Women with opioid use disorder may avoid visiting a family planning clinic or seeing a physician for contraceptive care and counseling because of their fear of stigma and judgment.
- The Sex and Female Empowerment (SAFE) intervention helps this at-risk group receive evidence-based contraceptive information safely and without risk of stigma.
- SAFE can be administered in one-on-one sessions with a trained educator or in a computer-adapted session.
- Both ways of delivering SAFE resulted in at least seven out of 10 women receiving long-acting reversible contraceptives after the intervention.
One challenge of providing reproductive health services to women with opioid use disorder is stigma. Even women in treatment for opioid use often are afraid of judgment and might avoid visiting a family planning clinic or seeing an OB/GYN for contraceptives.
“There is a lot of reluctance to talk to a doctor,” says Hendrée E. Jones, PhD, professor in the department of obstetrics and gynecology and executive director of UNC Horizons at the University of North Carolina at Chapel Hill. “Would they be discriminated against in some way? Would they be stigmatized? We found out that the women did not want to get pregnant, but were not actively trying not to get pregnant.”
Jones and co-investigators created an intervention to help this at-risk group receive evidence-based contraceptive information in a way that was safe for them. The Sex and Female Empowerment (SAFE) intervention was vetted by women in the target population.
SAFE works in both face-to-face sessions and in a computer-adapted session. A study of the intervention revealed that both SAFE methods were more successful than usual care, with higher completion, higher satisfaction, and higher contraception consultation visit attendance.1
“We had positive retention in our study,” Jones notes. “We were able to keep everyone in the study for the six months of their enrollment and follow-up. I thought that was fantastic.”
In terms of primary outcomes, Jones and researchers found good attendance to the interventions and good acceptance of reproductive health appointments. Also, the study participants who received the intervention acted on the information they received, and many received long-acting reversible contraception (LARC).
About 77% of the women who participated in the face-to-face intervention received LARC after the intervention. Seventy-three percent of the women who received the computerized SAFE intervention accepted LARC. By contrast, 23% of the women in the usual care group received a LARC.
Six months after the intervention, investigators asked women which contraceptive they were using. The results suggested that the majority continued with their LARC. “It didn’t seem like we had a lot of discontinuation of it, but that was at six months, and it’d be important to do a larger follow-up study,” Jones says. “I’d like to do a multisite trial with the SAFE intervention and follow people for a longer period of time to see it in the more global real world.”
SAFE was designed to help a population of women with a 60% to 80% prevalence of unintended pregnancy. The high rate is driven by women with opioid use disorder with a high need for reproductive autonomy and low utilization of effective contraception because of their concerns about side effects, insertion, and removal of methods.
In designing SAFE, researchers spoke to women with opioid use disorder, to men who were not their partners, and to providers. “We wanted to understand what people already knew about contraception and contraceptive practices. That drove the intervention we designed,” Jones explains. “I also was interested in seeing which providers would want to do something that takes 45 to 50 minutes to do in an office, or if an intervention on a computer would be more acceptable.”
The researchers explored the possibility that some women with opioid use disorder also would prefer a computerized intervention. “Maybe women don’t want to talk to anyone and would be more comfortable sitting at a computer and listening to vignettes and being interactive,” Jones says.
When researchers asked women whether they would prefer group educational sessions or one-on-one sessions, they preferred the one-on-one sessions. The sessions occurred in the opioid use disorder clinic. “It was mixed, but overall they preferred we’d do the sessions one-on-one,” she adds.
Also, the one-on-one sessions were not held with physicians or nurses. “It was not the medical staff doing that,” Jones says. “Ideally, it’d be great to have a nurse practitioner deliver it, but the behavioral health folks — bachelor’s or master’s level — did it.”
SAFE involves the following:
• Face-to-face sessions. Using a desktop stand and flip board, the intervention leader meets with a woman to talk about various reproductive health topics. The flip board displays information about basic anatomy and reproductive health. The other side of each page contains information the interventionist sees.
“The patient sees the picture, and on the other side is a scripted analysis of what the picture shows,” Jones explains. “The interventionist sees the written words, and can describe it or answer questions.”
The woman and interventionist hold conversations on how to talk with the doctor, what questions she should ask, and how to stand up for her own decisions — especially if she had unpleasant experiences previously.
• Reproductive health misconceptions. The intervention covers misconceptions about pregnancy and different contraception practices.
“It covers basic reproductive biology, saying, ‘This is how it works and how you get pregnant,’ and ‘Yes, you can get pregnant if you have sex standing up,’ and ‘Yes, you can get pregnant even if you wash immediately after having sex,’ as examples,” Jones says. “After we answer those questions, the next thing is to talk about whether they want to get pregnant in the next year. For those who didn’t have intention of getting pregnant, what kinds of things do they want in their pregnancy prevention method?”
Another misconception is that if a hormonal method stops their period, it could cause problems. “They fear the blood will back up in their body and explode,” Jones says.
• Shared decision-making. Interventionists can offer women information about different methods and explain how to maintain that method.
“We form an action plan, and women can go through that with their interventionist and talk about their worries,” Jones says. “They can write down a couple of things and go through those with the interventionist. We used a shared decision-making tool.”
They discuss pros and cons, the woman’s fears, and what the woman and her partner think of various contraceptive methods. “The partner dynamic is important,” Jones says. “Women might be reluctant to get an implant in their arm because their partner may be looking at it, or maybe they heard things about IUD strings interfering with sexual pleasure because men can feel it.”
Bleeding also might be an issue. Interventionists should ask the woman if she wants to stop bleeding, or if having a period is important to her. “If the woman wants a period, let’s use methods that ensure that happens,” she says.
• Computerized intervention. “We [review] the same information, but it is self-guided in the computer-adapted intervention,” Jones says. “It’s a basic review of sexual anatomy, but they can click through it or slow down and listen to it.”
They use videos and information from Bedsider, a nonprofit that provides information online about birth control methods and other issues related to reproductive health. For instance, if someone clicks on the picture of the birth control patch, they receive information about how it works, how much it costs, how to use it, side effects, and problems. It also includes two- to three-minute video testimonials from women who have used that particular method.2
At the end of the computerized intervention, women can decide which contraceptive methods they would like to use or learn more about. “The program provides a printout they can take to their [behavioral health professional], who will summarize things with them, talk about shared decision-making,” Jones says. “If they want to make an appointment with a physician, they can.”
The purpose of the intervention is to show how women with opioid use disorder can control their own decision-making process after they are given evidence-based information on contraceptives and their side effects. The process will suggest providers they could talk with. “It’s not just gaining access, but getting access to providers who have compassion and empathy and are advocates for the patient population we serve,” Jones says.
Although SAFE was studied with a population of women who had been treated in a methadone treatment program for at least 90 days, it could work well with another population with opioid use disorder. The key is the women need to be stable in their abstinence from active opioid use.
“An important question is, ‘Do we have to wait 90 days, or would we get the same result if we did it sooner in treatment?’” Jones says. “I also think there are things we could do to build a better mousetrap. We could do an app, which is even more cost-effective.”
- Jones HE, Martin CE, Andringa KR, et al. Sex and female empowerment (SAFE): A randomized trial comparing sexual health interventions for women in treatment for opioid use disorder. Drug Alcohol Depend 2021;221:108634. doi: 10.1016/j.drugalcdep.2021.108634. [Online ahead of print].
- Bedsider. Method explorer: Birth control options. 2021. www.bedsider.org/methods