Commentary: What’s behind the rise in unplanned pregnancies in Singapore?

SINGAPORE: My son was 8 years old when I first spoke to him about the “birds and bees”. It was during dinner time when he asked me a question about how he came out from mummy’s tummy.

I was stumped at first. Recovering after a couple of seconds, I assured him that asking about the awkward stuff was not just okay but also welcome. I used age-appropriate language providing clear information about the basics of reproductive health and puberty without sounding embarrassed.

Data shows that unplanned pregnancy is on the rise in Singapore. A study published by SingHealth Polyclinics (SHP) in November showed a 60 per cent increase in the number of local women seeking referrals from eight polyclinics for abortions between 2017 and 2020. Women seeking referrals were more likely single and aged below 20 or above 40 years of age, the study found. More than 10 per cent of the patients had repeated referrals for abortions.

In all, more than 4,000 abortions were performed on Singaporean women in 2020, according to the Ministry of Health.

IMPACT OF UNPLANNED PREGNANCIES

The increase in unplanned pregnancies can be attributed to various factors, including a lack of awareness and knowledge in sexuality education, limited understanding of the risks of medical abortion, cultural traditions, and inadequate access to personalised family services. 

Medical literature has shown that there are increased public health and social concerns associated with unplanned pregnancies. Women with unplanned, compared to planned pregnancies, tend to experience higher anxiety levels and negative feelings, higher levels of depressive symptoms during their pregnancies and are more prone to postpartum depression.

Legally, abortions can be performed at less than 24 weeks’ gestation. Medical abortion, a process using medication to terminate a pregnancy, comes with potential risks such as abdominal pain, prolonged bleeding, infection and retained production of conception requiring surgery in about 5 per cent of cases.

Surgical abortion, which can be performed between five and 14 weeks, involves the removal of the fetus and placenta via suction. The risks include anaesthetic complications and uterine perforation which is associated with an increased risk of blood vessel and bowel injury and may require additional surgery. Surgical abortions may also affect future fertility due to scarring inside the lining of the womb. Multiple abortions are associated with a higher risk of cervical weakness, increasing the risk of miscarriages, preterm labour and premature delivery. 

DON’T SHY AWAY FROM TALKING ABOUT THE BIRDS AND BEES

Addressing unplanned pregnancies requires a holistic approach. While Singapore integrates sexuality education into its curriculum starting from Primary 5, there's a case for introducing it even earlier in primary schools with age-appropriate topics like puberty and reproduction.

The appropriate use of social media can also play a crucial role in supplementing formal education. Through this, educators can disseminate accurate and reliable information, countering potential misinformation found in online spaces.

Fostering an environment of openness at home is also instrumental and can set the stage for a lifelong pattern of communication and trust. Parents should be encouraged to initiate candid discussions about the "birds and bees" earlier in their children's lives instead of shying away from the topic.

The timing of these conversations can vary from family to family, taking into consideration the child's maturity level, curiosity and the cultural context. Generally, experts recommend that parents initiate age-appropriate discussions early on from the time children enter preschool around four to five years old. This includes introducing children to where the private parts are and areas that should not be touched by others.

PERSONALISED FAMILY PLANNING SERVICES 

As children transition into adolescence and young adults, there's an opportunity to include discussions about protection and family planning services in a medically accurate and age-appropriate manner. Gynaecologists play an important role in providing personalised family planning services, and increasing access to such services is an essential part in addressing unplanned pregnancies. 

While many countries in Asia, including India, China and South Korea, allow access to birth control pills over the counter, Singapore does not.

Supporters of over-the-counter availability argue that making the pill more accessible may reduce the incidence of unintended pregnancies and abortions and eradicate barriers such as cost, or hesitation associated with doctor's visits. 

But there are valid concerns and considerations associated with making the pill available over the counter. Oral contraceptive pills may be unsuitable for women with significant medical histories like breast cancer or blood clot formation. Birth control pills, like any other medication, can have side effects and may not be suitable for every individual.

Maintaining prescription status ensures that a healthcare professional evaluates a person's medical history, taking into account potential contraindications and providing alternative contraception like the intrauterine device (IUD) instead.

Furthermore, over-the-counter availability may limit the opportunity for comprehensive education. Healthcare providers play a crucial role in educating individuals about proper usage, and what to do in case of missed doses. For instance, older women with unplanned pregnancies may erroneously assume that they do not need to use contraceptives due to declined fertility after 40 years of age.

Increasing the allocation of healthcare funding to family planning services for gynaecological care and general practitioner follow-ups could make it more affordable and accessible for women to accept contraception usage as an effective means of preventing pregnancies.

NO EASY ANSWERS

There are no easy answers when it comes to preventing unplanned pregnancies. An important consideration for women who undergo abortions is the thorny issue of protecting their longer-term reproductive health. This is an area of public education that requires more support.

It is important to adopt a multifaceted approach involving education and supportive healthcare services to reduce the number of unplanned pregnancies in Singapore and improve overall emotional and psychological well-being for women who find themselves in such a situation.

Dr Ryan Lee is a father of two and a Consultant Obstetrician and Gynaecologist with a special interest in maternal-fetal medicine. He practises at Thomson Specialists, The Woodleigh Mall.