Understanding the Family Planning Needs of Female Participants in a Syringe Exchange Program: A Needs Assessment and Pilot Project

Partnering with recovery community centers to build recovery capital by improving access to reproductive health

BACKGROUND

People with substance use disorders (SUD), especially opioid use disorder (OUD) have the highest rates of unintended pregnancies (80-95%) and report unmet reproductive health needs. Women of childbearing age have some of the highest death rates from opioids and are notably rising the most rapidly, and when pregnancy does occur overdose is one of the leading causes of maternal mortality. There are numerous gender-based health disparities and social determinants of health shaped by the distribution of power and privilege that influence the risk trajectories of people who can get pregnant or are pregnant with a substance use disorder (SUD).

PURPOSE

The purpose of this paper is to describe how reproductive health is essential to recovery and building recovery capital for people who can get pregnant, (1) introduce a pilot implementation science study working with trained peer support coaches to promote reproductive autonomy in the community, and (2) make policy and advocacy recommendations relevant to the new reproductive health landscape in the United States. We will also describe the adaptation and feasibility of the initial pilot study where we partnered with a recovery community center to train peer recovery coaches to provide low barrier resources (contraception, pregnancy tests and prenatal vitamins) and referrals to health care.

METHODS

This initiative is the merging of best practices in recovery and community-based global reproductive health, to empower people with SUD who can get pregnant in an implementation science framework. The pilot study will last 3 months in each city and aims to (1) assess and describe the effectiveness of the training of local peer recovery coaches on the link between recovery capital and reproductive health, and (2) assess the feasibility, acceptability, appropriateness, scalability, sustainability, and uptake and reach of low barrier reproductive health resources (pregnancy tests, prenatal vitamins, and emergency contraception). In this paper we are only reporting the initial findings regarding adaptation and feasibility.

FINDINGS

Informed by qualitative interviews with stakeholders and participants, the method of contraception was adapted from injectable to emergency to meet the needs and context of the community with SUD. Early outcomes such as uptake and acceptability indicate that this is a feasible model with peer recovery coaches and recovery community centers, with the greatest uptake of emergency contraception and pregnancy tests.

CONCLUSION

Considering recent policies limiting access to reproductive health, innovative community-based solutions are needed to engage and empower people who can get pregnant or are pregnant while in active drug use and in recovery. Providing low barrier reproductive health items by people with lived experience with SUD can serve as a valuable harm reduction model and improve recovery capital.

CLINICAL RELEVANCE

This is the first study to propose a methodology and context to implement a community-based study merging best practices in recovery with those in reproductive health with the potential to improve recovery capital and maternal/child health trajectories for people with SUD.

Client Characteristics Associated with Desire for Additional Services at Syringe Exchange Programs

Objectives

The objective of this study was to explore the relationship between client characteristics and desired services offered at syringe exchange program (SEP) sites among women who inject drugs (WWID). We investigated whether a desire for additional services varied as a function of these client characteristics.

Methods

A sample of 69 women who were syringe exchange clients participated in a survey about adding services to syringe exchange programs. Three Poisson regression analyses were run to examine if client age, education, housing status, polysubstance use, and previous pregnancies were associated with overall desire for services, desire for health-related services, and desire basic needs services.

Results

Participant characteristics of polysubstance use (IRR 1.62, 95% CI 1.34-1.96; p < .01) and greater number of previous pregnancies (IRR 1.14, 95% CI 1.08-1.22; p < .05), were predictive of a greater number of desired services. Engagement in polysubstance use was predictive of a greater number of desired basic need services (IRR 1.45, 95% CI 1.23-1.70; p < .05).

Conclusions

WWID desired services at SEP sites can inform policymakers to formulate policies to better promote utilization of health-related and basic need services among WWID and, in turn, facilitate improved outcomes for WWID.

Voluntary Pregnancy Screening at Syringe Exchanges: A Feasibility Study

The purpose of this study was to explore the feasibility of offering voluntary pregnancy screening at syringe exchange programs using the National Implementation Research Network Hexagon Discussion and Analysis Tool. We conducted a survey among female syringe exchange clients that assessed perceived needs, values, and behavioral intentions for parenting and entering treatment if they received a positive pregnancy screen and surveys among staff and core volunteers to assess organizational fit, capacity, and needed supports. Participants and staff reported that pregnancy screening was needed at syringe exchange and that capacity needs to be expanded to provide services. Pregnancy screening at syringe exchanges holds the potential to lead to early detection of pregnancy. Early detection of pregnancy among women who inject drugs may result in improved prenatal care, including substance use treatment and treatment of infectious diseases, for women who would otherwise be unlikely to receive prenatal care.

Understanding Contraceptive Needs of Women Who Inject Drugs in Orange County: A Qualitative Study

OBJECTIVES

Women with opioid use disorder experience higher rates of unintended pregnancy compared with the general US population. Our aim was to examine the factors that may affect access to desired contraception for women who use injection drugs.

METHODS

Using purposive sampling, we conducted semi-structured interviews pertaining to contraceptive use with 14 women ages 18 to 44 who were current users of injection drugs living in Orange County, CA between March and December 2019. Interviews were transcribed, coded, and analyzed using grounded theory.

RESULTS

Participants discussed logistical barriers, including homelessness and lack of transportation, as well as perceived barriers, such as a belief in the inability to become pregnant while using drugs, that affect access to contraceptive care. Women also discussed the factors that motivate them to use contraception despite these barriers, including the desire for sobriety before becoming pregnant and fear of harming a fetus while using substances. Some participants expressed feeling uncomfortable disclosing substance use to their healthcare providers out of concern for stigmatization. Several points of access for contraceptive care were elucidated, including visits for primary and postpartum care, as well as in carceral spaces. Finally, participants expressed a desire to obtain contraceptive services at a local syringe exchange program due to trusting relationships with providers and increased ease of access.

CONCLUSIONS

Our findings highlight several causative factors for the unmet contraceptive need among women who use injection drugs, and suggest that syringe exchange programs represent a unique access point for the provision of contraceptive care for this population.

Factors Affecting Contraception Access and Use in Patients With Opioid Use Disorder

Maternal opioid use disorder increased > 4-fold from 1999 to 2014 and is associated with poor maternal and fetal outcomes. Women with opioid use disorder are at 2 to 3 times greater risk for unintended pregnancy than the general population and may face additional barriers to accessing and effectively using contraception compared to women without opioid use disorder, particularly highly effective long-acting reversible contraception. Additionally, women with opioid use disorder tend to use less effective forms of contraception such as condoms alone. Barriers to contraceptive access include patient misconceptions or knowledge gaps regarding reproductive health and family planning, cost, intimate partner violence, fear of criminalization, difficulty accessing care, comorbid health conditions, and health care provider misconceptions or practice limitations. Strategies that may assist women with opioid use disorder in achieving their family planning goals include colocation of family planning services within opioid treatment facilities, optimization of patient care services to minimize the need for costly and/or time consuming follow-up, increasing provider education and awareness of best practices in family planning and opioid use disorder treatment, and providing patient-centered family planning education and counseling. Additional research is needed to identify and develop strategies that empower women who use opioids to effectively access and use their preferred contraceptive method.

Expanding Contraception Access for Women With Opioid-Use Disorder: A Qualitative Study of Opportunities and Challenges

PURPOSE

As almost nine in ten pregnancies among women with opioid use disorder (OUD) are unintended, expanding access to contraception is an underutilized but potentially effective strategy in increasing reproductive agency and reducing the overall burden of neonatal abstinence syndrome. We aimed to identify where and how contraceptive services could be integrated into existing points-of-contact for women with OUD.

APPROACH

In-depth qualitative interviews.

SETTING

Three diverse catchment areas in Missouri.

PARTICIPANTS

Women with OUD (n = 15) and professional stakeholders (n = 16) representing five types of existing OUD service points: syringe exchange programs, recovery support programs, substance use treatment programs, emergency departments, and Federally Qualified Health Centers.

METHOD

Interviews were audio-recorded, transcribed, and thematically coded using Dedoose software.

RESULTS

Six themes emerged as essential components for integrating contraceptive services into existing points-of-contact for women with OUD: (1) reach women with unmet need; (2) provide free or affordable contraception; (3) maximize service accessibility; (4) provide patient-centered care; (5) employ willing, qualified contraceptive providers; and (6) utilize peer educators. Participants affirmed the overall potential benefit of contraceptive service integration and illuminated various opportunities and challenges relevant to each type of existing service point.

CONCLUSION

As health promotion initiatives look to increase access to contraception among women with OUD, these six' participant-identified components offer essential guidance in selecting advantageous points-of-contact and addressing remaining gaps in services.

Integrating Reproductive Health Services Into Opioid Treatment Facilities: A Missed Opportunity to Prevent Opioid-exposed Pregnancies and Improve the Health of Women Who Use Drugs

: Opioid treatment programs (OTPs) are federally mandated to provide certain medical services to patients, and are often the only place where people with substance use disorders (SUD) obtain medical care. Just as medication for addiction treatment (MAT) should be part of comprehensive addiction care, so should reproductive health care be a part of comprehensive medical care. The most significant barrier that must be overcome is that the majority of OTPs believe that it is outside their scope of service to provide reproductive health services. Reproductive health care is basic medical care. It is imperative for the long-term health of women with SUD, their children and the community that they receive this care. OTPs can and should do better for their female clients.

Innovative approaches to reduce unintended pregnancy and improve access to contraception among women who use opioids

Dramatic increases in the rate of opioid use disorder (OUD) during pregnancy have been paralleled by substantial increases in the number of neonates diagnosed with neonatal abstinence syndrome (NAS). Women with OUD have reliably reported high rates of unintended pregnancy and a number of studies also indicate they desire easier access to contraception. Recent statements from the Centers for Disease Control and Prevention and the American Academy of Pediatrics/American College of Obstetricians and Gynecologists have drawn increased attention to efforts to prevent unintended pregnancy and improve access to contraception among women with OUD. We briefly review a number of innovative clinical approaches in these areas, including efforts to integrate family planning services into substance use disorder (SUD) treatment and other settings that serve people with OUD and interventions that aim to make family planning a higher priority among women with OUD. Results suggest many of these approaches have led to increases in contraceptive use and may aid in efforts to reduce unintended pregnancy and improve access to contraception among women with OUD now and in the future.