problems caused by the normal pill are a consequence of taking the hormone over a long period of time, whereas this pill involves a short higher dose. Unfortunately media coverage of Emergency Contraception often refers to it as the 'Morning After Pill' which fuels another misconception: that it must be taken the morning after sex. Consequently many women who could take advantage of it believe they have missed their chance.

Even given the 72 hours in which emergency contraceptive pills can be used, it may be difficult for a woman to obtain an appointment with a doctor who can issue the tablets. Most women have had the experience of telephoning a GP for an emergency appointment only to be told that earliest available appointment is in four days or so. Under pressure, when it is made clear that there really is an emergency it is usually possible to get an appointment that day. But this requires a persistence and determination that many women don't have. Not all acts of unprotected sex lead to a pregnancy and so emergency contraception is a safeguard against something that might not happen any way. Many women, faced with difficulties in obtaining it give up and trust to chance.

Contraception in the real world

In the final analysis contraception is something we all employ reluctantly. We do not take the pill, use a condom, or have an IUD fitted because we want to engage in that activity in its own right but as a precaution: to allow us to enjoy sex without pregnancy. We weigh up the pros and cons - the hassle of using a contraceptive appropriately is balanced against the fear of becoming pregnant. Any disincentives to use a method, whether it be the problem of obtaining it or unhappiness with the way a method makes us feel all help tip the balance against effective contraceptive usage.

Women who have accidental pregnancies are not stupid, they are not necessarily careless, and are certainly not feckless or irresponsible. Unplanned pregnancy is a potential hazard for every fertile, sexually active woman. The only way to remain 100 per cent safe from the threat of unplanned pregnancy is to restrict sex to those times when you want to conceive: a choice of lifestyle that most of us would find unacceptable.
 
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