Exposure to intimate partner violence (IPV), defined as physical violence, stalking, psychological harm, or sexual violence perpetrated by a romantic or sexual partner (Breiding et al., 2015), may have adverse implications for reproductive health during the perinatal period. People exposed to physical IPV before, during, and/or after pregnancy may be less likely to use contraception in the postpartum period (Cha et al., 2015; Horne et al., 2009; Scribano et al., 2013; Stevenson et al., 2020) and more likely to experience rapid repeat pregnancy, meaning an interpregnancy interval of 18 months or fewer (Scribano et al., 2013). One in three women becomes pregnant before the recommended 18-month interpregnancy interval in the United States (Gemmill & Lindberg, 2013). Rapid repeat pregnancy is associated with adverse birth outcomes, such as preterm birth, small for gestational age, and low birth weight (Conde-Agudelo et al., 2006; Fuentes-Afflick & Hessol, 2000; Khoshnood et al., 1998; Zhu, 2005). Thus, using contraception in the postpartum period may have benefits for postpartum people who want to avoid pregnancy, and the American College of Obstetricians and Gynecologists (ACOG)’s committee opinion mentions family planning services as a strategy to increase optimally spaced births (ACOG, 2019). Past research on the effects of IPV around the time of pregnancy on reproductive health behaviors has tended to focus on physical IPV, although non-physical aggression (i.e., emotional IPV or the use of verbal and nonverbal communication with the intent to harm and/or exert control over another person; Breiding et al., 2015), compared to physical violence, occurs more frequently around the time of pregnancy (D’Angelo et al., 2022; McMahon et al., 2011). Consequently, relatively little is known about how exposure to emotional IPV around the time of pregnancy is related to contraceptive use in the postpartum period.

Contraceptive counseling during both prenatal and postpartum care is an evidence-based best practice (ACOG, 2018). ACOG’s committee opinion mentions that healthcare providers should screen women of reproductive age for IPV, including during obstetric care (ACOG, 2012). Exposure to IPV around the time of pregnancy, however, may mitigate the potentially positive effects of counseling on postpartum contraceptive use. For example, a study of U.S. women with a recent live birth found an inverse relationship between physical IPV around the time of pregnancy and postpartum contraceptive use, regardless of receipt of prenatal birth control counseling (Cha et al., 2015). To our knowledge, no studies have investigated if receipt of counseling about either contraception or IPV (during prenatal or postnatal care) may mitigate the potentially negative effect of emotional IPV on use of postpartum contraception.

Reasons for nonuse of contraception in the postpartum period vary. A study using 2012–2015 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 7 found that not having sex, not wanting to use birth control, and being worried about side effects from birth control were primary reasons (Stevenson et al., 2020). In addition, some of these reasons varied by reported exposure to physical IPV around the time of pregnancy (Stevenson et al., 2020). Additionally, a content analysis of open-text responses on reasons for contraceptive nonuse from PRAMS 2012–2015 data found that the two most prominent reasons were personal preference to not use birth control and concerns with birth control side effects (Richards et al., 2022). It is unknown if reasons for nonuse of postpartum contraception vary by exposure to emotional IPV around the time of pregnancy.

The primary objective of this analysis was to assess the relationships between exposure to emotional IPV 12 months before, during, and after a live birth and postpartum contraceptive use. We also examined reasons for not using contraception by exposure to emotional IPV around the time of pregnancy to understand if reasons for nonuse vary by IPV exposure. Lastly, we sought to evaluate differences in postpartum contraceptive use among individuals who experienced emotional IPV by receipt of contraceptive counseling and IPV counseling prenatally and postnatally.

We used 2016–2021 data from the PRAMS. PRAMS is an ongoing population-based surveillance system, conducted in partnership with CDC and state and local health departments, of individuals who recently had a live birth. To implement PRAMS, individuals with a live birth who are residents of and delivered their infant in a participating site are identified via vital record birth certificate files and contacted 2–6 months after the live birth (Shulman et al., 2018). Potential participants are selected using a stratified systematic sampling scheme. Sites may stratify two of six variables for oversampling of subpopulations: birth weight, maternal race and ethnicity, education, and age, geographic area, and Medicaid status. PRAMS uses systematic sampling so that all potential participants have the same probability of being selected within each stratum (Shulman et al., 2018). PRAMS has approval from the CDC Institutional Review Boards and participating jurisdictions.

The PRAMS survey includes a core set of questions asked by all participating sites and standard questions that sites may choose to include in their questionnaires. Additionally, PRAMS requires a minimum overall response rate threshold for the release of data for each year (2015–2017: 55%; 2018–2020: 50%). Seven sites (Alaska [2016–2020], Iowa [2016–2020], Illinois [2016–2021], Indiana [2018], Maryland [2016–2020], Virginia [2016–2021], Wyoming [2016–2021]) that used a standard question about emotional IPV and met the minimum overall response rate threshold for one or more of the study years were included in this study.

The largest proportions of the sample were between the ages of 25–29 years (28.3%) and 30–34 years (31.4%) (Table 1). Fifty-seven percent of participants identified as non-Hispanic White; 17.5% identified as Hispanic of any race; 16.7% identified as non-Hispanic Black. The majority of participants had a previous live birth before most recent live birth (62.1%) and wanted their most recent live birth at that time or sooner (60.5%). Most participants were using contraception postpartum (80.3%). Across the three time periods, 2.0% of participants reported emotional IPV before pregnancy, 2.2% reported emotional IPV during pregnancy, and 1.9% reported emotional IPV after pregnancy. Three percent of the sample reported emotional IPV in any time period around the time of pregnancy. While 96.7% of participants did not report any emotional IPV, 1.5% reported emotional IPV in only one time period and 1.8% reported emotional IPV in two or more time periods.

Larger proportions of contraceptive nonusers reported emotional IPV before, during, and after pregnancy, compared to contraceptive users (2.9% vs. 1.8%, p < .01; 3.5% vs. 1.9%, p < .001; 2.6% vs. 1.7%, p < .01, respectively). Four percent (4.8%) of nonusers reported any emotional IPV around the time of pregnancy, compared to 2.9% of users (p < .001). Additionally, 2.8% of nonusers reported emotional IPV in two or more time periods, compared to 1.5% of users (p < .001).

Among contraceptive nonusers (n = 5,995), reasons for nonuse included not wanting to use birth control (39.3%), worry about the side effects from birth control (32.4%), not having sex (28.6%), other (22.9%), wanting to get pregnant (18.3%), husband or partner does not want to use birth control (9.2%), and problems paying for birth control (3.0%) (Table 2). Compared to individuals who did not report any emotional IPV around the time of pregnancy (n = 5,662), larger proportions of individuals who reported any emotional IPV (n = 333) cited not having sex (27.3% vs. 53.6%, respectively, p < .001) and husband or partner does not want to use birth control (8.8% vs. 17.8%, respectively, p < .01). A smaller proportion of individuals who reported any emotional IPV around the time of pregnancy reported wanting to get pregnant as a reason for nonuse compared to individuals who did not report any emotional IPV (10.8% vs. 18.7%, respectively, p < .01).

All emotional IPV indicators were significantly inversely associated with contraceptive use in the postpartum period, after adjusting for race and ethnicity, age, previous live birth before most recent live birth, state of residence, and wantedness of most recent live birth (Table 3). Individuals who reported emotional IPV 12 months before, during, and after pregnancy had 43% (95% CI: [0.43, 0.76]), 49% (95% CI: [0.39, 0.66]), and 37% (95% CI: [0.46, 0.84]) lower odds of contraceptive use in the postpartum period, respectively, compared to individuals who did not report emotional IPV in each respective time period. Individuals who reported any emotional IPV at one or more of the time periods around the time of pregnancy had 43% (95% CI: [0.46, 0.71]) lower odds of postpartum contraceptive use, compared to individuals who did not report emotional IPV in any time period. Lastly, compared to individuals who did not report emotional IPV in any time period, individuals who reported emotional IPV in one time period and two or more time periods had 37% (95% CI: [0.45, 0.89]) and 48% (95% CI: [0.39, 0.70]) lower odds of contraceptive use in the postpartum period, respectively.

Among individuals who reported any emotional IPV around the time of pregnancy and received prenatal care (n = 1,134), those who were asked if someone was hurting them emotionally or physically by a healthcare worker during prenatal care had 2.22 times greater odds (95% CI: [1.33, 3.70]) of using contraception in the postpartum period, compared to individuals who were not asked (Table 4). However, being asked about plans to use birth control after delivery by a healthcare worker during prenatal care was not significantly associated with postpartum contraceptive use (aOR 1.62; 95% CI: [0.82, 3.22]). Among individuals who reported any emotional IPV around the time of pregnancy and received postpartum care (n = 956), those who were asked if someone was hurting them emotionally or physically by a healthcare worker during postpartum care had 2.11 times greater odds (95% CI: [1.26, 3.52]) of using contraception in the postpartum period, compared to individuals who were not asked. Yet, being asked about plans to use birth control after delivery was not significantly associated with postpartum contraceptive use (aOR: 0.67; 95% CI: [0.33, 1.40]).

Prevention of all forms of IPV is important for optimal sexual and reproductive health (McMahon et al., 2011; Rowan, 2016). Yet, emotional IPV has received less attention relative to physical or sexual IPV in the literature (Jewkes, 2010). This analysis explored associations between emotional IPV around the time of pregnancy and post-partum contraceptive use. Participants who experienced emotional IPV in the year before pregnancy, during pregnancy, or shortly after had reduced odds of postpartum contraceptive use. Additionally, there was a stronger association for individuals who experienced emotional IPV during multiple time periods, compared to a single time period. Taken together, the results support that postpartum contraceptive use may be adversely affected by exposure to emotional IPV. These findings are similar to those from quantitative studies that found lower rates of postpartum contraceptive use among those experiencing physical IPV (Cha et al., 2015; Scribano et al., 2013; Stevenson et al., 2020; Van Horne et al., 2009). However, adequate comparison between studies is challenging, as they are heterogenous in the measurement of IPV types and analyze different contraceptive outcomes. Our study provides evidence for the negative consequences of emotional IPV on postpartum contraceptive use for which comparable estimates are lacking.

The mechanisms linking emotional IPV with reduced contraceptive use have not been thoroughly investigated. Partner control of reproductive decisions may be one plausible and important mechanism of action to consider. We found that larger proportions of individuals who experienced any emotional IPV reported that their husband or partner did not want to use contraception, compared to individuals who did not experience any emotional IPV. This response option may be an indication of reproductive coercion, which is a form of IPV that can involve physical, sexual, or psychological tactics that interfere with reproductive goals, such as delaying or avoiding pregnancy (Grace & Anderson, 2018). However, we note that PRAMS did not ask participants about reproductive coercion directly, and further investigation would be needed to know if this response does indicate that a participant experienced it. It may be important to understand if and how emotional IPV and reproductive coercion cooccur, and how they jointly influence contraceptive outcomes. Reproductive coercion is significantly associated with unintended pregnancy independent from physical and/or sexual IPV, and it also interacts with other forms of IPV to increase risk of unintended pregnancy (Grace & Anderson, 2018; Miller et al., 2010). Contraceptive outcomes may also be impacted by reproductive coercion. For example, women might be less likely to use any method or their ideal contraceptive method (Rosenfeld et al., 2018). Recognition that individual-level reproductive decisions are often shaped by complex interpersonal and relational contexts could help inform and improve family planning services (Lévesque et al., 2021; Malarcher & World Health Organization, 2010), like client-centered counseling and trauma-informed care.

We also found that healthcare providers asking about IPV during prenatal or post-partum care had a significant relationship with postpartum contraceptive use (controlling for providers asking about contraceptive use) among participants experiencing emotional IPV. However, asking about contraceptive use (controlling for providers asking about IPV) was not associated with postpartum contraceptive use among participants experiencing emotional IPV. IPV counseling is an important component of Quality Family Planning Services (Gavin et al., 2014). The perinatal period provides a unique and crucial opportunity for universal IPV screening with education, intervention, and ongoing support (ACOG, 2012). CDC’s IPV prevention resources and the U.S. Preventative Services Task Force also highlight the importance of IPV screening coupled with referral and ongoing support (Curry et al., 2018; Niolon et al., 2017). Despite these recommendations, numerous barriers including lack of privacy, time constraints, and inadequate resources and training, curtail the IPV screening and support (Furniss et al., 2007; Sprague et al., 2012; Waalen et al., 2000). Interventions that move beyond education only and use a holistic, trauma-informed approach that considers the multilevel barriers to screening (e.g., institutional policies, providers’ values, and attitudes) may improve care.

PRAMS is a cross-sectional survey. Thus, information about the timing and ordering of experiences to establish causality or temporal relationship cannot be established. The findings of this study are not generalizable to all of the United States and limited to the sites included in the analysis. Additionally, this analysis only represents experiences of those with a live birth and not other pregnancy outcomes, such as still birth or pregnancy loss. We examined postpartum contraceptive use with a single question, precluding a more nuanced investigation of types of contraceptives used, duration, frequency, or periods of discontinuation. In addition, reports of emotional IPV were also limited to one question each. Therefore, the specific acts and severity of emotional IPV cannot be ascertained. Further, the emotional IPV variable was limited to 12 months prior to pregnancy; thus, it was not possible to distinguish participants with longer IPV histories. In addition, 12 months prior to pregnancy is longer than the typical 3-month preconception period. Finally, information on the content and extent of healthcare provider discussions about IPV and contraceptive use were not available. Despite these limitations, we captured exposure in important time periods around pregnancy, proximately capturing chronicity as exposure to emotional IPV in more than one period. Future in-depth examination of the relationships between emotional IPV and contraceptive use, including an elucidation of mechanisms that may link emotional IPV and contraceptive use, for example, self-esteem, self-efficacy, or fear of retribution, may help identify factors that support or hinder use of contraceptives.