Reproductive decision-making of women in methadone clinics: A mixed methods study
Awarded 2016
Complex Family Planning Fellowship Research
Agatha Berger, MD
University of California, Los Angeles

Opioid use in the United States has continued to increase over the past few decades, including among reproductive-aged women.  Substance use disorders can affect women’s reproductive and sexual health in multiple ways, ranging from irregular menses to sexually transmitted diseases, sexual abuse and unplanned pregnancy.  Several barriers to obtaining reproductive health care have been identified in previous research.  These include negative experiences with health care providers or difficulty accessing care.  Current research acknowledges that there is a higher burden of reproductive disease, a discrepancy in contraceptive use and unintended pregnancy, and low health service utilization in this population as compared to the national average, and most energy has been focused on eliminating access barriers.  However, one CDC initiative demonstrated that eliminating access barriers doesn’t necessarily equate higher contraceptive use or utilization of reproductive health services.  More knowledge of what influences the reproductive and sexual decisions of these women, thus revealing potential unidentified barriers to care, would aid development of more effective reproductive health interventions for these women.
This study sought to identify what factors influence the reproductive decision making of women with opioid use disorders.  Female patients attending methadone treatment clinics in Los Angeles were recruited to share their experiences and perspectives.  The first arm was qualitative in nature, involving semi-structured interviews.  Thematic saturation was achieved after twenty-two interviews and the data was analyzed for over-arching themes.  This information was then used to inform development of the questionnaire instrument currently being used in the quantitative arm.  Participants are being actively recruited at a wider range of methadone clinics in the Los Angeles area for the questionnaire survey. 
The qualitative findings of this study elicited numerous findings regarding reproductive decision making of women enrolled in methadone clinics.  One major theme was that the majority reported either reluctance or inattention to obtaining reproductive health care in the previous few years, and if accessed, was typically for an acute concern.  A fear of judgment or stigmatization was a prevalent reason for reluctance in seeking care, and many reported having had previous negative experiences due to their history of drug abuse.  Over a third of participants revealed that they don’t disclose their history to healthcare providers.  Many women also stated they had difficulty navigating the healthcare system, and had other needs of higher priority such as childcare or homelessness. 
Another theme was an altered risk perception, especially regarding their risk of becoming pregnant.  All participants did not desire pregnancy, however over half of them were not using preventative measures like birth control.  Many felt that they were infertile due to not having conceived yet.  Other reasons given for being at low risk of pregnancy were that the methadone was protective, that their menses were absent, that they had intercourse infrequently or that they were not healthy enough to conceive.
The significant role of the methadone clinic in these women’s lives was an additional theme, and the desire for it to play a larger role in their healthcare.  Many reported having learned most of their sexual health knowledge from treatment clinics.  The majority expressed a desire for clinics to inquire and advise them about sexual health and healthcare.
This study raised several new concepts about women with opiate use disorders.  The high number of women who fail to disclose their history to health care providers has not been described before.  Additionally, the desire for methadone treatment counselors to bring up sexual and reproductive health was widely shared.  This population requires more resources and attention to help deliver appropriate education, counseling and care.  These findings can help support the development of healthcare delivery that is more appropriate for this population.