The aim of this study was to elucidate the patterns of RCA and whether RCA was more frequently aimed at pregnancy promotion or pregnancy prevention/abortion. We found no difference in overall rates of RCA across the services with RCA identified as being experienced by around 15% of clients at both MSA and C by C. Overall, the rates of coercion that promoted and prevented pregnancy were also similar. Much of the previous research focuses on forced pregnancy and condom sabotage, which effectively excludes half of those experiencing RCA and makes prevalence appear lower. In particular, a large body of research draws on the National Intimate Partner and Sexual Violence survey conducted in the United States of America [26], which only includes pregnancy coercion and condom refusal when measuring RCA. Conclusions drawn from this data pertaining to racial differences (i.e., [11]) may be misrepresenting the scope and complexity of the issue experienced by different cultural and racial groups.

Interestingly, we found that 2% of the sample reported experiencing both coercion towards abortion and coercion that was pregnancy promoting. Scant attention has been paid to what forms RCA takes within and across different pregnancies and our findings suggest that people may be contending with coercive and abusive behaviours that are contradictory. More research is needed to understand whether the different types of RCA were perpetrated by the same person or different people and also the temporal pattern of the different forms of RCA. If it is perpetrated by the same person, it raises interesting questions about the role of intent and what this looks like. For example, the pattern of RCA may mirror patterns of coercive control, where the tactics used to assert control may change over time (i.e., sexual assault to promote pregnancy and then coercion or abuse to promote or induce abortion), based on the abuser’s knowledge of the victim/survivor, and where the victim/survivor feels they are walking on eggshells as the rules change [27]. It could also be that, as with sexual violence [28], those who have previously experienced particular forms of RCA may be at risk of experiencing them again. Alternatively, there may be different abusers where a person/people are using coercion or abuse to force one decision while another person is forcing a different one (i.e., a young person whose parents are coercing one decision or extended family in some communities may be more likely to coerce pregnancy and the man involved in the pregnancy using coercion to force a different decision).

Another key finding was that people who identified as Aboriginal and/or Torres Strait Islander were more likely to experience coercion that promoted pregnancy than coercion towards abortion/pregnancy prevention. Rather than speculate on why this might be, we instead argue that further research is warranted to understand reproductive autonomy and what that means to Aboriginal and/or Torres Strait Islander peoples, including facilitators and barriers to reproductive autonomy. For example, Griffiths et al. [22] highlighted a complex interplay between reproductive autonomy, modern contraceptive use, and traditional cultural practices for Aboriginal women in Western Australia and emphasized the need for respectful and inclusive reproductive health services. Exploring the root causes of coercion that promotes pregnancy may lead to greater cultural safety and improved health outcomes for Aboriginal and/or Torres Strait Islander peoples.

We also found that there were no significant differences in the experience of the different forms of RCA for people from migrant and refugee backgrounds nor across different age groups. This is an important finding that highlights the need to recognise that clients of any age and background could be experiencing RCA and to remember to sensitively enquire, as well as to provide culturally appropriate education materials, health system support, and interventions across the reproductive lifespan.

In Australia, family, domestic and sexual violence is under-reported, and barriers to accessing a full suite of sexual and reproductive health services (including abortion care) and help-seeking for victims/survivors of violence persist ([29] [AIHW], [30]). These are particularly salient for people experiencing intersecting disadvantages, including those who live in under-resourced areas outside of urban centres [31, 32]. RCA inherently further exacerbates challenges victim/survivors face in accessing the services they need to facilitate autonomous reproductive decision making, compounding accessibility issues for those who experience other structural, geographic or financial barriers. The identification of RCA may be useful as a ‘soft entry’ to identifying further family, domestic or sexual violence, given their co-occurrence, and crucial to ensuring victim-survivors accessing sexual and reproductive health services are able to make autonomous reproductive health decisions. Therefore, understanding, enquiry for, and workforce training around RCA is ever more crucial to ensure the realisation of reproductive health, rights, and justice for all. Recently, interviews with primary care clinicians around Australia identified a lack of awareness of, structural and practical support for [33], and confidence in identifying or responding to RCA in primary care settings. Similarly, “reproductive coercion” was a relatively new term for workers in domestic violence services, who tended to define it very broadly [34]. There are indications that coercive control and violence, lack of culturally responsive service delivery, and structural barriers to essential health care and support, compound to make some women and pregnant people particularly vulnerable, and these sorts of intersections warrant further research attention [23, 35].

The current study diverged from most of the extant literature by measuring prevalence based on counsellor-identified RCA rather than relying on self-report data. This was in part an opportunistic decision based on the availability of routine practice data from our project partners; yet, it should also be noted that this method may have some advantages. These include allowing a broader range of behaviours to be identified compared to a measure with limited items that may not capture the complexity or scope of RCA. The counsellors at both MSA and C by C had received training around RCA and were likely to have a good understanding of what behaviours constitute it. On the other hand, it is also possible that counsellors were too broad or too inclusive. There is some controversy around when and at what point ‘pressure’ is considered coercion. While papers such as Tarzia and Hegarty [3] for example, have centred intent, fear, and control as fundamental components of RCA that differentiate it from other behaviours, we have no knowledge of whether these were assessed by counsellors in all instances. Conversely, RCA may not have been disclosed during the counselling session/s, which would mean that our findings are conservative. Future research is needed to improve measurement of RCA including the development of standardized, evidence-based screening procedures and training for providers. This will improve both data collection and identification of women and pregnant people in need of support.

Further, depending on the length of contact with the client, demographic factors may or may not have been collected, meaning that our study may be under representative of those from migrant and refugee and Aboriginal and/or Torres Strait Islander communities. We also utilised a crude measure of a person’s racial and/or ethnic identity and did not collect more accurate data (i.e., whether they were particular visa holders, how long they have been in Australia, place of birth, etc.) or broader intersecting categories of identity (e.g., disability, gender or gender diversity, sexuality or intersex status). Future research is warranted to explore the intersectional experiences of RCA across Australia. While the sample included participants from all Australian states, it was not nationally representative, with Queensland overrepresented and South Australia underrepresented, most likely due to the legal and policy contexts and service agreements for pregnancy options counselling and abortion provision in those states. Thus, our findings may only be representative of clients who choose to access pregnancy decision making counselling or post-abortion support from these particular services. Finally, our study was descriptive in nature and the field would benefit from more rigorous assessment of RCA and its antecedents and consequences.