Provider Perspectives of Barriers to Contraceptive Access and Use among Women with Substance Use Disorders

Uptake of gynecological consultation following domestic or sexual violence: A case-control study in the context of induced abortion

OBJECTIVE

The aim of this study was to determine the prevalence of domestic and sexual violence and to characterize the association between exposure to domestic and sexual violence and low uptake of gynecological care, in the context of induced abortion.

STUDY DESIGN

We conducted a case-control study among women seeking abortion care, in mother and child centers and sexual health centers in the Paris, France area (April 2022-March 2023).

RESULTS

A total of 103 women were included in the study during induced abortion care. Physical, psychological or sexual domestic violence was reported by 48.5 % and sexual violence, whoever the perpetrator, was reported by 23.3 %. In the bivariate analysis, a history of physical, psychological or sexual domestic violence was not associated with the absence of a gynecological consultation in the past two years, compared with no history of intimate partner violence (p = 0.09). After adjustment for regular pelvic pain, dysmenorrhea, vulvodynia and dyspareunia, there was no association between a history of sexual violence and the absence of a gynecological consultation in the past two years (OR 1.05; CI95% 0.27-4.13, p = 0.93).

CONCLUSION

Violence was a common finding among women seeking abortion care. We did not find any association between a history of sexual violence and the absence of a gynecological consultation in the past two years. We suggest investigating multiple or frequent use of gynecological care following violence. The combination of ethical, moral, and psychological constraints associated with violence screening and abortion care is a challenge to patient recruitment in future studies.

Integration of a facilitated access pathway for contraception into alcohol and other drug treatment services: A cohort study comparing metropolitan and regional settings

INTRODUCTION

Women who attend alcohol and other drug (AOD) services experience higher rates of unintended pregnancy, and access less contraception, than the general population. This study aims to observe contraceptive initiation and use after contraception services were offered at metropolitan and regional AOD services.

METHODS

Clinical staff were provided contraception education. One hundred women aged 16-49 were recruited from two services between 2017 and 2021. Women completed a questionnaire on their obstetrics and gynaecological history, pregnancy plans and contraception use. Women were provided education on contraception options and offered referral to a contraception pathway. The primary outcome was initiation of highly reliable contraception; secondary outcomes were the types of contraception initiated, and contraception use and pregnancy at 12 months. We compared the initiation of contraception across the two study sites.

RESULTS

At baseline, 91% of women were not planning a pregnancy within 12 months, with 21% of these using highly reliable contraception. Of all women not planning a pregnancy, 28% initiated highly reliable contraception via the pathway (2% metropolitan, 51% regional, p < 0.001), with intrauterine devices being the most frequent method initiated (15%). At 12 months, 44% were using highly reliable contraception and 15% had recorded pregnancies.

DISCUSSION AND CONCLUSIONS

Contraception pathways for women in AOD treatment can improve initiation of highly reliable methods of contraception, although pregnancy rates were still high and there were large differences between the study sites. Care navigation and clinical champions are some potential facilitators to contraception access, and understanding additional barriers to access may be useful.

Multiple marginalized identities: A qualitative exploration of intersectional perinatal experiences of birthing people of color with substance use disorder in Massachusetts

INTRODUCTION

Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals.

METHODS

Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development.

RESULTS

The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination.

CONCLUSION

Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.

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.

"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.

A Socioecological Model of Heart Failure Self-Care

Heart failure is a chronic, progressively worsening condition afflicting more than 64 million individuals worldwide. Heart failure outcomes are influenced by self-care, a naturalistic patient-centered decision-making process. The situation-specific theory of heart failure self-care addresses how this decision-making process determines actions and outcomes. However, little is known about the impact of socioecological determinants of health on heart failure self-care. A theoretical synthesis could advance the situation-specific theory of heart failure self-care through the inclusion of socioecological determinants of health. Thus, socioecological determinants of health related to heart failure self-care can be better explored, understood, and overcome through research and health promotion.