Barriers to reproductive health services among opioid-dependent women in substance abuse treatment

Awarded 2015
Complex Family Planning Fellowship Research
Lauren MacAfee, MD
University of Michigan

The rising misuse and addiction to opioids has resulted in a public health epidemic. This epidemic has disproportionately impacted women because women are more likely to have chronic pain, be prescribed painkillers and given higher doses for a longer period of time. As a result, there has been a dramatic increase in opioid misuse and addiction, overdoses and neonatal abstinence syndrome for women who use opioids during pregnancy. Furthermore, women with opioid use disorders have been shown to have high rates of unintended pregnancy and sexually transmitted infections and low rates of contraceptive use and cervical cancer screening. Despite frequent interactions with the healthcare system, women with an opioid use disorder who are enrolled in substance use treatment have significant unmet reproductive health needs.
The purpose of this study was to characterize and better understand the reproductive health history and needs for women in treatment for opioid use disorder. To achieve this, we conducted a study that would involve perspectives from substance use treatment facility administrators, clinical care providers and women in substance use treatment in Michigan. We used both surveys and interviews to answer our research question.
We conducted our study in three separate phases. The first phase was a survey of reproductive health services offered at substance use treatment programs in Michigan. In the second phase, we interviewed patients and providers to gain a deeper understanding of the needs for, barriers and facilitators to women receiving reproductive health services while in substance use treatment. Finally, our third phase was a survey of 300 women in substance use treatment.
The survey of treatment programs showed that directors recognize the importance of reproductive health for women in their care, however few facilities offered either reproductive health services on site or a referral for such services. Many facilities lacked a physical exam room and many directors cited the lack of time, equipment and training as reasons for not offering the service or providing referrals.
In our interviews with patients and providers, a number of themes emerged that helped to better understand why women weren’t accessing reproductive health care. Women reported fear of stigma and mistreatment because of their substance use and concern about the involvement of child protective services if they were pregnant or parenting. Prior to enrolling in substance use treatment, both women and providers noted that health care is a very low priority for women who are actively using drugs and recognized that substance treatment is an ideal place to engage women in reproductive health care. Patients and providers alike were very interested about the possibility of integration of services to remove many of the barriers to accessing reproductive health services.
Finally, our survey of women in substance use treatment identified that many women have a history of sexually transmitted infections, abnormal pap smears, intimate partner violence and unintended pregnancies. Additionally, less than half of women were using any type of birth control and very few reported condom use for infection prevention. This confirms that women in substance use treatment have unmet reproductive health needs. Women noted cost, fear of mistreatment, concern about abnormal results/findings, involvement of child protective services and not knowing where to go as some of the most common barriers to not accessing reproductive services. Many women were interested in receiving services at their substance use treatment program if it were available.
Out study demonstrates that while there is recognition of the importance for reproductive health care for women in substance use treatment programs in Michigan, there are significant unmet needs and many barriers to accessing care. We hope to shed light on this unmet need and the potential to avoid adverse reproductive health outcomes by integrating services and improving comprehensive healthcare for women with substance use disorders.