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Contraception |
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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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