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

Abstract

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.

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

“…Four studies identified concerns related to LARC placement or removal, including: concerns about the insertion or removal process ( Matusiewicz et al, 2017 ), fear of pain during insertion ( Rey et al, 2020 ), concerns about forgetting when to remove a method and potential fertility effects ( Sobel et al, 2021 ), and not wanting foreign objects in the body ( Rey et al, 2020 ) or in a particular location in the body ( Rey et al, 2020 , Smith et al, 2019 ). Method maintenance, including having to remember appropriate use ( Florsheim et al, 2020 ) or to take a daily pill ( Sobel et al, 2021 ), were barriers for HC methods, whereas not having control over starting and stopping the method was a LARC barrier ( Rey et al, 2020 ). Lack of knowledge ( Matusiewicz et al, 2017 , Meschke et al, 2018 , Rey et al, 2020 , Smith et al, 2019 ) or having enough knowledge ( Heil et al, 2016 ) about contraception were consistent barriers, as were having past negative experiences with contraception related to method failure ( Bornstein et al, 2019 , Florsheim et al, 2020 ), side effects ( Bornstein et al, 2019 ), appropriate storage and use ( Florsheim et al, 2020 ), and complications ( Smith et al, 2019 ).…”

“…Method maintenance, including having to remember appropriate use ( Florsheim et al, 2020 ) or to take a daily pill ( Sobel et al, 2021 ), were barriers for HC methods, whereas not having control over starting and stopping the method was a LARC barrier ( Rey et al, 2020 ). Lack of knowledge ( Matusiewicz et al, 2017 , Meschke et al, 2018 , Rey et al, 2020 , Smith et al, 2019 ) or having enough knowledge ( Heil et al, 2016 ) about contraception were consistent barriers, as were having past negative experiences with contraception related to method failure ( Bornstein et al, 2019 , Florsheim et al, 2020 ), side effects ( Bornstein et al, 2019 ), appropriate storage and use ( Florsheim et al, 2020 ), and complications ( Smith et al, 2019 ). Concerns that contraception would cause infertility ( Bornstein et al, 2019 , Rey et al, 2020 , Smith et al, 2019 ); delay a desired future pregnancy ( Bornstein et al, 2019 , Smith et al, 2019 ); and physically or psychologically interfere with sex ( Rey et al, 2020 , Smith et al, 2019 ), the body’s natural processes ( MacAfee et al, 2020a ), and mood stabilizing medications ( Sobel et al, 2021 ) were barriers.…”

“…Perceived low risk of pregnancy while using opioids and other substances was a consistently reported barrier ( Bornstein et al, 2019 , Florsheim et al, 2020 , MacAfee et al, 2020a , Smith et al, 2019 ). Contributing factors for this perception included reduced or no sexual activity ( Bornstein et al, 2019 , Smith et al, 2019 ), irregular or no menses ( Bornstein et al, 2019 , Florsheim et al, 2020 ), older age leading to lower fertility levels ( Smith et al, 2019 ), not having a past pregnancy while using substances or methadone despite having unprotected sex ( Bornstein et al, 2019 ), and belief that substance use has caused infertility or actual infertility ( Bornstein et al, 2019 , MacAfee et al, 2020a , Rey et al, 2020 ). Competing priorities over pregnancy prevention, reproductive health, and self-care during periods of active substance use ( Florsheim et al, 2020 , Hurley et al, 2020 , MacAfee et al, 2020b , Sobel et al, 2021 ) and over preventive care and health needs during early recovery ( Hurley et al, 2020 , MacAfee et al, 2020b ) were commonly reported barriers.…”

“…Ambivalent attitudes toward pregnancy or pregnancy prevention were present among individuals not using contraception ( Bornstein et al, 2019 , MacAfee et al, 2020a , Meschke et al, 2018 , Smith et al, 2019 ). Passive attitudes around planning, decision-making, and taking action related to reproductive health or life matters ( Armstrong et al, 1991 , Bornstein et al, 2019 , Florsheim et al, 2020 , Heil et al, 2016 ) and fatalistic attitudes toward the ability to prevent pregnancy ( Armstrong et al, 1991 , Bornstein et al, 2019 ) were commonly reported barriers. Having the attitude that contraception was inconvenient was reported as a barrier in one study ( MacAfee et al, 2020a ).…”

“…Characteristics of methods, including higher efficacy/effectiveness ( Fischbein et al, 2018 , Smith et al, 2019 ), perceptions of fewer side effects ( Fischbein et al, 2018 ), and not having to remember ongoing maintenance ( Florsheim et al, 2020 ), were facilitators for HC-LARC methods. One study documented higher contraceptive-related knowledge among persons using contraception than those not using contraception ( Meschke et al, 2018 ).…”