Contraception and Healthcare Utilization by Reproductive-Age Women Who Use Drugs in Rural Communities: a Cross-Sectional Survey

Abstract

Background Women who use drugs (WWUD) have low rates of contraceptive use and high rates of unintended pregnancy. Drug use is common among women in rural U.S. communities, with limited data on how they utilize reproductive, substance use disorder (SUD), and healthcare services. Objective We determined contraceptive use prevalence among WWUD in rural communities then compared estimates to women from similar rural areas. We investigated characteristics of those using contraceptives, and associations between contraceptive use and SUD treatment, healthcare utilization, and substance use. Design Rural Opioids Initiative (ROI) — cross-sectional survey using respondent-driven sampling (RDS) involving eight rural U.S. regions (January 2018–March 2020); National Survey on Family Growth (NSFG) — nationally-representative U.S. household reproductive health survey (2017–2019). Participants Women aged 18–49 with prior 30-day non-prescribed opioid and/or non-opioid injection drug use; fecundity determined by self-reported survey responses. Main Measures Unweighted and RDS-weighted prevalence estimates of medical/procedural contraceptive use; chi-squared tests and multi-level linear regressions to test associations. Key Results Of 855 women in the ROI, 36.8% (95% CI 33.7–40.1, unweighted) and 38.6% (95% CI 30.7–47.2, weighted) reported contraceptive use, compared to 66% of rural women in the NSFG sample. Among the ROI women, 27% had received prior 30-day SUD treatment via outpatient counseling or inpatient program and these women had increased odds of contraceptive use (aOR 1.50 [95% CI 1.08–2.06]). There was a positive association between contraception use and recent medications for opioid use disorder (aOR 1.34 [95% CI 0.95–1.88]) and prior 6-month primary care utilization (aOR 1.32 [95% CI 0.96–1.82]) that did not meet the threshold for statistical significance. Conclusion WWUD in rural areas reported low contraceptive use; those who recently received SUD treatment had greater odds of contraceptive use. Improvements are needed in expanding reproductive and preventive health within SUD treatment and primary care services in rural communities.

A gender‐based secondary analysis of the ADAPT‐2 combination naltrexone and bupropion treatment for methamphetamine use disorder trial

“…Women who use drugs have higher rates of unintended pregnancies [42] and lower rates of using highly effective contraception compared to women who do not use drugs [43]. Recent use of methamphetamine alone or in combination with opioids compared to no use of methamphetamine has been associated with a lower likelihood of using effective contraception among women living in rural US communities [44]. Women who use drugs incorrectly frequently believe they are unable to conceive [45], which may be partially related to menstrual cycle dysregulation that can continue even after disrupting use [46].…”

Programs and practices that support pregnant people who use drugs’ access to sexual and reproductive health care in Canada: a scoping review

“…Among people using opioids in the United States, approximately 80% of pregnancies are unintended compared to approximately 45% of the general population [ 13 – 15 ]. The high rate of unplanned pregnancies is attributed to low use of contraceptives, misconceptions about fertility while using drugs, and limited access to sexual and reproductive health (SRH) services [ 11 , 16 – 19 ]. People may continue to use drugs throughout their pregnancy for a number of reasons, including to manage withdrawal, or to cope with an unexpected pregnancy, gender-based violence and other traumas [ 2 , 20 ].…”

“…Substance use during pregnancy can create unique harms for the birth parent and foetus. In addition to gendered substance-use related harms (e.g., increased risks of HIV and hepatitis C), pregnancy-related harms include transmission of HIV, low birth weight, neonatal abstinence syndrome, preterm delivery, maternal morbidity, placenta rupture, and delayed child development [ 11 – 14 , 16 , 17 ].…”

“…SRH services focus on promoting and maintaining good sexual health through information and education, access to family planning, preventing, and managing sexually transmitted infections (STIs), and supporting healthy pregnancies [ 24 ]. Key barriers to accessing SRH services include fear of forced abortion/sterilisation, fear of their child(ren) being taken into state care due to parental substance use, disapproval from partner, stigma, fear of judgement, lack of knowledge of service options, limited service availability, limited transportation, limited hours of operation, mistrust of health services, negative previous experiences and cost of uninsured services [ 11 , 13 , 14 , 17 , 22 , 25 – 28 ].…”

“…Despite these barriers, there are some promising practices that support PPWUD’s access to SRH services. In the United States, the integration of SRH services in primary care, substance use treatment and harm reduction programs have supported access to contraception and family planning services [ 11 , 29 , 30 ]. Other research has suggested that PPWUD prefer to access SRH services in spaces they already frequent, such as harm reduction programs, or through mobile outreach services [ 15 , 31 , 32 ].…”