Intervene earlier to help women maintain control of reproductive decision making
To the Editor: We read with great interest the recent article by Upadhyay et al. [1] on factors associated with discontinuation of contraceptive use and unintended pregnancy within 1 year after abortion. While we agree that proximal factors likely contribute to a woman's inability to take charge of her reproductive life, we also submit that a woman's reproductive trajectory may be influenced by events much earlier in the life course. Our previous work has shown that age at sexual debut less than 15 years has been associated with gaps in contraceptive use throughout reproductive life [2] and increased risk of multiple unintended pregnancies [3]. Further, reported nonconsensual sexual debut less than age 15 years increased the odds of multiple unintended pregnancies dramatically. Indeed, those who report younger age at sexual debut are more likely to report a nonautonomous reason (such as peer pressure or desire to please a partner) for engaging in their first intercourse. This may lead to reduced self-efficacy ultimately influencing a woman's ability to protect herself from sexual risks, including unintended pregnancy [4]. The finding reported by Upadhyay et al. that women with a history of abortion were more likely than women without such history to have selected their contraceptive method due to the provider interaction may also influence contraceptive discontinuation. This may represent ambivalence toward contraception use in general, reduced information about contraceptive options prior to counseling or a desire to avoid provider conflict. Ambivalence or a desire to avoid conflict may be representative of a larger inability to make autonomous reproductive decisions. Primary prevention efforts to empower girls to make informed and autonomous decisions about sexual debut as well as cognitive–behavioral interventions aimed at increasing sexually assertive beliefs, behaviors and practices for women of all ages may be justified.