Using behavioral economic theory to increase use of effective contraceptives among opioid-maintained women at risk of unintended pregnancy

Abstract

Objective An unsettling aspect of the US opioid epidemic is the high rate of in utero exposure, especially since most of these pregnancies are unintended, due in part to low rates of effective contraceptive use among opioid-using women. This study tested an intervention informed by behavioral economic theory and aimed at promoting effective contraceptive use among opioid-maintained women at risk of unintended pregnancy in the Burlington, VT area between 2011–2013. Methods Thirty-one women were assigned (initial 5 consecutively, subsequent 26 randomly) to either usual care or an experimental intervention. Participants in usual care received condoms, a dose of emergency contraception, and referral to local providers. Participants in the experimental condition received usual care plus the World Health Organization’s contraception initiation protocol, including free prescription contraceptives, and financial incentives for attending 13 follow-up visits over 6 months to help manage side effects and other issues. Results Significantly more women in the experimental vs. usual care control conditions initiated prescription contraceptive use (100% vs. 29%) and reported prescription contraceptive use at 1-month (63% vs. 13%), 3-month (88% vs. 20%), and 6-month (94% vs. 13%) assessments. None of the experimental condition participants became pregnant during the 6-month protocol vs. three women (20%) in the control condition. Conclusions These results provide the first experimental evidence supporting the efficacy of an intervention for increasing prescription contraceptive use among opioid-maintained women at risk of unintended pregnancy.

Integration of a contraception clinic into an opioid treatment setting to improve contraception knowledge, accessibility and uptake: a pilot study

“…Overall, we found that almost half the women attending the OAT program were potentially eligible for the contraception clinic and that most were supportive of the provision of contraception services within the OAT, yet few presented. A small randomised controlled trial in the US found contingency management effective at engaging women receiving OAT in contraceptive care, with 56% of women in the intervention group using LARC at six months compared to 7% in the control group and no reported pregnancies 15 . This approach requires further exploration in the Australian context, where overall patterns of contraceptive use are similar 4 .…”

Unintended pregnancy prevention in women using psychoactive substances: A systematic review

“…41,42 Only one study reported a consistent and significant effect of financial incentives on LARC use during a 6-month follow-up (g=1.282-2.385, p<0.05), but the effect on unintended pregnancy rate was comparable to usual practice (g=-1.196, p=0.153). 33 Three motivational interventions had a moderate but significant effect on adherence to regular contraceptive use at 3-month follow-up. 19,26,29 The effect of motivational interventions on contraceptive use was quite stable and moderate (g ranged between 0.274 and 0.684, p<0.05) at 6 and 9 months post-intervention.…”

“…A study conducted by Heil et al found that financial incentives had the most pronounced effect on unintended pregnancy prevention, compared with dissemination of written information. 33 However, participants were not randomly assigned to the intervention group and the sample size was relatively small (n=31). In recent decades, there have been many debates regarding the ethics of providing financial incentives to women with addiction problems to start LARCs or accept sterilization.…”

“…46 It is worth noting that the intervention conducted by Heil et al preserved the reproductive autonomy of women using substances and should not be confused with interventions exchanging money for contraception. 33 Free contraceptive choice is one of the fundamental reproductive rights of all women that must be respected by family planning programs, especially among vulnerable and underserved women. 47 Another important element is onsite contraceptive counseling with free provision of contraceptives included in the intervention.…”

Editorial: 3rd Special Issue on behavior change, health, and health disparities

“…In a creative and important effort to prevent unwanted pregnancies, Heil et al (2016—in this issue) demonstrate the efficacy of a behavioral economic intervention that combines financial incentives with a World Health Organization intervention for making effective contraception easier to access. The incentives are not provided contingent on using the contraceptives.…”