Refer to: Miller WB: Psychological antecedents to conception

among abortion seekers. West J Med 122:12-19, Jan 1975

Psychological Antecedents to
Conception Among Abortion Seekers
WARREN B. MILLER, MD. Stanford

At a university hospital, 642 women seeking induced abortion for an unwanted

pregnancy were surveyed before the procedure regarding their perception of
what psychological and behavioral factors, if any, played a role in their be-
coming pregnant: 35 percent said they had had intercourse during what they
believed was a "safe period"; 33 percent believed that they had experienced a
contraceptive failure; 29 percent indicated fear of side effects influenced their
use of a contraceptive method; 27 percent and 21 percent, respectively, indi-
cated that they had thought pregnancy "couldn't happen to me" or had "put
the thought of pregnancy out of my mind." The women's responses indicated
that a number of additional attitudes, beliefs, and behaviors were also im-
portant and that for any individual woman at least three or four factors had
often combined in a dynamic sequence to greatly increase her risk of preg-
nancy. The implications of the findings for educational and counseling pro-
grams are discussed.

AMONG THE CONSEQUENCES of unwanted preg-
nancies, three are most salient: the effects of
being unwanted upon the child himself; the effects
of an unwanted child upon the parents and the
family; and the effects of unwanted children upon
society at large, especially with respect to over-
population, resource utilization and the overall
quality of life. In spite of the problematic and un-
desirable nature of the effects, there is consider-
From the Department of Psychiatry, Stanford University School
of Medicine.
Submitted June 5, 1974.
This study was supported under U.S. Public Health Service Con-
tract HSM 21-71-500.
Reprint requests to: W. B. Miller, MD, Department of Psy-
chiatry, Stanford University School of Medicine, Stanford, CA
94305.
able evidence that in the United States we are far
from having mastered the psychological and be-
havioral antecedents to conception.' For example,
recent survey data indicate that in intact marriages,
on the average, one in five children is unwanted.2
Adding to this the growing incidence of thera-
peutic abortion in states with liberalized abortion
laws:' and the rising illegitimacy rate,4 it is clear
that unwanted pregnancies, by whatever criteria
one wants to measure their occurrence, are a
major public health problem.
In order to better understand what psychologi-
cal factors might play a role in the occurrence of
pregnancies which were perceived as unwanted

12 JANUARY 1975 * 122 * 1

 ABORTION SEEKERS
after conception, a pilot investigation was carried
out in a large group of women seeking induced
abortions. These women were surveyed regarding
their own perceptions of the psychological and
behavioral factors which led to their unwanted
pregnancies. Given its survey nature, attention was
focused in this study upon consciously accessible
psychological factors such as the attitudes, expec-
tations and beliefs of respondents with regard to
their own sexuality, their fertility (ability to con-
ceive), their use of contraception and the mean-
ing of pregnancy to them. Within this large focus
of concern, special emphasis was placed upon the
women's antecedent use of contraception.
Methods
Concurrent with passage by the California Leg-
islature in 1967 of a therapeutic abortion law
which allowed the interruption of pregnancy to
preserve the physical and mental health of the
mother, there occurred a liberalization of physi-
cian and community attitudes toward the pro-
cedure. Local custom determined that an abortion
could be obtained for very broadly interpreted
mental health reasons upon the recommendation
of two psychiatrists. Since a large majority of local
psychiatrists readily approved women for abortion
(the refusal rate was a fraction of 1 percent),
therapeutic abortion became available to virtually
all women living in the urban and suburban cen-
ters who desired it and sought it out. As a result,
there was a pronounced increase in the number
of abortions done throughout the state. These de-
velopments resulted in the initiation of a one-year
medical and demographic survey of all abortion
patients at Stanford University Hospital, begin-
ning in October, 1970. The data which constitute
the subject of this report were collected within the
context of this survey over a six-month period,
during which time 692 women received abortions
at the hospital. Each woman was asked to com-
plete a short questionnaire (the Contraceptive
and Sexual Attitude Questionnaire) and to answer
a brief set of questions regarding her personal
history and contraceptive practice. If she agreed,
the woman signed a consent form, completed the
questionnaire and was interviewed for ten to fif-
teen minutes.
Three quarters of the respondents were private
patients, and one quarter were clinic patients. The
private patients were all contacted the day they
came to the hospital to be admitted for the pro-
cedure. Most of the clinic patients were also inter-
viewed at that time, although approximately 25
percent of them were interviewed one day before
their admission when they attended the obstetrics
clinic for a preoperative examination. Approxi-
mately half of all the respondents expressed in-
terest in the study and were glad to have someone
with whom to talk before the procedure. A large
majority of the remaining respondents appeared to
accept the study and to participate in a straight-
forward way without showing either enthusiasm
or resistance. Those respondents who were too
anxious or upset to discuss personal matters or to
complete the questionnaire were either excluded
from the study or were given the option of keep-
ing the questionnaire, completing it within the next
few days and mailing it back to the investigator.
Of the 692 eligible subjects, 7 percent were un-
able to participate in the study or refused to do
so. Of the 642 subjects who did participate in the
study, 2 percent mailed the questionnaire back
rather than complete it at the time of the inter-
view.
There were three interviewers ranging in age
from 21 to 32. All three were white, two were
unmarried and one was married. Initially, each
was given a broad range of basic information on
sexuality, contraception and abortion. At the same
time each was trained regarding interview tech-
niques. Their ongoing interview behavior was then
monitored through daily individual supervision as
needed and regular weekly group supervision.
The Contraceptive and Sexual Attitude Ques-
tionnaire consists of 53 items describing attitudes,
beliefs and expectations relevant to the contra-
ceptive and sexual behavior of women. The re-
spondent completes the questionnaire by checking
each item suggesting a factor which played a role
in her becoming pregnant. These items were
selected using information from many interviews
with women applying for therapeutic abortion or
attending a gynecological clinic for contraception
or pregnancy testing. The items were carefully
worded to conform as closely as possible to the
way these women expressed themselves when de-
scribing the psychological and behavioral condi-
tions under which they became pregnant or feared
they might become pregnant. After the question-
naire had been pretested and used in the study
for two months, five more items were added as a
result of comments and suggestions made by wo-
men who had already participated in the survey.
More complete evaluation of some of the re-
spondents' actual use of contraception was ac-
THE WESTERN JOURNAL OF MEDICINE 13
 ABORTION SEEKERS
complished by interviewing the second half of the
sample (328 subjects) more intensively regarding
the details of their use of contraception at the time
of conception. This interview also followed ad-
ministration of the Contraceptive and Sexual
Attitude Questionnaire, and focused upon the
degree to which a respondent's pregnancy ap-
peared to result from the failure of an effectively
used contraceptive method. Criteria for effective
use were based on a standard contraceptive text.5
Results
The study sample was characterized by demo-
graphic and personal history characteristics: 96.5
percent of the respondents lived in California;
36.9 percent were 19 years of age or under, 33.1
percent were 20 to 24, 15.9 percent were 25 to
29 and 14.0 percent were 30 or above; 61.4 per-
cent of the respondents were never married, 21.2
percent were currently married and 17.4 percent
were formerly married; 81.2 percent of the re-
spondents were white, 10.7 percent were black and
8 percent were of other racial-ethnic backgrounds;
36.9 percent of the respondents were Protestant,
21.5 percent were Roman Catholic, 5.8 percent
were of other religious affiliations and 35.8 per-
cent had no affiliation; 23.4 percent of the re-
spondents had less than a high-school education,
32.3 percent had achieved a high-school diploma,
30.9 percent had one to three years of college and
13.5 percent had at least a college degree. The
sample's previous reproductive history was char-
acterized: 55 percent of the respondents had no
living children, 13 percent had one, 11 percent
had two, and 11 percent had three or more; 18
percent of the respondents had had at least one
previous out-of-wedlock conception and 9 per-
cent of the respondents had had at least one pre-
vious induced abortion. All of the respondents
were asked what method of contraception they
used at or around the time of conception: 54 per-
cent indicated that they had used nothing and the
remainder indicated that they had used rhythm
(14 percent), foam (9 percent), withdrawal (5
percent), oral contraception (5 percent), dia-
phragm (5 percent), intrauterine contraceptive
device (IUD) (3 percent), condom (3 percent) or
some other method (2 percent).
The responses of the respondents to the Contra-
ceptive and Sexual Attitude Questionnaire are
shown in Table 1. In this table, the items are listed
in order of decreasing frequency. Low-frequency
items are shown, as well as high-frequency ones,
14 JANUARY 1975 * 122 * 1
in order to demonstrate the importance of the
psychological and behavioral variables relative to
each other. The mean number of items checked
by all respondents was 3.5, with a range of I
(most commonly Item 2) to 12.
Because of the frequency with which respond-
ents indicated that their pregnancy resulted from
a contraceptive failure, it was of interest to con-
sider to what extent checking Item 2 coincided
with a contraceptive failure as judged by the in-
terviewers. For the 328 respondents who com-
pleted the questionnaire and were interviewed
regarding their actual use of contraception at the
time of conception, the following data were ob-
tained: 20 (8 percent) of the 239 respondents
who did not check Item 2 were judged to have had
a contraceptive failure and 21 (24 percent) of the
89 respondents who did check Item 2 were judged
not to have had a contraceptive failure. Of the 21
false positives, 15 respondents (71 percent) were
using rhythm or oral contraception at the time of
conception in a way which they felt was adequate,
but which the interviewer (using a stricter set of
criteria regarding effective use of contraception)
judged to be inadequate. In general, these stricter
criteria involved a narrower definition of the "safe
period" and a stricter definition of what counts as
adequate pill-taking.
In order to examine further the relationships
between psychological factors and contraceptive
behavior, a chi-square analysis was done on the
relationship between contraception at the titne of
conception and the response to each questionnaire
item. The data for those items with a significant
chi-square analysis are presented in Table 2.
Discussion
With respect to age, marital status and racial-
ethnic status, the study sample is very similar to
the population receiving therapeutic abortions dur-
ing the same time period in the State of California
as a whole.6 Compared with a much larger national
population receiving therapeutic abortions during
this same time period, the age distribution for the
study sample is also very similar.3 Thus, the find-
ings in this pilot investigation may cautiously be
generalized to many populations of women in the
United States who are at risk for an unwanted
pregnancy and favorably disposed toward thera-
peutic abortion as a problem-solving technique.
The distribution of responses to the Contra-
ceptive and Sexual Attitude Questionnaire supple-
ments the clinical observations made by others in
 ABORTION SEEKERS

TABLE 1.-Percentage of respondents in the study group who checked each Contraceptive
and Sexual Attitude Questionnaire item, indicating it played a role in the occurrence of their
unwanted pregnancy. (N= 642)
Percent of
Respondents
Item Checking
Number Questionnaire Item Item
1. I thought it was during the safe period ................................... 35
2. I took precautions but the contraceptive method didn't work ..... ............ 33
3. I was afraid of the side effects of certain contraceptives ..... ................ 29
4. I thought it couldn't happen to me ...................................... 27
5. I put the possibility of pregnancy out of my mind ..... .................... 21
6. I didn't think pregnancy was likely because I had intercourse so infrequently ... 14
7. I didn't think I would get pregnant because I have often had intercourse without
precautions and have never gotten pregnant before ..... ................. 14
8. I realized that if I did get pregnant I could probably get an abortion .... ...... 13
9. I decided to take a chance and count on good luck ..... ................... 12
10. I had planned not to have any more intercourse for a while ..... ........... 11
11. I just never got around to getting contraception ...... ..................... 10
12. I got carried away before I could think about contraception ..... ........... 9
13. I halfway wanted to get pregnant ....................................... 8
14. He was supposed to withdraw but he didn't .............................. 8
15. I was embarrassed or afraid to see a doctor about contraception .... ........ 8
16. I didn't like deliberately planning for the possibility of intercourse .... ...... 8
17. I loved him and nothing else mattered .................................. 8
18. I knew I might get pregnant but that uncertainty didn't concern me very much . . 6
19. I was in the process of beginning a new contraceptive method* .... ......... 6
20. I didn't think I was fertile* ......... ................................... 6
21. I was afraid someone would find out if I tried to get a contraceptive* .... .... 6
22. I assumed that he would take some kind of precautions ..... ............... 5
23. I felt that having intercourse on that occasion was worth the chance of pregnancy 5
24. My judgment was affected by alcohol ..................................... 5
25. I wanted to prove my love by taking a chance ...... ...................... 4
26. I was embarrassed or afraid to talk to him about contraception .... .......... 3
27. I sort of liked putting myself in a risky situation ..... .................... 3
28. I felt a contraceptive would interfere with the natural expression of love ...... 3
29. At the time I wanted to get pregnant ..................................... 3
30. I really didn't care that much whether I got pregnant ..... ................. 3
31. He wanted to have a baby even though I didn't ...... ..................... 3
32. I couldn't say no even though there wasn't any available contraception ....... 3
33. My judgment was affected by a drug (marijuana, LSD, etc.) ..... ............ 3
34. I was forced against my will to have intercourse ..... ..................... 3
35. I thought that using contraception would make it harder to say no in the future . . 3
36. He assured me he was sterile or that he could not make me pregnant .... ..... 3
37. I didn't know how to get contraception* ................................. 2
38. He didn't want me to use contraception .................................. 2
39. I was confused by my doctor about contraception ..... .................... 2
40. I felt that all available contraceptives were distasteful ..... ................. 2
41. The doctor made it hard for me to get the contraceptive I wanted .... ........ 2
42. I thought that if I got pregnant we would get married ..... ................. 2
43. We couldn't agree what kind of contraceptive method to use ..... ........... 2
44. I didn't think any contraceptive really worked ...... ...................... 1
45. I was trying to hurt or punish myself .................................... 1
46. I wanted to prove that I was fertile ..................................... 1
47. I felt it was wrong and against my beliefs to use contraceptives .... .......... 1
48. I thought that using a contraceptive would change how he felt about me ...... 1
49. I wasn't able to take precautions because he was in such a hurry .... ......... 1
50. I thought that if I got pregnant it would improve our marriage .... .......... 1
51. My usual contraceptive method was not available* ..... ................... 1
52. I only felt right if there was a chance of pregnancy ......................... 0
53. I wanted to get back at someone by getting pregnant ..... ................... 0
*These five items were added after questionnaire distribution began. The N of subsample for these five
=373.

THE WESTERN JOURNAL OF MEDICINE 15

 ABORTION SEEKERS

TABLE 2.-Percentage of respondents saying "yes" to questionnaire items, by all respondents and by respondents
using different methods of contraception at time of conception.

ik~~~~~~~~~~~~~~~b
Item Contraceptive and Sexual 'i QF:
Number Attitude Questionnaire Item i4Lb 94
1. Thought during safe period ..... ..... 35 32 40 76 42 22 23 10 0 .001
2. Method didn't work ....... .......... 33 7 37 39 74 75 83 87 100 .001
3. Afraid of side effects ...... .......... 29 29 30 35 21 9 44 27 22 .1
4. Couldn't happen to me ...... ........ 27 31 30 25 26 25 23 7 6 .1
5. Put possibility out of mind ..... ...... 21 28 13 17 21 22 10 7 6 .01
6. Intercourse infrequently ...... ........ 14 17 20 22 21 0 3 0 0 .01
7. Never gotten pregnant before ..... .... 14 20 13 13 0 6 7 3 0 .01
10. Planned no more intercourse ..... .... 11 15 20 11 5 3 5 3 0 .1
11. Never got around to getting contraception 10 12 30 13 16 0 2 0 0 .001
12. Got carried away ................... 9 13 7 5 5 3 2 3 0 .1
14. He was supposed to withdraw ........ 8 11 30 4 0 0 3 0 0 .001
15. Embarrassed or afraid to see MD ..... 8 8 20 11 11 6 2 0 0 .01
19. Beginning new method .............. 6 3 0 10 0 21 13 0 0 .1
N of sample: ..................... 642 346 30 92 18 32 59 30 19

a nonsystematic way7 by suggesting the relative
importance of different psychological antecedents
for unwanted pregnancies which are aborted.
However, in the interpretation of each question-
naire item, it must be kept in mind that the re-
spondent was asked to check all those items which
played some role in her becoming pregnant, and
that most respondents checked three or more
items. In the infrequent instances when respond-
ents checked only one item, it usually was Item
2, which deals with actual contraceptive failure.
Thus, none of the psychological factors suggested
by questionnaire items should be viewed as oper-
ating alone. Rather they should be thought of as
operating in conjunction with several other factors.
The importance of such a multifactorial approach
can be appreciated by recognizing that obtaining
and successfully using a contraceptive method
almost always involves a complicated sequence of
psychological and behavioral events,' which tend
to occur in a stepwise sequence: deciding to be
sexually active, or acknowledging to oneself that
one is sexually active; recognizing the possibility
of pregnancy and the implications that this would
have for oneself and for others; thinking about,
talking about and planning methods for preventing
pregnancy; acquiring a contraceptive method for
personal use; keeping it available in situations
where one might decide to have intercourse; de-
ciding what to do when it is not available and
using it regularly. Each item of the Contraceptive
and Sexual Attitude Questionnaire relates to
failure at one or more of the steps in this psycho-
logical and behavioral sequence. In checking
multiple items, the typical respondent is there-
fore indicating what combination of step failures
led to her unwanted pregnancy.
The most frequently checked item in Table 2
indicates that the respondents felt sexual inter-
course was taking place during a nonfertile period
in the menstrual cycle. On the basis of interviews
with a subsample of respondents, however, it can
be said that only a small minority of the women
who checked this item were actually well informed
on the facts of ovulation and the correct use of
the method of periodic abstinence. Rather, most
respondents appeared to be using the concept of
the "safe period" as a way of rationalizing the
safety of a particular act of sexual intercourse
after they were in a situation where they wanted
to have intercourse but had no suitable contra-
ceptive method available, and, in some cases,
after unprotected intercourse had already taken
place. It was this consistent finding that led the
author's research assistants to coin the term
"retrospective rhythm."
The second most frequently checked item on
the questionnaire indicates that a third of the re-
spondents felt conception resulted from a contra-
ceptive failure. If this figure is adjusted for the 24
percent of those respondents checking Item 2 who
were judged as false positives on the basis of the
interview, there still remains approximately 25
percent of the total sample who accurately per-
ceive themselves as becoming pregnant because
of a contraceptive method failure. Therefore, it

16 JANUARY 1975 * 122 * 1

 ABORTION SEEKERS
appears that for a large group of abortion seekers
psychological factors have not played a primary
role in their unwanted pregnancies.
The third most frequently checked item indi-
cates that the respondent was afraid of certain
contraceptive method side effects. In the study
sample, the methods toward which most of this
concern was directed were oral contraception and
the IUD. Unfortunately, these are the two most
effective methods available. During the interviews
this fear and concern appeared to operate at three
levels: by influencing whether the woman obtained
contraception, which contraceptive method was
chosen and how the contraceptive method was
used once it was obtained.
The fourth and fifth most frequently checked
items indicate that the respondents excluded
thoughts about becoming pregnant from con-
sciousness. In and of itself, such exclusion may
be either an adaptive or maladaptive mental
mechanism. For example, a small group of re-
spondents checked both Item 2 and one or both
of Items 4 and 5, indicating that they took reason-
able contraceptive precautions and that this en-
abled them to suppress the thought or fear of
pregnancy. However, a majority of the respond-
ents who checked Items 4 or 5 were practicing
maladaptive denial, in that they excluded thoughts
or fears of pregnancy at the same time that they
were taking inadequate contraceptive precautions.
A number of the questionnaire items were
checked with an intermediate frequency of be-
tween 8 percent and 14 percent. Item 6 suggests
a poor comprehension of the actual risks of preg-
nancy. This appears to be based on the common
fallacy that low-frequency exposure to an out-
come which is only probabilistic will prevent the
occurrence of that outcome. Items 7 and 20 indi-
cate that the respondent believed she was sub-
fertile (in demographic usage, subfecund). This
was most commonly true among the adolescents
and the women undergoing menopause. As the
author has discussed elsewhere,8 women appear
to be more vulnerable to an unwanted pregnancy
during the periods of adolescent and menopausal
subfertility because of their failure to learn contra-
ceptive vigilance in the former or their relaxation
of an acquired vigilance in the latter. Item 8 sug-
gests that the perceived availability of abortion
may have decreased the strength of contraceptive
vigilance in a significant fraction of women in the
sample and thus affected the adequacy of their
contraceptive practice or the extent to which they
took risks. A willingness to take risks was very
directly suggested by Item 9. For many of the wo-
men interviewed, checking this item meant that
the respondent had decided on a particular occa-
sion that intercourse was "worth the chance of
pregnancy."
Items 10, 11 and 16 each suggest a somewhat
different type of problem with future planning.
Item 10 suggests difficulty in following through
on a plan to abstain from further sexual inter-
course. There were two basic situations which
tended to facilitate the making of such a plan:
breakup with or separation from a long-standing
sexual partner and an episode of sexual involve-
ment about which the woman felt considerable
remorse or guilt. In both situations, the woman's
reactive psychological state led her to temporarily
reject the thought of further sexual activity. This
resulted in her being contraceptively unprepared
when she did resume her sexual activity. Item 11
suggests an inability to plan for sexual intercourse
through the prior securing of contraception. This
inability may represent an inhibition of planning
because of negative feelings about sexuality or
contraception, or it may simply represent a lack
of future orientation. Finally, Item 16 suggests an
inhibition of planning for intercourse because of
the deliberateness and the implicit psychological
initiative which such planning involves. On the
one hand, deliberateness implies a lack of spon-
taneity. This consideration is also reflected in the
relatively low-frequency Item 28. On the other
hand, initiative implies assertiveness, even aggres-
siveness. Such an implication runs strongly counter
to traditional views of female sexuality.
Poor sexual impulse control is suggested by
Item 12. This type of difficulty has the most ser-
ious implication for respondents using coitus-
dependent contraceptive methods because of the
requirement that the user temporarily inhibit on-
going sexual activity in order to apply the method.
Items 13 and 29 both indicate a conscious wish to
become pregnant. While the latter suggests a
strong, active wish, the former is phrased in a way
which suggests a more passive, semiconscious or
ambivalent wish. It is noteworthy that the active
wish to become pregnant was relatively unimpor-
tant among all the psychological factors. The pas-
sive wish, on the other hand, was almost three
times as important. It was our observation that this
passive form of the wish to be pregnant was more
THE WESTERN JOURNAL OF MEDICINE 17
 ABORTION SEEKERS
commonly expressed in the woman's fantasy
rather than translated directly into action and
probably affected the chances of conception by
slightly modifying the adequacy of each step in
her contraceptive behavior sequence.
Item 14 indicates that the respondent perceived
the pregnancy as resulting from her sexual part-
ner's failure to withdraw. Many women reported
difficulty discussing their sexual feelings and con-
traceptive preferences with their partners. But
more is reflected in this item than poor communi-
cation. It also provides some measure of the wo-
man's tendency to project the blame for the preg-
nancy onto her partner. In addition, since the man
sometimes misled her about withdrawal or simply
failed to follow through on his intention, this item
also reflects the woman's misplaced trust in her
partner. Item 15 indicates an embarrassment on
the part of the respondent in seeing a doctor about
contraception. This consideration was especially
prominent among the younger respondents in the
sample, especially those still living at home and
limited to their family doctor, or those living in a
small town or on a college campus where confi-
dentiality was a major consideration. Item 17 in-
dicates an absorption in the present and in the
respondent's current heterosexual relationship.
This consideration was also more prevalent in the
younger members of the sample. Finally, Items 24
and 33, one or the other of which was checked
by 8 percent of the respondents, indicate poor
judgment regarding contraception and pregnancy
resulting from the use of alcohol or other psycho-
active compounds.
Some of the infrequently checked items are
noteworthy because they are traditionally assumed
to be relatively important factors in the occurrence
of an unwanted pregnancy. Items 42, 50 and 53
all imply the manipulative use of a pregnancy or
a child to influence others. It seems likely that
Items 42 and 50 represent factors which may
actually be more significant for all pregnancies in
a population than just for those pregnancies which
are aborted since it will be primarily when the
manipulation fails that the woman seeks an abor-
tion. Item 46 implies the respondent's use of con-
ception to reassure herself regarding her own
reproductive ability. While this factor is a fre-
quently mentioned motive for premarital preg-
nancy in nulliparous women, its low frequency in
Table 1 suggests either that, in fact, it is rela-
18 JANUARY 1975 * 122 * 1
tively unimportant or that it operates largely out-
side of the awareness of the woman herself. Items
37 and 47 represent frequently discussed societal
and moral obstacles to the use of contraception.
Their low frequency in this sample almost certainly
reflects the ready availability and general accept-
ance of contraception in the geographic area from
which the sample was drawn.
Table 2 provides some interesting information
regarding the behavioral problems associated with
specific contraceptive methods. In that table, the
first column represent the entire study sample and
indicates the percentage of all respondents saying
"yes" to the particular questionnaire item listed
on the left-hand side of the table. The next eight
columns present data from the eight subgroups of
respondents grouped with reference to contracep-
tive use at the time of conception. The subgroups
are arranged according to the adequacy of each
subgroup's contraceptive practice, with the least
effective contraceptors (no contraception) on the
left, and the most effective (IUD) on the right. In
between, the subgroups are arranged, from left to
right, to show increasing adequacy of contracep-
tion as determined by the percentage of each sub-
group's respondents who indicated they had a
method failure (by checking Item 2). The general
appropriateness of this ordering of subgroups is
confirmed by examining the percentage of each
subgroup checking the other questionnaire items
which reflect the adequacy of contraceptive prac-
tice at the time of conception, such as the denial,
planning or impulsivity items.
The item profile of IUD-using respondents is
clearly the most favorable, although that of the
diaphragm-users is very similar. The item profile
of foam-users is also similar, although this sub-
group tends to be higher on rationalization (Item
1) and denial (Items 4 and 5 ). Respondents using
oral contraception are similar to the foam-users.
However, they have two item response patterns
that tend to differentiate them from all other con-
traceptors: they are far the least fearful of side
effects and they are most likely to experience an
unwanted pregnancy while beginning a new
method. The first of these patterns is not unex-
pected, since the Pill-users have selected the very
method about which there has been the most pub-
lic discussion of problematic side effects. The
second pattern reflects two facts especially relevant
to oral contraception. First, there is often a con-
siderable delay between the decision to obtain
oral contraception and actual procurement of the
 ABORTION SEEKERS
medication. A doctor or a clinic must be identi-
fied, an appointment must be made, an examina-
tion must be obtained from a physician and often
a prescription must be filled before the medica-
tion is in hand. Second, the transition period dur-
ing which a woman changes from some other
contraceptive method (or no method) to oral con-
traception has certain inherent ambiguities regard-
ing when to begin administration and when to
consider that protection has begun. Some patients
who are instructed to wait until after their next
menstrual period before beginning administration
become pregnant in the interim. Others who mis-
takenly believe they are protected from conception
with the first pill also become pregnant.
The item profile for the condom-users is similar
to those of the Pill- and foam-users except for
their responses to Items 1, 6, 11 and 15, which
together suggest a set of resistances to planning
contraception which probably fosters more fre-
quent reliance on their male partner for contra-
ception. Except for the noncontraceptors, the
users of withdrawal and rhythm are the least ade-
quate contraceptor groups. Their item profiles are
very similar except for their responses to Items 1
and 14, which relate very specifically to the re-
spective methods.
When interpreting the data in Table 2, it must
be kept in mind that the psychological factors
associated with a particular contraceptor subgroup
cannot be attributed to all users of that method.
The respondents in each contraceptor subgroup
were selected out of the large pool of users of that
method by virtue of their failure to prevent con-
ception. However, because of this selective pro-
cess, the psychological factors associated with
particular methods in the data of this investigation
suggest behavioral dispositions in a potential con-
traceptor which may predispose her to failure
should she use that particular method. The nature
and importance of such interactions between a
user's psychological characteristics on the one
hand and the set of behaviors required by each
contraceptive method on the other have been dis-
cussed at greater length by the author in other
writings.9'10
Conclusion
The results of this survey of women seeking
abortion support the proposition that many dif-
ferent psychological factors play an antecedent
role in the occurrence of unwanted pregnancy,
although in a quarter of the cases psychological
factors appeared not to have played a fundamental
role. Each of the more important psychological
factors in this survey appears to operate at one
point or at different points in the complex be-
havioral sequence which leads to effective contra-
ception. If sex education and counseling programs
and birth control or family planning clinic pro-
grams could communicate more about these fac-
tors, the frequency of unwanted pregnancy might
be considerably reduced. Such a goal might be
accomplished if educators, counselors and clini-
cians gave special emphasis to certain material:
the facts and risks of both rhythm and withdrawal
as methods of contraception; the major side effects
and undesired consequences of both contraception
and pregnancy; the psychological mechanisms of
suppression and denial, with their adaptive and
maladaptive functions; the statistics of concep-
tion following random and infrequent sexual inter-
course; the types and implications of subfertility;
the sequence of behaviors necessary for adequate
contraceptive use; the psychological factors which
predispose persons to the ineffective use of each
contraceptive method; motivations for sexual in-
tercourse and the medical, psychological and
ethical aspects of induced abortion.
REFERENCES
1. Miller WB: Conception mastery: Ego control of the psy-
chological and behavioral antecedents to conception. Comments on
Contemporary Psychiatry 1:157-177, 1973
2. Bumpass L, Westoff CF: The "perfect contraceptive" popu-
lation. Science 169:1177-1182, Sep 1970
3. Center for Disease Control: Abortion surveillance report.
Jan, Mar 1971; Mar 1972
4. Cutright P: Illegitimacy: myths, causes and cures. Fam
Plann Perspect 3(l):25-48, Jan 1971
5. Calderone MS (Ed): Manual of Family Planning and Contra-
ceptive Practice, second edition. Baltimore, Williams and Wilkins
1970
6. Fifth Annual Report on the Implementation of the Cali-
fornia Therapeutic Abortion Act, Bureau of Maternal and Child
Health, Department of Public Health, State of California, 1972
7. Sandberg EC, Jacobs RI: Psychology of the misuse and re-
jection of contraception. Am J Obstet Gynec 110(2) :227-239, May
1971
8. Miller WB; Psychological vulnerability to unwanted preg-
nancy. Fam Plann Perspect 5(4), Fall 1973
9. Miller WB: Personality and ego factors relative to family
planning and population control, in Proceedings of the Conference
on Psychological Measurement in the Study of Population Prob-
lems, held under the joint auspices of the Institute of Personality
Assessment and Research, University of California, Berkeley, and
The American Psychological Association Task Force on Psy-
chology, Family Planning, and Population Policy, Feb 1971
10. Miller WB: Psychological and psychiatric aspects of popu-
lation problems, In Hamburg DA, Brodie HK (Eds): American
Handbook of Psychiatry, Vol VI (in press)
THE WESTERN JOURNAL OF MEDICINE 19