We're careful about what we call an accident in my house. When my son breaks a windowpane playing soccer in the living room, it's no accident. When my daughter destroys the finish on the coffee table removing polish from her nails, again, no accident.
Most people throw the term "accident" around more loosely, however. They use it to describe everything from spilled milk to car crashes — including unintended pregnancies.
More than one-third of all pregnancies in the United States are mistimed or unwanted, according to the Centers for Disease Control and Prevention. But in fact, there's very little that's accidental about the majority of them. Most occur because people choose not to use contraception or use it in the wrong way.
The CDC recently surveyed more than 7,000 women of child-bearing age about their contraceptive practices. The results, published in August, suggest that 4.5 million sexually active women aren't using contraceptives despite the fact that they say they want to avoid pregnancy. (Of course, men, too, bear responsibility for the problem of unintended pregnancies, but most surveys on this subject focus on the part women play.)
Even women who practice contraception often fail to use birth control consistently and correctly. Women who rely on oral contraceptives forget to take them every day or are late refilling their prescriptions; those who depend on condoms for protection use them only intermittently or begin or end a sexual encounter without one.
Not surprisingly, birth control doesn't work as well when it's used this way.
Under ideal circumstances, barrier methods of contraception (such as condoms and diaphragms) are more than 95% effective (per year of use). The way they're actually used, however, their effectiveness drops to roughly 85%. Birth control pills, when used correctly, should be more than 99% effective — and yet, because they are frequently misused, the number is closer to 91%.
"It doesn't seem to make sense that women who don't want to get pregnant wouldn't use a form of birth control," says Dr. Mary Nettleman, chair of the department of medicine at Michigan State University and a women's health researcher. "But women are making decisions that seem logical to them at the time."
A variety of factors influence a woman's decision to use contraception or not. Some women can't afford contraceptives or have difficulty getting to a family-planning clinic for regular care; others don't fully understand how birth control works or hesitate to use it for religious reasons.
Many women are unwilling to take hormonal contraceptives, such as the birth control pill, because of potentially serious side effects such as an increased risk of heart attack and stroke; others are scared off by the possibility of weight gain or bloating.
Sexual partners also influence women's decision-making. In the CDC survey, 7% of women who had experienced an unintended birth reported that their male partner hadn't wanted them to use birth control; an additional 10% said that their partner had resisted using contraception himself.
Sometimes women choose to forgo birth control because they don't think they can get pregnant: Some may believe that they can't conceive during certain parts of their menstrual cycle; others might consider themselves infertile because they've never gotten pregnant before.
And then there's lack of forethought: 14% of women in the study went without contraception because they hadn't expected to have sex.
Other surveys on this topic have reported similar results. A study published in 2009 in the Journal of Family Practice found that among contraception non-users, 87% cited at least one of the following reasons: "just not thinking about birth control," "not planning to have sex," "getting caught up in the heat of the moment" or "just went with the flow."
For women, the consequences of an unintended pregnancy are obvious. But there are consequences for the baby as well. Women who aren't actively trying to conceive may not recognize that they're pregnant immediately — and, as a result, would be more likely to engage in potentially risky behaviors like drinking and smoking during the first few weeks of fetal development. Prenatal care, meanwhile, is often delayed. "The risk for damage is significant," Nettleman says. A 2009 study she authored found that women who were late in learning that they were pregnant were more likely to have babies who are born prematurely.
Unfortunately, there's no quick fix. "Some unintended pregnancies will be with us always," Nettleman says. "It's a complex issue. Simply telling women to straighten up and fly right isn't the answer."
Undoubtedly, women need to be better educated about birth control and its proper use. And more acceptable methods of contraception — ones that have fewer side effects and are more convenient to use — must be developed. But straightening up and flying right is part of the solution too.
With few exceptions, unintended pregnancies are not "accidents." They are predictable consequences of having sex without contraception.
Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. The M.D. appears once a month.