Barriers to Long-Acting Reversible Contraceptive Uptake Among Homeless Young Women

Improving Reproductive Health Communication Between Providers and Women Affected by Homelessness and Substance Use in San Francisco: Results from a Community-Informed Workshop

OBJECTIVES

Many cisgender women affected by homelessness and substance use desire pregnancy and parenthood. Provider discomfort with patient-centered counseling about reproductive choices and supporting reproductive decisions of these women poses barriers to reproductive healthcare access.

METHODS

We used participatory research methods to develop a half-day workshop for San Francisco-based medical and social service providers to improve reproductive counseling of women experiencing homelessness and/or who use substances. Guided by a stakeholder group comprising cisgender women with lived experience and providers, goals of the workshop included increasing provider empathy, advancing patient-centered reproductive health communication, and eliminating extraneous questions in care settings that perpetuate stigma. We used pre/post surveys to evaluate acceptability and effects of the workshop on participants' attitudes and confidence in providing reproductive health counseling. We repeated surveys one month post-event to investigate lasting effects.

RESULTS

Forty-two San Francisco-based medical and social service providers participated in the workshop. Compared to pre-test, post-test scores indicated reduced biases about: childbearing among unhoused women (p < 0.01), parenting intentions of pregnant women using substances (p = 0.03), and women not using contraception while using substances (p < 0.01). Participants also expressed increased confidence in how and when to discuss reproductive aspirations (p < 0.01) with clients. At one month, 90% of respondents reported the workshop was somewhat or very beneficial to their work, and 65% reported increased awareness of personal biases when working with this patient population.

CONCLUSIONS FOR PRACTICE

A half-day workshop increased provider empathy and improved provider confidence in reproductive health counseling of women affected by homelessness and substance use.

"It's Not a Top Priority": A Qualitative Analysis of Provider Views on Barriers to Reproductive Healthcare Provision for Homeless Women in the United States

Women experiencing housing insecurity are at an elevated risk for adverse reproductive health outcomes due to the prevalence of chronic health conditions and higher risk behaviors. Social service and healthcare providers are front line in addressing women's needs when they seek support. Thus, we sought to explore reproductive healthcare barriers using in-depth interviews with 17 providers at 11 facilities serving housing-insecure women in Salt Lake County, Utah, USA from April to July 2018. Providers noted a number of system-, provider-, and individual-level barriers. Dominant themes include reliance on unstable funding, lack of provider training on reproductive health, and perceived logistical challenges to care. Due to the prevalence of immediate needs among housing-insecure women, providers attest that reproductive health needs often do not emerge as their urgent concern. Our findings suggest that addressing policy and funding challenges to prioritizing reproductive needs among housing-insecure women can help mitigate the potential for long-term adverse reproductive outcomes.

Contraception-related knowledge, attitude, belief contexts among US women experiencing homelessness: A scoping review

Contraception provision may help reduce undesired pregnancies, but women experiencing homelessness may have low health literacy, specific attitudes, and certain beliefs that influence contraception uptake. This scoping review identifies what is known about pregnancy prevention and contraception knowledge, attitudes, and beliefs among US women experiencing homelessness. This review examined English articles that measured the context of knowledge, attitudes, and beliefs related to contraceptive use for avoiding pregnancy among US women experiencing homelessness. Using PRISMA-ScR guidelines, articles published before May 2022 were located via PubMed, EBSCOhost, and Embase. The initial search identified 1204 articles, and 10 met the inclusion criteria. There were five quantitative, four qualitative, and one mixed-methods study, published between 2000 and 2022, with samples of 15-764 women ranging from ages 15-51. Contraception knowledge, attitudes, and beliefs related to pregnancy prevention suggested several knowledge gaps (e.g., contraception efficacy), contraception preferences and past experiences, interpersonal relationship influences, and vulnerability to clinic and shelter-specific barriers. These findings may ultimately inform contraception interventions in partnership with the community of US women who experience homelessness and the health care and social service organizations who serve them.

Development of a clinical questionnaire to support contraception decisions in an adolescent reproductive health clinic in Colorado

CONTEXT

Adolescents need support to make informed decisions about contraception. Few clinical questionnaires exist to help adolescents and their healthcare providers align contraception decisions with patient needs and preferences.

METHODS

Our mixed-methods study involved a convenience sample of English-speaking, female patients aged 13-19 seeking contraception services at an adolescent reproductive health clinic in Colorado, USA. Qualitative interviews informed development of clinical questionnaire items. The questionnaire elicited demographic characteristics, pregnancy and contraception use history, preferred contraception attributes, peer and family involvement, healthcare information and support needs, motivations for contraceptive use, and barriers to contraceptive services. We identified key decision-making factors and reduced the number of questionnaire items through principal components analysis. Using multivariable analyses, we examined the correlation between questionnaire responses and current contraceptive method.

RESULTS

Twenty individuals participated in interviews and 373 individuals completed the preliminary questionnaire with 63 candidate items. We identified five contraceptive decision-making factors: side-effect avoidance (eight items, Cronbach's alpha = 0.84), preferred method attributes (six items, Cronbach's alpha = 0.67), parental involvement (three items, Cronbach's alpha = 0.67), life goals prior to parenting (four items, Cronbach's alpha = 0.88), and access to a contraceptive provider (two items, Cronbach's alpha = 0.92) and nine stand-alone items. In multivariable analyses, we found that questionnaire responses for decision-making factors varied among participants using different contraceptive methods.

CONCLUSIONS

Multiple priorities may influence adolescent contraceptive decisions. This clinical questionnaire can elicit these priorities before or during a healthcare encounter. Future studies should assess generalizability of the questionnaire and examine impact on method choice, continuation, satisfaction, and reproductive health outcomes.

Hidden in plain sight: A systematic review of coercion and Long-Acting Reversible Contraceptive methods (LARC)

In recent years there has been extensive promotion of long-acting reversible contraceptives (LARC) globally to increase access to what is widely considered a highly effective contraceptive method. Yet, despite these efforts, evidence points towards the worrying propensity for LARCS to be associated with coercion. Hence, we undertook a meta-narrative review across nine databases to draw together the heterogeneous and complex evidence on the coercive practices associated with LARC programs. A total of 92 papers were grouped into three metanarratives: (1) law, (2) public health and medicine, and (3) the social sciences. Across disciplines, the evidence supports the conclusion that coercive practices surrounding LARC programs always target marginalized, disadvantaged and excluded population(s). Looking at coercion across disciplines reveals its many forms, and we present a continuum of coercive practices associated with LARC programming. We found that each discipline provides only a partial picture of coercion, and this fragmentation is a knowledge practice that prevents us from collecting accurate information on this subject and may contribute to the perpetuation of these suspect practices. We present this review to address longstanding silences around coercion and LARCs, and to encourage the development of clinical and programmatic guidance to actively safeguard against coercion and uphold reproductive rights and justice.

Reproductive justice for unhoused women: An integrative review of the literature

This review examines the reproductive health experiences of unhoused women and youth. Guided by the reproductive justice framework, this review examines barriers to accessing contraception, medical abortion, and prenatal care while homeless. Twenty-one articles were identified through keyword searches in Google Scholar, Ebscohost Academic Search Premier, and PsycINFO. In included articles, barriers were identified at the individual, relational, and contextual levels. Findings from this scoping review illustrate the need to examine multiple levels of analysis when seeking to improve access to family planning services for individuals experiencing homelessness. Included literature suggests an overabundance of research documenting barriers to contraceptive care relative to the literature examining abortion and prenatal care experiences and a scarcity of research examining barriers to reproductive justice among unhoused individuals who do not identify as women.

A socioecological perspective to contraceptive access for women experiencing homelessness in the United States

OBJECTIVE

Although persons who are pregnancy-capable and experiencing homelessness may have a strong desire to avoid pregnancy, they face unique barriers to contraception. This multimethod qualitative study aimed to identify preferences for, barriers to, and facilitators of contraceptive access and use among women experiencing homelessness in the United States using a systems perspective.

STUDY DESIGN

We conducted semistructured interviews with women experiencing homelessness (n = 19), healthcare providers (n = 6), and social service providers (n = 6). We recruited participants from community-based, housing, and medical organizations in North Texas in the United States. Two coders conducted thematic analysis and reached consensus for codes.

RESULTS

Women participants were in emergency shelter, unsheltered, or transitional/rapid rehousing. We stratified themes using the Socioecological Framework to illustrate factors affecting contraception access at individual, interpersonal, organizational and community, and societal levels. Notable results include women's preferences for long-acting reversible contraception, difficulties healthcare providers face in initiating contraceptive counseling, and the underutilized role of social service providers in reproductive healthcare. Insurance policies, connections between health clinics and community organizations, and organizational priorities both facilitated and hindered women experiencing homelessness's access to women's healthcare services.

CONCLUSION

This study identified opportunities throughout the healthcare and social service systems to support contraceptive access for women experiencing homelessness. Future interventions should strengthen and leverage these connections to promote access among this vulnerable population with the goal of supporting reproductive autonomy.

IMPLICATIONS

This study explored the reproductive health needs of women experiencing homelessness. Multilevel interventions, such as interdisciplinary care, patient-centered approaches, and an emphasis on health literacy, are needed to adequately provide the preferred methods of contraception for women experiencing homelessness, thus enabling reproductive autonomy for this population.

Caregivers of youth in foster care in Texas and their role in contraception decision-making for adolescents in care

OBJECTIVES

This study describes the perspectives of caregivers of youth in foster care in Texas about the caregiver's role in adolescent contraception decision-making for adolescents in their care, particularly for long-acting reversible contraception. The study also explores how providers and foster care agencies can better support pregnancy prevention for youth in care.

STUDY DESIGN

Researchers recruited 18 caregivers of youth in care from an academic center in Texas to complete in-person, one-on-one, semistructured interviews from August to December 2019. Two independent coders identified the main concepts with thematic analysis; discrepancies were resolved by consensus.

RESULTS

Most caregivers identified as female (88%), Black (59%), and ranged in age from 30 to 69 years old. Half (47%) reported previously caring for an adolescent who was pregnant or parenting. Themes from the interviews included the importance of building relationships before contraception conversations, the balance between adolescent autonomy and strict caregiver oversight in contraceptive decision-making, variation in beliefs about contraception for youth in care, and extreme reactions to long-acting reversible contraception in both directions. Providers and foster care agencies played an important role managing confidential expectations and providing resources or trainings about contraception.

CONCLUSIONS

In a region of the country with high rates of adolescent pregnancy, strategies that empower adolescent autonomy allow delicate caregiver oversight, provide comprehensive information about all contraceptive options, and respond to extreme long-acting reversible contraception reactions and trainings that focus on the context of contraception that should inform communication-based interventions to address teen pregnancy prevention among youth in care.

IMPLICATIONS

Few studies address the experiences of caregivers of adolescents in foster care. This study highlights a range of caregiver attitudes about contraception for adolescents in care. Provider training regarding contraception should include strategies to manage caregiver beliefs and extreme reactions to contraception use among youth in care.

Patient and provider perspectives on barriers and facilitators to reproductive healthcare access for women experiencing homelessness with substance use disorders in San Francisco

BACKGROUND

Women experiencing homelessness with substance use disorders face unique and intersecting barriers to realizing their reproductive goals.

OBJECTIVE

This study explored the reproductive aspirations of this population, as well as the barriers to accessing reproductive services from the perspectives of affected individuals, and the healthcare providers who serve them.

DESIGN

This mixed-methods study included surveys and interviews with women experiencing homelessness with substance use disorders and healthcare providers.

METHODS

We conducted surveys and semi-structured interviews with women recruited from opiate treatment programs and homeless encampments in San Francisco, California in 2018. We also conducted interviews and focus groups with healthcare providers in reproductive health and substance use treatment settings. Interviews were recorded, transcribed, and coded. Descriptive statistics of survey results were performed.

RESULTS

Twenty-eight women completed surveys, 96% of whom reported current substance use. Ten women participated in interviews. One-third (9/28) reported desiring pregnancy in the next year; over half (16/28) reported they would be somewhat or very happy to learn they were pregnant. A majority used no contraception at last intercourse (14/28). Twenty-six healthcare providers participated in interviews (n = 15) and focus groups (n = 2). Patients and providers identified similar barriers to care access, including discrimination, logistical and financial challenges, and delayed pregnancy awareness. While providers proposed solutions focused on overcoming logistical challenges, patients emphasized the importance of transforming the healthcare environment to treat patients affected by substance use and homelessness with dignity and respect.

CONCLUSION

Women experiencing homelessness with substance use disorders face intersecting and compounding barriers to accessing reproductive health services. For patients, the impact of stigma and bias on treatment experiences are particularly salient, in contrast to logistical barriers emphasized by providers. Improving access will require structural and individual-level solutions to address stigma and create person-centered, trauma-informed, and respectful care environments.

"It Just Depends on Their Stability": A Qualitative Examination of Patient Factors Influencing Providers' Contraceptive Counseling Approaches for Persons With Substance Use Disorders

OBJECTIVES

This qualitative study examined how patient-related factors influence providers' contraceptive counseling for persons with substance use disorders (SUDs). Specifically, we explored individual behavior and social factors that contribute to providers modifying their contraceptive counseling approaches and described how providers alter their counseling recommendations and communication strategies in the presence of such factors.

METHODS

In 2019, we purposively recruited a national sample of contraceptive providers (N = 24) and conducted semistructured phone interviews to inquire about their contraceptive counseling practices for women with SUDs. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis with inductive codes.

RESULTS

Participants included 10 medical doctors, 8 nurse practitioners, and 6 certified nurse-midwives. We found that providers modify their contraceptive counseling provision when their patients are actively using substances or have unstable living conditions, such as intimate partner violence or homelessness. With patients experiencing these instabilities, providers reported postponing contraceptive discussions until patients are stabilized in treatment, recommending long-active reversible contraceptive methods, and varying communication styles according to their own perceptions of patients' communication needs. Providers perceived that individuals in long-term recovery have increased stability and fewer barriers to contraceptive access and adherence and therefore reported increased willingness to provide greater autonomy during contraceptive decision making and shift the counseling focus to short-acting contraceptive methods.

CONCLUSIONS

This study highlights that substance use and social "stability" of patients contributes to how providers approach their contraceptive counseling and make methods recommendations for their patients with SUDs. More research is needed to understand strategies that individuals with SUDs use to overcome barriers to contraceptive access and adherence in the context of active substance use and social instability.

Long-acting reversible contraception: Targeting those judged to be unfit for parenthood in the United States and the United Kingdom

There is a long history of regarding marginalised groups as unfit to parent and of eugenic policies targeting those with 'undesirable' bodily conditions or behaviours. This is part of a broader pattern of stratified reproduction - structural conditions that enable or discourage certain groups from reproducing - that often brings about and exacerbates injustices. This paper critically assesses the US and UK social and medical literature on applying pressure to marginalised groups, or those who have behaved 'irresponsibly', to use long-acting reversible contraception (LARC). Targeting young people for LARC fails to recognise that social inequality is the context for teenage pregnancy, not the result of it. Provider pressure on women of colour to use LARC is linked to institutional racism, whilst policy for those with physical and intellectual disabilities is shaped by disability discrimination. Other groups to be targeted include so-called 'welfare mothers', substance users, those who have had children put into care and offenders. Particularly controversial are cases in which LARC has been ordered by courts. LARC policy incorporating these kind of discriminatory practices needs to stop; future policy should focus on person-centred care that bolsters reproductive justice.

Associations Between Income Status and Perceived Barriers to Using Long-Acting Reversible Contraception: An Exploratory Study

Introduction

Barriers to long-acting reversible contraception (LARC) use in the United States have been described in prior studies, but few have focused on women's income status. We explored associations between income status and perceived LARC barriers in a community-based sample of reproductive-aged women.

Methods

Non-pregnant, heterosexually active women aged 18 to 40 years completed a cross-sectional survey at a large community event in the Midwestern U.S. in 2018. Outcome measures were comprised of 26 survey items gauging perceived barriers to LARC use (e.g., access barriers, side effects). We estimated crude and age-adjusted prevalence ratios (PRs) for each outcome by participants' income status: low-income (≤ 200% of federal poverty guideline) versus higher income.

Results

Low-income women (n = 72) were significantly more likely than higher income women (n = 183) to endorse 11 of the 26 barriers to LARC use (PR range, 1.23–7.63). Cost of LARC was the most frequently identified access barrier and was more acute for low-income women (PR 1.57, 95% CI 1.17–2.11). After adjustment for age, most associations were attenuated. However, low-income women were still more likely to report concerns about LARC use due to family expectations or beliefs (aPR 3.69, 95% CI 1.15–11.8).

Conclusion

Low-income women perceive more barriers to LARC access and more negative perceptions about use. While these associations also correlate with age, they nonetheless reflect concerns that impact contraceptive equity. Efforts to increase LARC access should address these barriers and focus on concerns more common among low-income women regarding LARC use.

Sexual and Reproductive Health and Reproductive Coercion in Women Victim/Survivors Receiving Housing Support

Housing instability and intimate partner violence (IPV) compromise women's sexual and reproductive health (SRH) through reduced contraceptive access and increased risk of unintended pregnancy. This study describes the reproductive health status and needs of IPV survivors receiving housing support and explores factors influencing their experience of reproductive coercion (RC), specifically. Cross-sectional baseline data from a quasi-experimental study of 70 IPV survivors enrolled in housing programs in the Baltimore, MD, metropolitan area from June 2019 through December 2020 were analyzed. Of the 70 women enrolled in the study, 70.3 percent (n = 45) desired to avoid pregnancy, but 57.4 percent were either using no contraceptive method (31.2%) or methods with low effectiveness (26.2%). Approximately, 1 in 6 women (16.4%, n = 11) experienced RC in the past 3 months, which was associated with frequency and severity of IPV (p = 0.001 to 0.005) and PTSD (p = 0.001), as well as not sharing children with the abusive partner (p = 0.002). This study highlights reproductive health risks in an important and under-studied population of women seeking housing due to IPV. Leaving an abusive relationship is a uniquely vulnerable time, and also a time of opportunity, as women are accessing services that can be tailored to their SRH needs. Significant results highlight vulnerability to and consequences of RC in this population. This study has implications for IPV support programs and housing programs that serve women.

Reproductive Coercion, Intimate Partner Violence, and Unintended Pregnancy Among Latina Women

Reproductive coercion (RC) describes a range of behaviors that restrict reproductive autonomy including pregnancy coercion, birth control sabotage, and controlling the outcome of a pregnancy. RC is associated with pregnancies that are mistimed and unwanted (i.e., unintended). Past research demonstrates that Latina women have higher risk for RC and for unintended pregnancy. This cross-sectional descriptive study with Latina women (n = 482) examined prevalence and risk factors for RC, evaluated the association of RC and unintended pregnancy among women with a past-year pregnancy, and explored use of safety and harm reduction strategies. A tablet survey was administered to women attending a community health center, between the ages of 15 and 45, who self-identified as Latina and who had a dating or sexual partner in the past year. Approximately one in six (16.8%) experienced past-year RC and risk factors included younger age (adjusted odds ratio [AOR] = 0.95, 95% confidence interval [CI] = [0.91, 1.00], p = .038) and concurrent intimate partner violence (IPV; AOR = 4.47, 95% CI = [2.06, 9.70], p < .001). IPV questions were specific to the partner involved with RC behaviors. For the 185 participants who reported a past-year pregnancy, RC was associated with lower pregnancy planning scores (β = -.27, 95% CI = [-0.41, -0.13], p < .001). The combination of experiencing RC and IPV appeared particularly potent in lowering pregnancy planning scores (β = -.15, 95% CI = [-0.29, 0.00], p = .052). Approximately 10.6% of participants engaged in harm reduction strategies, most commonly ending an unhealthy or abusive relationship (6.1%) and using less detectable methods of contraception so that partners would not find out (3.4%). The study articulates the risk of RC and its intersection with IPV and unintended pregnancy for Latina women. Providers working with racially and ethnically marginalized women have an important role in promoting safety and harm reduction strategies that include offering less detectable methods of contraception and support in leaving unhealthy and abusive relationships.

Pregnancy and parenting support for youth experiencing homelessness

This study explored the perceptions and experiences related to pregnancy and parenting support among youth while homeless. This study employed a qualitative descriptive design using data collected from focus group discussions. We assessed the experiences and perceptions of youth related to pregnancy and parenting support. Eighty-one youth participated in eight focus group discussions and were recruited from shelters, drop-in centers, and organizations that serve youth in a large metropolitan areas in the southern United States. Thematic content analyses were used to generate results from the qualitative data. Four main themes emerged: youth encountered barriers to accessing healthcare services at the individual and system levels; pregnancy and parenting are stressful, especially during homelessness; support can help overcome the stresses of parenting; and embracing responsibility or "stepping up" is a positive influence of pregnancy and parenting during homelessness. Youth experiencing homelessness (YEH) face significant challenges to accessing healthcare services and adjusting to the parental role. Interventions for pregnant and parenting youth should be co-designed with and tailored for youth and address the existing health inequities within the healthcare and social service systems.

Women's perceptions and experiences of reproductive coercion and abuse: a qualitative evidence synthesis

BACKGROUND

Reproductive coercion and abuse is a major public health issue, with significant effects on the health and well-being of women. Reproductive coercion and abuse includes any form of behaviour that intentionally controls another person's reproductive choices. The aim of this qualitative evidence synthesis is to explore women's experiences of reproductive coercion and abuse globally, to broaden understanding of the different ways reproductive coercion and abuse is perpetrated, perceived and experienced across settings and socio-cultural contexts.

METHOD

We searched Medline, CINAHL and Embase for eligible studies from inception to 25th February 2021. Primary studies with a qualitative study design that focused on the experiences and perceptions of women who have encountered reproductive coercion and abuse were eligible for inclusion. Titles and abstracts, and full texts were screened by independent reviewers. We extracted data from included studies using a form designed for this synthesis and assessed methodological limitations using CASP. We used Thomas and Harden's thematic analysis approach to analyse and synthesise the evidence, and the GRADE-CERQual approach to assess confidence in review findings.

RESULTS

We included 33 studies from twelve countries in South Asia, the Asia Pacific, North America, South America, Africa and Europe. Most studies used in-depth interviews and focus group discussions to discuss women's experiences of reproductive coercion and abuse. Reproductive coercion and abuse manifested in a range of behaviours including control of pregnancy outcome, pregnancy pressure or contraceptive sabotage. There were a range of reasons cited for reproductive coercion and abuse, including control of women, rigid gender roles, social inequalities and family pressure. Women's different responses to reproductive coercion and abuse included using covert contraception and feelings of distress, anger and trauma. Across contexts, perpetration and experiences of reproductive coercion and abuse were influenced by different factors including son preferences and social exclusion.

CONCLUSIONS

We reflect on the importance of socio-cultural factors in understanding the phenomenon of reproductive coercion and abuse and how it affects women, as well as how the mechanisms of power and control at both individual and societal levels work to perpetuate the incidence of reproductive coercion and abuse against women.

Social Network Influences on Young Women's Choice to Use Long-Acting Reversible Contraception: A Systematic Review

INTRODUCTION

Long-acting reversible contraception (LARC; including intrauterine devices and implants) is recommended as the first-line contraceptive choice by several professional organizations (eg, American College of Obstetricians and Gynecologists); however, rates of uptake are lower than those of other contraceptive methods. A young woman's social network may influence the decision to use LARC. The purpose of this review was to determine the role of health care providers (HCPs), family, peers, and sexual partner(s) on young women's decisions to initiate LARC.

METHODS

Several databases (PubMed, CINAHL, and PsycINFO) were searched for articles published between 2000 and 2020 that studied the social network influences of HCPs, family, peers, and sexual partner(s) on LARC initiation among women in the United States aged 18 to 25. A narrative synthesis of the included articles was conducted.

RESULTS

Twenty-nine articles met the inclusion criteria (21 qualitative, 6 quantitative, 2 mixed methods). HCPs are an important influence on a young woman's LARC decision-making. Peers and family also have a role but were often sources of negative or inaccurate information. Gaps in the literature were identified, including a lack of data on implant users and a dearth of studies on the role of sexual partner influence; most studies were not guided by theory.

DISCUSSION

HCPs are integral to LARC initiation and may be more influential than other social network members. Future research should focus on understanding how social network members interact to result in LARC initiation. Gaining insight into these influences may improve existing interventions or contribute to the development of new interventions and ultimately promote LARC use among young women.

Birth Control Access and Selection among Youths Experiencing Homelessness in the United States: A Review

Youths experiencing homelessness (YEH) become pregnant at five times the general population rate. Education, social, and health care systems struggle to adequately address this young community's sexual and reproductive health needs, yet social workers are well positioned across sectors to address their sexual and reproductive health and well-being. A growing body of literature exists on the factors affecting YEH's access and selection of birth control, prompting the present review that aimed to understand this process and inform better attuned sexual and reproductive health approaches. Using a systematic search and analytic approach, we retrieved 203 articles, of which 23 met inclusion criteria. Key findings emerged across socioecological levels, including barriers and facilitators to condom use; the differential impact on YEH of hormonal birth control side effects; and the devastating effects of economic insecurity leading to sexual exploitation, survival sex, and exposure to violence. Implications include the need for multilevel intervention that addresses youths' knowledge, attitudes, and behavior as well the need to improve social norms and system design to provide better attuned care for YEH.

Perceived barriers and facilitators to accessing and utilising sexual and reproductive healthcare for people who experience homelessness: a systematic review

INTRODUCTION

People who experience homelessness face disproportionately poor reproductive health and adverse pregnancy outcomes, including but not limited to unintended pregnancy, abortion, low birth weight and preterm birth, as well as a higher risk of sexually transmitted infections (STIs). Precarious living conditions are known to contribute to poor uptake and engagement with sexual and reproductive healthcare (SRH) for this population.

AIM

To identify and understand the perceived barriers and facilitators for accessing and utilising SRH for people who experience homelessness from their perspective, and the perspective of support staff/volunteers and healthcare professionals.

METHODS

Electronic databases and online sources were searched. Two reviewers independently carried out the screening, data extraction, critical appraisal, data synthesis and thematic analysis of findings.

RESULTS

Following deduplication and screening, 23 papers/reports were considered eligible for the review. Barriers for people experiencing homelessness to accessing and utilising SRH were identified within the themes of complexity, feelings and knowledge (ie, individual-level factors), as well as patient/provider interaction and healthcare system (ie, organisational factors). Facilitators were identified within all of the above themes except for complexity.

CONCLUSIONS

Both population characteristics and attributes of the healthcare system influence access and utilisation of SRH by people experiencing homelessness. Given the complexity of living conditions associated with homelessness, greater efforts to improve access should be placed on healthcare systems and aspects of care delivery. This systematic review highlights current gaps in the literature and provides recommendations for enhancing future research and practice to meet the needs of this vulnerable group more effectively.

The ethics of state-sponsored and clinical promotion of long-acting reversible contraception

OBJECTIVES

To review ethical aspects of the promotion and provision of long-acting reversible contraception (LARC). Specifically, to examine (1) the tension between informational exchange and the active promotion of LARC methods to new and existing contraceptive users by healthcare professionals; and (2) the distinct ethical issues arising from the promotion of LARC methods by state-sponsored actors and healthcare professionals.

METHODS

Narrative review and ethical analysis.

FINDINGS

There is an ethical difference between raising awareness/informational provision and actively promoting or prioritising specific contraceptive methods. It matters whether the policy choice is made, or the promotional activity about contraception is undertaken, by individual healthcare professionals at a local level or by more remote state-sponsored actors, because the relationship between the promoter and the (potential) contraceptive user is of a different kind. Imposing a dual responsibility upon healthcare professionals for raising awareness/informational exchange and the active promotion of LARC creates an unnecessary tension and barrier for the delivery of patient-centred care.

CONCLUSIONS

This review highlights the need for ethical reflection on the central role of the promoting agent and the distinction between facilitating informational awareness and active promotion of LARC. LARC methods should not be prioritised in isolation and without regard to the wider implications of public promotion. A balanced narrative and information-sharing programme that respects the individual interests of each contraceptive user is called for, especially in direct professional/service user relationships. No assumption should be made that user decision-making will necessarily be determined and influenced solely by the relative effectiveness of the contraceptive method.

Trends and factors influencing long-acting contraceptive utilisation among contraceptive users in Ethiopia: repeated cross-sectional study

OBJECTIVES

Although nationally representative data are helpful in designing strategies and policies of programmes in a country, there is paucity of evidence with regard to trends and factors influencing utilisation of long-acting contraceptives (LACs). Thus, this study aimed to assess the trends and factors influencing LAC utilisation among contraceptive users in Ethiopia.

DESIGN

A repeated cross-sectional study.

SETTING AND PARTICIPANTS

The Performance Monitoring and Accountability (PMA2020) national community-based survey data were used, and 2035 contraceptive users participated. To identify trends, proportions of LAC users were analysed using PMA data from round 1 in January 2014 to round 6 in July 2018.

MAIN OUTCOME MEASURES

Users using LAC methods or otherwise.

RESULTS

There was a difference in trends in LAC utilisation in the last 4.5 years. There was a 7% increase in the proportion of implant users, while there were no significant changes in utilisation of intrauterine device and female sterilisation. Women in the middle wealth quintile were 1.7 times more likely than those in the lowest quintile to use LAC, while contraceptive users who received recommendations from healthcare providers as well as those who made decisions jointly with healthcare providers were more likely to use LAC compared with those who decided on their own. Women with access to their desired method of contraception were less likely to use LAC, while those informed about intrauterine contraceptive device were more likely to use LAC compared with their counterparts. Women served at health posts, private hospitals and others (family planning clinics, pharmacies and non-governmental organisations) were less likely to use LAC compared with women served at public hospitals.

CONCLUSION

Overall the utilisation of LAC in Ethiopia is low. Therefore, much has to be done in terms of raising awareness about intrauterine device, how healthcare providers can help users in choosing contraceptive methods, and sharing of experiences between public hospitals and other family planning service delivery points.

Contraceptive usage in homeless women accessing a dedicated primary care service in Scotland, UK: a case note review

BACKGROUND

Of the 70 000 people experiencing homelessness in Scotland, at least 40% are women. Little is known about their contraceptive usage. Most pregnancies in homelessness are unintended and children are usually looked after in the care system.

METHODS

A case note review of women's current contraceptive usage in a primary care service serving women experiencing homelessness in Edinburgh, Scotland. The service electronic database was searched for keywords relating to contraception to determine current usage, but also reproductive health, wider demographics and previous pregnancies.

RESULTS

Of 174 women (16-55 years), 75 (43%) were recorded as using a contraceptive method. 49 (28%) were using long-acting reversible contraception (LARC), most of which was the contraceptive implant. However, 6/41 (15%) of the most effective LARC (intrauterine contraception and implant) was being used beyond its' expiry date. 34 (20%) had no mention of contraceptive use in their medical record and 32 (19%) were not using contraception despite being sexually active. 6 (3%) had been hysterectomised/female sterilisation. 26 (15%) were not sexually active. 179 of the 233 (77%) children mentioned in women's electronic records were recorded as being looked after out with their care. 138/174 (79%) had current/previous drug or alcohol misuse. 100/174 (57%) had a history of domestic violence or abuse. 22/174 (13%) were involved/had been involved in sex work.

CONCLUSIONS

Primary care services need to give greater attention to the contraceptive needs of homeless women to empower them to become pregnant when the time is right for them and prevent the consequences of unintended pregnancy and homelessness.

Desire for and barriers to obtaining effective contraception among women experiencing homelessness

Background

Homelessness is a significant and growing problem in the United States. Women experiencing homelessness face unique challenges as they have high rates of unintended pregnancy. They often face significant barriers to obtaining effective contraception. This study aimed to explore the contraceptive preferences, desire for, and barriers to obtaining effective contraception among women experiencing homelessness.

Study design

In this cross-sectional study, 54 women experiencing homelessness in Chicago who were at risk for unintended pregnancy were surveyed.

Results

While 94% of the women experiencing homelessness surveyed desired avoiding pregnancy, most were using the least effective contraceptive methods. Among participants, 80% had health insurance, 75% had a high school diploma, and 90% knew where to obtain birth control. Despite these factors, participants faced barriers to obtaining contraception. One significant barrier was lack of comprehensive contraceptive counseling as 62% report a physician had never counseled them on LARC methods. Approximately half of participants desired or would consider using a LARC in the future.

Conclusions

Women experiencing homelessness in our study demonstrate significant unmet needs for effective contraception. Women experiencing homelessness would benefit from comprehensive contraceptive counseling and improved access to effective forms of contraception.

Feasibility and acceptability of using a web-based contraceptive support tool in a university health clinic

Objective: To evaluate feasibility of integrating Bedsider.org, a web-based contraceptive decision support tool, at a university health clinic (UHC). Participants: Female students (ages 18-29) seeking contraceptive care at the UHC were enrolled in September 2015 (n = 46). Methods: Providers recruited eligible patients during reproductive healthcare visits and introduced Bedsider. Surveys were administered immediately following the visit and a follow-up 2-4 weeks later. Electronic health records through 6 weeks post-enrollment were extracted. Results: Most patients had positive views toward Bedsider and appreciated receiving information during their UHC encounters. None were using long-acting reversible contraceptives (LARC) at enrollment. At follow-up, two patients self-reported IUD use. Among those recently sexually active, use of more effective contraceptive methods increased from 65% to 74%; 11% had initiated or were scheduled to receive a LARC. Conclusion: Bedsider can be feasibly integrated into UHC visits and may support women's selection of more effective contraceptive methods, including LARCs.

The effect of a no-cost contraceptive initiative on method selection by women with housing insecurity

OBJECTIVES

To compare the sociodemographic characteristics of participants in a contraceptive initiative by housing security and determine the association between housing insecurity on contraceptive method selection before and after the removal of cost.

STUDY DESIGN

This cross-sectional assessment includes 4,327 reproductive-aged participants in the HER Salt Lake Contraceptive Initiative who sought new contraceptive services and reported housing status at enrollment. HER Salt Lake prospectively explored the impact of improved contraceptive access on socioeconomic outcomes in Salt Lake County (USA). For six months (September 2015-March 2016) we collected control data, which included clinic standard-of-care cost-sharing. The intervention started March 2016, and provided no-cost contraception services and unlimited opportunities for method switching over the subsequent three years.

RESULTS

There were 964 (22%) housing-insecure participants. Compared to those with stable housing, housing-insecure individuals more commonly identified as a sexual minority, received public assistance and lacked health insurance. Housing-insecure women preferentially selected long-acting reversible contraception during the control period (aOR 1.60; 95%CI 1.01-2.56), but method selection equalized across housing status during the intervention.

CONCLUSIONS

When cost is not a barrier, all women desire a comprehensive selection of contraceptive methods, regardless of housing security. Contraceptive clients in this vulnerable population need interventions which address access barriers to all methods to support reproductive planning.

IMPLICATIONS

Unintended pregnancy during housing insecurity may result in homelessness. This study found housing-insecure women desire access to all contraceptive methods, not just long acting reversible contraception. Integration of comprehensive family planning initiatives into efforts to address homelessness is essential to support this vulnerable population in their reproductive planning.

Efficacy-based Contraceptive Counseling for Women Experiencing Homelessness in Iowa City, Iowa

This study evaluated homeless women's contraception knowledge and demonstrated improved knowledge following efficacy-based contraceptive counseling. Women were surveyed using a pre-test then post-test following standardized efficacy-based contraceptive counseling. 47 women participated. 13/19 (68.4%) of reproductive-aged women were not using contraception. After education there was significant increase in good-excellent self-rated knowledge (35, 75.5% vs 44, 93.6%; p < .001) and correct identification of most effective contraception OR 5.90 (95% CI = 2.31-15.02; p < .001). In conclusion, homeless women overestimated their understanding of contraception. Following education, there was significantly increased understanding of efficacy. While most did not desire pregnancy, few were using effective contraception and may benefit from education. Abbreviations: SH: Shelter House; LARC: Long-Acting Reversible Contraception; IUD: Intra-Uterine Device; ACOG: American College of Obstetricians and Gynecologists.

"It seems kinda like a different language to us": Homeless youths' attitudes and experiences pertaining to condoms and contraceptives

Homeless youth become pregnant or involved in pregnancies at high rates. There are many ways by which unintended pregnancies may be prevented, including the use of condoms and other contraceptives. However, there is a dearth of research regarding contraceptive use among this vulnerable youth population, and especially through lenses that consider homeless youths' diverse gender identities, expressions, and sexualities. This study qualitatively explores homeless youths' attitudes and experiences regarding condom and other contraceptive use. Data were obtained from interviews with 30 youth experiencing homelessness, ages 18-21. Youth reported inconsistent use of condoms and other contraceptives, which youth often attributed to their perceptions of contraceptive inaccessibility and exorbitant cost. Most youth also did not know where to obtain contraceptive information and services, and reported transportation barriers and fear of being stigmatized in health care settings, particularly in relation to their gender identities and sexualities. Findings suggest that reproductive and sexual health information and services are urgently needed by all homeless young people, and from low-barrier, non-judgmental, and empathetic sources.

A Qualitative Study Exploring Contraceptive Practices and Barriers to Long-Acting Reversible Contraceptive Use in a Sample of Adolescents Living in the Southern United States

STUDY OBJECTIVE

To understand contraceptive practices of female adolescents in the Deep South and determine barriers to their use of long-acting reversible contraception (LARC).

DESIGN

Semistructured interviews were conducted that addressed current contraceptive choice, factors influencing choice, LARC awareness, concerns, and barriers to using LARC. Interviews were audio recorded, transcribed, and analyzed using qualitative content analysis to identify themes.

SETTING

Adolescent medicine clinic in an urban academic medical center in the Deep South region of the United States.

PARTICIPANTS

Sexually active girls between the ages of 14 and 21 years who were not currently using LARC.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Themes generated during semistructured interviews.

RESULTS

Fifteen participants were interviewed with a mean age of 17 years. Fourteen of 15 were African American. Thirteen of 15 were currently using non-LARC methods and 2 of 15 were not using any contraceptive method. Contraceptive choice was driven by perceived ease of use, desire for pregnancy prevention, and seeking relief of menstrual concerns. Thirteen of 15 participants were aware of LARC with 11 of 15 (73%) noting information came from a health care provider. Barriers to current and future LARC use included concerns about side effects, LARC ineffectiveness, device longevity, and LARC invasiveness. Sixty-three percent of participants noted that they would not consider using a LARC in the future.

CONCLUSION

Increasing use of LARC goes beyond awareness. Concerns about effectiveness, future fertility, duration of devices, and perceived invasiveness represent barriers for adolescents. Further research is needed to determine how to address these barriers because it pertains to counseling of sexually active girls on the use of LARC.

Youth-Friendly Family Planning Services for Young People: A Systematic Review Update

CONTEXT

Youth-friendly family planning services may improve youth reproductive health outcomes. A systematic review conducted in 2011 was updated in 2016 to incorporate recent data examining the effects of youth-friendly family planning services on reproductive health outcomes and the facilitators and barriers facing young people in accessing family planning services.

EVIDENCE ACQUISITION

PubMed, POPLINE, EMBASE, and other databases were used to identify relevant articles published from March 2011 through April 2016.

EVIDENCE SYNTHESIS

Eighteen studies met inclusion criteria and were added to 19 studies from the review conducted in 2011. Of these, seven assessed the effect of youth-friendly services on outcomes: two showed a positive effect on reducing teen pregnancy, three on contraceptive use, and three on knowledge and patient satisfaction (not mutually exclusive). Facilitators or barriers were described in 32 studies. However, none were RCTs and most were at high risk for bias due to selection, self-report, and recall bias among others.

CONCLUSIONS

The studies in this review suggest some positive effects of youth-friendly family planning services on reproductive health outcomes, but the need for more rigorous research persists. This review identified numerous factors relevant to young people's access to family planning services, reaffirming findings from the initial review: young people value confidentiality, supportive provider interaction, specialized provider training, and the removal of logistic barriers. Further, it illuminates the importance young people place on receiving comprehensive, client-centered family planning counseling. These findings should be considered when developing, implementing, and evaluating reproductive health services for young people.

THEME INFORMATION

This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Client Preferences for Contraceptive Counseling: A Systematic Review

CONTEXT

Providers can help clients achieve their personal reproductive goals by providing high-quality, client-centered contraceptive counseling. Given the individualized nature of contraceptive decision making, provider attention to clients' preferences for counseling interactions can enhance client centeredness. The objective of this systematic review was to summarize the evidence on what preferences clients have for the contraceptive counseling they receive.

EVIDENCE ACQUISITION

This systematic review is part of an update to a prior review series to inform contraceptive counseling in clinical settings. Sixteen electronic bibliographic databases were searched for studies related to client preferences for contraceptive counseling published in the U.S. or similar settings from March 2011 through November 2016. Because studies on client preferences were not included in the prior review series, a limited search was conducted for earlier research published from October 1992 through February 2011.

EVIDENCE SYNTHESIS

In total, 26 articles met inclusion criteria, including 17 from the search of literature published March 2011 or later and nine from the search of literature from October 1992 through February 2011. Nineteen articles included results about client preferences for information received during counseling, 13 articles included results about preferences for the decision-making process, 13 articles included results about preferences for the relationship between providers and clients, and 11 articles included results about preferences for the context in which contraceptive counseling is delivered.

CONCLUSIONS

Evidence from the mostly small, qualitative studies included in this review describes preferences for the contraceptive counseling interaction. Provider attention to these preferences may improve the quality of family planning care; future research is needed to explore interventions designed to meet preferences.

THEME INFORMATION

This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.