Expanding Contraceptive Access for Women With Substance Use Disorders: Partnerships Between Public Health Departments and County Jails

Building an implementation framework to address unmet contraceptive care needs in a carceral setting: a systematic review

BACKGROUND

The provision of contraceptive care for incarcerated individuals has been largely inconsistent and has contributed to, at best, inadequate care, and at worst reproductive abuses, violence, and coercion. While previous research has identified strategies to remedy known issues, to date, very few recommendations have been implemented across the carceral system. To address this, we conducted a systematic review of policy and practice recommendations to improve contraceptive care to reproductive-aged, incarcerated individuals in the United States.

METHODS

We conducted this systematic review utilizing the Joanna Briggs Institute methodology and framed it within the National Implementation Research Network's (NIRN) Exploration stage. We searched PubMed, PSYCInfo, SCOPUS, ProQuest, Web of Science, MedLine, Social Science Citation Index and reference sections of included materials. Basic study information, explicitly stated policy and practice recommendations, and discussions and conclusions that subtly provide recommendations were extracted in full text. We utilized a thematic analysis approach to analyze the extracted text.

RESULTS

A total of 45 materials met the inclusion criteria. Seven overarching themes were identified: 1) policy changes needed to implement care; 2) need for contraceptive care in carceral systems; 3) justice agency barriers regarding contraceptive care provision; 4) policy barriers to contraceptive access; 5) funding strategies to improve care; 6) patient preferences for contraceptive care delivery; and 7) healthcare provider knowledge regarding contraceptive care. The seven themes identified shed light on the need for, gaps, barriers, and facilitators of current contraceptive care provision to incarcerated individuals.

CONCLUSION

This systematic review accomplished two goals of NIRN's Exploration stage. First, the compiled evidence identified a clear need for change regarding policies and practices pertaining to contraceptive care provision to incarcerated individuals in the United States. Second, our findings identified several evidence-based solutions supported both by research and professional healthcare organizations to address the identified need for change. This study provides an initial blueprint for correctional agencies to implement the necessary changes for improving contraceptive care provision to incarcerated populations. The correctional system is in a unique position to deliver much-needed care, which would result in many potential benefits to the individuals, correctional system, and community at large.

Barriers to and facilitators of hormonal and long-acting reversible contraception access and use in the US among reproductive-aged women who use opioids: A scoping review

Existing research has found that women who use opioids (WWUO) experience challenges to hormonal and long-acting reversible contraception (HC-LARC) access and use. Facilitators of such use are unclear. We conducted a scoping review to comprehensively map the literature on barriers to and facilitators of HC-LARC access and use in the United States among reproductive-aged WWUO. In accordance with the JBI Manual of Evidence Synthesis, we conducted literature searches for empirical articles published from 1990 to 2021. Independent reviewers screened references, first by titles and abstracts, then by full-text, and charted data of eligible articles. We coded and organized HC-LARC barriers and facilitators according to a four-level social-ecological model (SEM) and categorized findings within each SEM level into domains. We screened 4,617 records, of which 28 articles focusing on HC-LARC (n = 18), LARC only (n = 6), or testing an intervention to increase HC-LARC uptake (n = 4) met inclusion criteria. We identified 13 domains of barriers and 11 domains of facilitators across four SEM levels (individual, relationship, community, societal). The most frequently cited barriers and facilitators were methods characteristics, partner and provider relations, transportation, healthcare availability and accessibility, cost, insurance, and stigma. Future studies would benefit from recruiting participants and collecting data in community settings, targeting more diverse populations, and identifying neighborhood, social, and policy barriers and facilitators. Reducing barriers and improving equity in HC-LARC access and use among WWUO is a complex, multifaceted issue that will require targeting factors simultaneously at multiple levels of the social-ecological hierarchy to effect change.

Measurement and Operationalization of the Social Determinants of Health and Long-Acting Reversible Contraception Use in the U.S.: A Systematic Scoping Review

Introduction

The objective of this review was to conduct a systematic evaluation of the measurement and operationalization of the social determinants of health in research on long-acting reversible contraception use in the U.S. To contribute to the ongoing refinement of the quality of social determinants of health and long-acting reversible contraception use research, this systematic scoping review examines how social determinants of health are measured and operationalized in studies that examine long-acting reversible contraception initiation and usage at the patient level.

Methods

A detailed search of 5 electronic databases (PubMed, Embase, Web of Science, CINAHL, and PsycINFO) was conducted between December 2020 and January 2021 according to PRISMA guidelines. Determinants were assessed using the Dahlgren and Whitehead model. The protocol and data extraction template were developed a priori.

Results

A total of 27 articles representing 26 studies were included in our study. A total of 12 studies were retrospective and cross-sectional in design; the remaining studies were a combination of designs. Healthcare services and health insurance were identified as the most frequently researched categories of determinants. There was wide variation in reported operationalization of race and ethnicity, limited engagement with sexuality, and uneven geographic representation across studies.

Discussion

This systematic scoping review is the first, to the best of our knowledge, to focus on the measurement and operationalization of social determinants of health and on current long-acting reversible contraception use research. Future research on the impact of social determinants of health on long-acting reversible contraception use must explore the full range of factors shaping contraceptive decision making and use and focus on equity-informed data collection methods and reporting.

Overlapping needs for sexual and reproductive health and HIV prevention in women with substance use disorders

OBJECTIVES

Women with substance use disorders have high unmet needs for HIV prevention and drug treatment and face challenges accessing care for other unique health issues, including their sexual and reproductive health.

METHODS

We did a cross-sectional evaluation of sexual and reproductive health behaviors and outcomes among women with substance use disorders, who were enrolled in one of two concurrent clinical trials of pre-exposure prophylaxis for HIV prevention. Descriptive analyses and bivariate logistic regression were used to assess factors driving contraceptive use, and other essential sexual and reproductive health services utilization and outcomes.

RESULTS

Among 226 women, 173 (76.5%) were of reproductive age. Most women had histories of unintended pregnancy (79.2%) or miscarriage (45.1%) and high HIV risk behaviors (53.5%). Most (61%) participants did not use any form of contraception at the time of assessment, although few (15%) reported pregnancy intentions. In bivariate models, ongoing criminal justice involvement was associated with 2.22 higher odds of not using contraception (95% confidence interval = 1.09-4.53; p = 0.03) and hazardous drinking was protective against not using contraception (odds ratio = 0.33, 95% confidence interval = 0.13-0.81; p = 0.02). Contraception use was not significantly associated with any other individual characteristics or need factors.

CONCLUSIONS

This is the first study that identifies the unmet sexual and reproductive health needs of women with substance use disorders who are engaging with pre-exposure prophylaxis. We found that women accessed some health services but not in a way that holistically addresses the full scope of their needs. Integrated sexual and reproductive care should align women's expressed sexual and reproductive health intentions with their behaviors and outcomes, by addressing social determinants of health.

Perceptions of long-acting reversible contraception among women in an urban U.S. jail

OBJECTIVE

Given incarcerated women's lack of access to contraception prior to, during, and post-incarceration and concerns of potential reproductive coercion in correctional settings, the objective was to explore incarcerated women's perspective of making provider-controlled methods of long-acting reversible contraception (LARC) available in an U.S. urban jail.

STUDY DESIGN

Using a concurrent mixed-methods approach, we explored contraceptive use and method choice prior to and after incarceration among women detained in a U.S. urban jail. Focus group discussions primarily focused on incarcerated women's perceptions of LARC.

RESULTS

In the 30 days prior to arrest, 28 of 116 women (24%) were using a non-barrier contraceptive method. Methods of LARC were used the least, and the majority (n = 74, 64%) were not interested in initiating LARC in jail. Concern about the potential side effects of LARC was the main reason for disinterest followed by distrust in correctional health care staffs' qualifications. Study participants did not reference coercion as a concern.

CONCLUSIONS

Apprehension about the training of health care providers and cleanliness of the detention facility outweighed participants' concerns regarding autonomy restrictions associated with provider-controlled methods of LARC. Despite limited interest in initiating LARC use while incarcerated, participants supported making all forms of contraception more accessible in jail settings.

IMPLICATIONS

Understanding incarcerated women's reproductive and contraceptive desires, including their perceptions of LARC, will help improve the provision of equitable reproductive health care in correctional settings. Our findings highlight the importance of contextual factors in determining women's willingness to access contraceptive care in carceral settings, if available.

Prevalence and correlates of having sexual and reproductive health priorities met by HIV providers among women living with HIV in a Canadian setting

OBJECTIVE

To: (1) describe the prevalence of key reproductive health outcomes (e.g., pregnancy, unintended pregnancy; abortion); and (2) examine social-structural correlates, including HIV stigma, of having key sexual and reproductive health (SRH) priorities met by participants' primary HIV provider, among women living with HIV.

METHODS

Data were drawn from a longitudinal community-based open cohort (SHAWNA) of women living with HIV. The associations between social-structural factors and two outcomes representing having SRH priorities met by HIV providers ('being comfortable discussing sexual health [SH] and/or getting a Papanicolaou test' and 'being comfortable discussing reproductive health [RH] and/or pregnancy needs') were analyzed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios (AOR) and 95% confidence intervals [95% CIs] are reported.

RESULTS

Of 314 participants, 77.1% reported having SH priorities met while 64.7% reported having RH priorities met by their primary HIV provider at baseline. In multivariable analysis, having SH priorities met was inversely associated with: sexual minority identity (AOR: 0.59, 95% CI: 0.37-0.94), gender minority identity (AOR: 0.52, 95% CI: 0.29-0.95) and recent verbal or physical violence related to HIV status (AOR: 0.55, 95% CI: 0.31-0.97) and positively associated with recently accessing women-centred services (Oak Tree Clinic) (AOR: 4.25, 95% CI: 2.20-8.23). Having RH priorities met was inversely associated with: sexual minority identity (AOR: 0.56, 95% CI: 0.40-0.79), gender minority identity (AOR: 0.45, 95% CI: 0.25-0.81) and being born in Canada (AOR: 0.29, 95% CI: 0.15-0.56) and positively associated with recently accessing women-centred services (AOR: 1.81, 95% CI: 1.29-2.53) and a history of pregnancy (AOR: 2.25, 95% CI: 1.47-3.44).

CONCLUSION

Our findings suggest that there remain unmet priorities for safe SRH care and practice among women living with HIV, and in particular, for women living with HIV with sexual and/or gender minority identity and those who experience enacted HIV stigma. HIV providers should create safe, non-judgmental environments to facilitate discussions on SRH. These environments should be affirming of all sexual orientations and gender identities, culturally safe, culturally humble and use trauma-informed approaches.

Physical health programs and interventions with women during incarceration: a scoping review

PURPOSE

The USA outpaces most other countries in the world in the rates at which it incarcerates its citizens. The one million women held in US jails and prisons on any day in the USA face many physical health challenges, yet interventional work to address physical health in carceral settings is rare. This study's purpose was to summarize the literature on programs and interventions implemented with women in US carceral settings (jail or prison) that primarily addressed a physical health issue or need.

DESIGN/METHODOLOGY/APPROACH

A scoping review was conducted. The authors searched databases, reference lists, individual journals and websites for physical health program descriptions/evaluations and research studies, 2000-2020, that included women and were set in the USA.

FINDINGS

The authors identified 19 articles and a range of problem areas, designs, settings and samples, interventions/programs, outcomes and uses of theory. The authors identified two cross-cutting themes: the carceral setting as opportunity and challenges of ethics and logistics.

RESEARCH LIMITATIONS/IMPLICATIONS

Much potential remains for researchers to have an impact on health disparities by addressing physical health needs of women during incarceration.

ORIGINALITY/VALUE

Interventional and programmatic work to address physical health needs of women during incarceration is sparse and diversely focused. This review uniquely summarizes the existing work in a small and overlooked but important area of research and usefully highlights gaps in that literature.

Reproductive Life Goals: A Systematic Review of Pregnancy Planning Intentions, Needs, and Interventions Among Women Involved in U.S. Criminal Justice Systems

Background: Women involved in criminal justice systems (WICJ) are affected by multilevel biological and sociocultural factors that result in adverse health outcomes and health disparities. Criminal justice systems (CJS) must be appropriately resourced to address these issues. Materials and Methods: We developed a systematic review to understand the intentions and needs for pregnancy prevention and planning among WICJ to inform future reproductive health services. We conducted a systematic literature review of epidemiologic and interventional studies that addressed the pregnancy prevention and planning needs of U.S. WICJ (2000-2019). An initial screen identified 7061 articles and 3 independent reviewers determined that 28 articles (16 descriptive studies in adults, 7 descriptive studies in adolescents, and 5 interventional studies) met inclusion criteria. Results: The literature review identified high rates of contraception underutilization and negative attitudes toward pregnancy among WICJ in a wide variety of settings. WICJ described minimal access to reproductive health services, including evidence-based contraception, and experienced high rates of unplanned and undesired pregnancies. Results were interpreted in the context of the reproductive justice (RJ) framework. Conclusions: The CJS, although not designed to provide health care, should dedicate resources to address the multilevel barriers to care experienced by women. WICJ require targeted, gender-responsive, trauma-informed pregnancy prevention and planning interventions that acknowledge the history of reproductive coercion in this population and address key aspects of RJ, including the right to and to not have a child.

Revisiting the Fetal Assault Law in Tennessee: Implications and the Way Forward

The rising prevalence of opioid use disorder (OUD) among those living in the United States has demanded a collaborative response from health care and policy spheres. Addressing OUD among pregnant women is especially difficult, given the controversies surrounding the medical and ethical balance between meeting maternal versus fetal/newborn needs. Most medical organizations discourage the criminalization of drug use in pregnancy due to the adverse public health outcomes of such an approach. Despite this recommendation, many states continue to use punitive law to address drug use in pregnancy. In 2014, the Fetal Assault Law in Tennessee (TN) became the first law in the United States to directly allow women to be prosecuted for drug use in pregnancy. Since its expiration in 2016, this law has been re-introduced several times to the TN legislature in support of permanent implementation. This article outlines the impact of the initial Fetal Assault Law on maternal/newborn health in TN and provides alternative immediate, short-term, and long-term health policy strategies through which health care providers and legislators can better advocate for the well-being of both mothers with OUD and their infants.

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.

Local Health Department Interest in Implementation of a Jail-Based Human Papillomavirus Vaccination Program in Kansas, Iowa, Missouri, and Nebraska

CONTEXT

Local health departments (LHDs) play a vital role in community vaccination programs for human papillomavirus (HPV) infection, but little research has been done to assess LHD interest in cross-sectoral partnerships to vaccinate high-risk groups, specifically incarcerated persons.

OBJECTIVE

To describe factors associated with interest in a novel implementation strategy linking LHDs with jails in 4 Midwestern states to deliver HPV vaccine.

DESIGN

Survey based on the Consolidated Framework for Implementation Research (CFIR) model given to LHD administrators. A modified Poisson relative risk regression was used to assess the relationship between independent variables and LHD interest in implementation of a jail-based HPV vaccination program.

SETTING

LHDs in Kansas, Missouri, Iowa, and Nebraska.

PARTICIPANTS

From September 2017 to April 2018, two-thirds (237/344) of invited LHD administrators from the 4 states responded to the survey.

MAIN OUTCOME MEASURE

LHD interest in implementation of a jail-based HPV vaccination program.

RESULTS

Forty-five percent of LHDs were interested in learning more about implementing a jail-based HPV vaccination program, and 2% already offered or had plans to offer HPV vaccine in their jails. Barriers to implementation were cost (66%), inmates' short incarcerations (47%), and availability of medical staffing (43%). LHD characteristics associated with interest in implementation of a jail-based HPV vaccination program included "inner setting" CFIR variables, which capture the structural and cultural context for program implementation: 7 or more employees (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.24-3.95), perception of importance to provide HPV vaccine in jails (OR = 3.70; 95% CI, 2.00-6.84), and already providing any vaccines in jails (OR = 2.62; 95% CI, 1.18-5.80).

CONCLUSIONS

Nearly half of LHDs in the region expressed interest in partnering with local entities to meet HPV vaccination needs of high-risk groups. Research on cross-sectoral partnerships and what these collaborations look like in practice is needed for public health impact.

Contraceptive use in Appalachian women who use drugs and were recruited from rural jails

This study describes a secondary data analysis of contraceptive use across the lifetime and within the six months prior to incarceration in a sample of 400 currently incarcerated women recruited from rural, Appalachian jails, who were using drugs prior to incarceration. Phase 1 (baseline) data from an NIH funded study were used to examine rates of contraceptive use, reasons for nonuse of condoms, and correlates of condom use. Results indicate that the majority (96.5%) of respondents reported lifetime use of contraceptives, and most (70.5%) had a history of using multiple methods, with male condoms, oral contraceptive pills, and contraceptive injections being the most commonly used methods. Almost 69% of respondents reported nonuse of contraceptives within the last six months, despite high rates of involvement in risky, intimate male partnerships prior to incarceration. Contraceptive use was found to be historically acceptable in this sample, in stark contrast to rates of use within the last six months prior to incarceration, suggesting that reproductive justice-informed, social work interventions to help improve current contraceptive use are warranted as a harm-reduction approach.