Unintended pregnancy prevention in women using psychoactive substances: A systematic review

Contraception use among individuals with substance use disorder increases tenfold with patient-centered, mobile services: a quasi-experimental study

BACKGROUND

Individuals with substance use disorders (SUD) have disproportionately high rates of unintended pregnancy. Reducing harm associated with this risk and its biopsychosocial consequences requires evidence-based, non-coercive interventions that ensure access to contraception for individuals who choose to prevent pregnancy. We examined feasibility and impact of SexHealth Mobile, a mobile unit-based intervention that aimed to increase access to patient-centered contraceptive care for individuals in SUD recovery programs.

METHODS

We conducted a quasi-experimental study (enhanced usual care [EUC] followed by intervention) at three recovery centers with participants (n = 98) at risk for unintended pregnancy. EUC participants were offered printed information on community locations where they could access contraception care. SexHealth Mobile participants were offered same-day, onsite clinical consultation on a medical mobile unit and contraception if desired. The primary outcome was use of contraception (hormonal or intrauterine device) at one-month post-enrollment. Secondary outcomes were at two-weeks and three-months. Confidence in preventing unintended pregnancy, reasons for non-use of contraception at follow-up, and intervention feasibility were also assessed.

RESULTS

Participants (median age = 31, range 19-40) enrolled in the intervention period were almost 10 times more likely to be using contraception at one-month (51.5%) versus the those enrolled in the EUC period (5.4%) (unadjusted relative risk [URR] = 9.3 [95%CI: 2.3-37.1]; adjusted relative risk [ARR] = 9.8 [95%CI: 2.4-39.2]). Intervention participants were also more likely to be using contraception at 2-weeks (38.7% vs. 2.6%; URR = 14.3 [95%CI: 2.0-104.1]) and three-months (40.9% vs. 13.9%; URR = 2.9 [95% CI: 1.1-7.4]). EUC participants reported more barriers (cost, time) and less confidence in preventing unintended pregnancies. Mixed-methods feasibility data indicated high acceptability and feasible integration into recovery settings.

CONCLUSIONS

Mobile contraceptive care based on principles of reproductive justice and harm reduction reduces access barriers, is feasible to implement in SUD recovery settings, and increases contraception use. Expanding interventions like SexHealth Mobile may help reduce harm from unintended pregnancies among individuals in SUD recovery. Trial Registration NCT04227145.

Exploring Family Planning Perspectives Among Men Receiving Medications for Opioid Use Disorder: Implications for Service Development

OBJECTIVE

Studies have consistently found high rates of unintended pregnancy among women with substance use disorder. While research efforts have begun to focus on understanding needs and providing family planning services for women in treatment, few studies have included men. This has resulted in a gap in the literature regarding men's reproductive health experiences and family planning desires.

METHODOLOGY

Between December 2019 and February 2020, we conducted semistructured qualitative interviews with adult men receiving medications for opioid use disorder at a safety-net healthcare system in Denver, Colorado. Interviews were recorded and analyzed using the Rapid Assessment Process.

RESULTS

Fifteen men participated in an interview. Overall, men described feeling excluded from family planning education and services as well as from decision making with their partners. Participants desired knowledge and resources related to contraceptive methods, partner communication, and parenting. Additional themes included loss of autonomy around pregnancy decisions, the importance of fatherhood, and the importance of addressing family planning during recovery. Participants expressed interest in a family planning intervention but indicated that engaging men on this topic may be challenging.

CONCLUSIONS

Our findings suggest that men in treatment desire education and involvement in family planning. Participants endorsed access to a subject expert within the treatment environment, but engagement strategies that underscore topic relevance to men will be critical. Initiating a conversation involving education and service navigation in the treatment setting may be a promising strategy for engaging men in recovery in family planning and improving men's access to needed services and resources.

Preconception health service provision among women with and without substance use disorders

BACKGROUND

Drug and alcohol use during pregnancy is associated with significant adverse birth outcomes and maternal morbidity. Addressing health and risky behaviors before pregnancy, in the preconception period, can improve both maternal and infant outcomes. However, the prevalence of preconception service delivery among women with substance use disorders (SUD) is unknown.

METHODS

Using Optum®, a de-identified Electronic Health Record dataset containing data from 5 million nationally distributed US adults from 2010 to 2018, we conducted a cross-sectional analysis of 18-55-year-old women with delivery between 2012 and 2018 (n = 52,565). Preconception services received in the year before pregnancy were identified using ICD-9/10 V and Z codes. Logistic regression was used to assess the relationship of any SUD vs. no SUD and preconception services received before and after adjusting for confounding.

RESULTS

Average age was 29.3 ( ± 5.0 years); 6.4% (n = 3371) of the sample had a diagnosis of any SUD and 6.0% (n = 3144) received any preconception services in the year before pregnancy. Women with SUD vs. without had higher prevalence of receiving any preconception services (9.6% versus 5.7%, p < 0.001). Compared to women without SUD, women with SUD had increased odds of receiving preconception services adjusting for medical comorbidities (OR=1.39; 95% CI=1.22-1.58) that was no longer significant when psychiatric comorbidities were added (OR=1.11; 95% CI=0.97-1.27).

CONCLUSIONS

There are numerous missed opportunities to provide preconception services to women with and without SUD. While delivering preconception services, healthcare providers have an opportunity to screen for SUD which may be more prevalent among women with psychiatric and medical problems.

Preconception Substance Use and Risk of Unintended Pregnancy: Pregnancy Risk Assessment Monitoring System 2016-17

OBJECTIVE

This study examined the association between preconception substance use and unintended pregnancy in a large, nationally representative sample of women.

METHODS

In this cross-sectional study, we used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) comprising, 74,543women who had birth during 2016-17. Logistic regression was used to assess the independent association of unintended pregnancy overall and by subtypes to preconception substance use (smoking and other nicotine/tobacco use, alcohol consumption, and use of cannabis, illicit/recreational drugs) and specific medication including prescription opioids, antidepressants and over the counter pain relief.

RESULTS

Overall, 41% of pregnancies were unintended. Nearly 57% of participants reported alcohol consumption during the preconception period, with 32% indicating binge drinking, 17% reported preconception smoking, and 10% cannabis use. Unintended pregnancy was significantly associated with substance use, including smoking (adjusted odds ratio [AOR]:1.5, 95% confidence interval [CI]: 1.4-1.6); as well as the use of other nicotine/tobacco (AOR:1.4, 95% CI: 1.3-1.5); cannabis (AOR: 1.9, 95% CI: 1.5-2.3); illicit/recreational drugs (AOR:1.7, 95% CI: 1.2-2.4), prescription opioids (AOR:1.4, 95% CI: 1.02-1.9), and prescription antidepressants (AOR 1.8, 95% CI: 1.1-3.0). The likelihood of unintended pregnancy was significantly elevated with heavy smoking, heavy alcohol consumption, and binge drinking. Analyses by unintended pregnancy subtype yielded similar results.

CONCLUSIONS

Preconception substance use was significantly and positively associated with unintended pregnancy. Evidence-based interventions are needed addressing substance use behavior and effective contraceptive use to prevent unintended pregnancy and related adverse effects on maternal and child health.

Increasing access to family planning services among women receiving medications for opioid use disorder: A pilot randomized trial examining a peer-led navigation intervention

OBJECTIVE

High rates of unintended pregnancy occur among women with opioid use disorder (OUD). OUD treatment settings may provide an ideal opportunity to address the family planning needs of patients. However, few studies have rigorously evaluated interventions designed to address family planning needs in the OUD treatment setting. This study assessed the feasibility, acceptability, and preliminary efficacy of a peer-led navigation intervention designed to educate and link women receiving medications for OUD to family planning services.

METHODS

The study recruited women from four OUD treatment programs in Denver, Colorado, to participate in a pilot randomized controlled trial from March 2018 to February 2019. Eligible participants were English-speaking adult females who were neither pregnant nor desiring a pregnancy and who were not using a long-acting reversible contraceptive (LARC) method. Participants completed a baseline survey, and the study randomized them to receive a two-session, peer-led family planning navigation intervention or usual care. The study assessed feasibility by participant engagement in the intervention. The study used follow-up self-report surveys and electronic health record data to assess intervention acceptability and intervention efficacy for the primary outcomes of a family planning visit and use of a LARC method.

RESULTS

The study enrolled 119 women who were randomized to the Sexual Health Initiative for Navigation and Empowerment (SHINE) peer-led navigation intervention (n = 56) or usual care (n = 63). The average age was 32 (SD = 6.4); 76% were receiving methadone, 24% were receiving buprenorphine and 19% reported a treatment provider had ever discussed family planning with them. Most had a previous pregnancy (82%) and of these, 93% reported an unplanned pregnancy. Among intervention participants, 93% completed the first navigation session, 90% felt that intervention topics were important, 76% indicated that the information was new, and 82% found working with a peer helpful. At six months postbaseline, significantly more (p = 0.01) intervention participants (36%) received a family planning visit compared to control participants (14%). There was no between-group difference on use of LARC methods.

CONCLUSIONS

A peer-led family planning navigation intervention was feasible to implement, acceptable to participants, and showed evidence of preliminary efficacy. This model may be an effective and potentially sustainable approach to support the family planning needs of women in treatment for OUD.

Perspectives on preconception health among formerly incarcerated women with substance use disorders

INTRODUCTION

Women involved in the criminal justice system have high rates of substance use disorders (SUD) placing them at increased risk for unintended pregnancy and adverse pregnancy outcomes. Little is known about the factors that influence the decision-making of formerly incarcerated women with SUD prior to becoming pregnant, in the preconception period. The goal of this study is to understand formerly incarcerated women's perceptions of changing substance use behaviors before pregnancy.

METHODS

We analyzed 33 semi-structured interviews with formerly incarcerated women in Saint Louis, Missouri. We asked questions about factors that influenced decision-making related to substance use and pregnancy. Interviews were recorded and transcribed verbatim. Transcripts were coded and analyzed using a grounded theoretical approach with ATLAS.ti software.

RESULTS

Four main themes emerged: (1) participants' understanding of preconception behavior change was influenced by their experiences with unplanned pregnancies and lack of control over outcomes; (2) substance use created challenges for women in considering their reproductive wishes; (3) while pregnant, participants weighed the medical and legal risks in their decision-making about their substance use; and (4) participants described how the internal motivation necessary to stop substance use during pregnancy was influenced by factors such as hitting rock bottom and witnessing negative outcomes experienced by others.

CONCLUSIONS

Preconception health services must be provided to women with SUD during opportunistic times such as during incarceration or while in SUD treatment. Services need to be non-judgmental and supportive rather than penalizing and should increase internal motivation to adopt behavior change.