EXECUTIVE SUMMARY

Women with opioid use disorder (OUD) are more likely to become pregnant unintentionally. They often encounter contraception barriers, including inadequate counseling.

  • Women with OUD sometimes have had negative experiences in the healthcare system, leading to a lack of trust.
  • Reproductive health providers can create a safe and protective environment by keeping communication open and nonjudgmental.
  • Another solution is to ask peers, who have been through similar experiences, to help with reproductive education.

The number of pregnant women with opioid use disorder (OUD) in the United States increased fourfold over the past decade. Family planning tactics could help reduce unintended pregnancies among women with OUD, reducing harm and risk, new research suggests.1

Women with OUD are about twice as likely to become pregnant unintentionally as the general population, despite most women with OUD reporting that they want to prevent pregnancy.1

“When we went into this study, we wanted to be here for women with opioid use disorder and [support] their ability to family-plan effectively,” says Stephani L. Stancil, PhD, APRN, lead study author and assistant professor in the department of pediatrics at Children’s Mercy Kansas City (MO).

Women with OUD who want to prevent pregnancy need information about various contraception choices. They need understanding of their own views on long-acting reversible contraceptives (LARCs) as well as access if they desire this method.

Without adequate contraceptive counseling and access, women with OUD can become pregnant, which could be harmful. When the baby is born, it could be damaging if child services becomes involved and removes the child from the parents — even if that is the best answer, Stancil explains.

“All of that can be traumatic, so preventing pregnancy is reducing harm,” she says.

Access to contraceptives and counseling can reduce harm by preventing unintended pregnancies, which have a long-lasting effect, she adds. Unintended pregnancies can affect the woman and her family for years to come. Contraception is a way to reduce one of the negative effects related to opioid use. The biggest barrier to contraception for the women with OUD was access, including education about contraceptives.

For women using opioids or in recovery from using opioids, navigating the healthcare system is complex. “Having access to receive comprehensive birth control education is the biggest barrier these women shared with us,” Stancil explains.

Trust also plays a role. Women with OUD often have encountered negative experiences with healthcare providers. They might have felt judged by clinicians. This lack of trust for the healthcare system can create a barrier. “There’s a way to build positive experiences and trust in providers,” she says.

Reproductive health providers can create an environment that is safe and protective for patients. They can work to ensure positive experiences through open communication and making sure women feel heard and not judged. This requires clinicians to ask women what they want and not assume that avoiding pregnancy is best for them because of their opioid use.

“If you tell them, ‘You shouldn’t get pregnant because you’re using opioids, and so you should use birth control,’ that’s rarely going to work,” Stancil says. “It’s better if you explore with them and ask, ‘Hey, you’re using opioids, would you like to have a baby right now?’”

Then, if the patient says, ‘No,’ the provider can talk about birth control options and ask how they can help the patient reach contraceptive goals. “Take baby steps,” she advises.

Researchers asked women with OUD what they wanted in terms of contraceptive care and reproductive health. They heard that the women wanted to hear information from peers who had been through experiences similar to their own. This would make seeing a doctor less intimidating and make the women more comfortable in talking about sensitive topics.

It is helpful if healthcare facilities can connect these patients with someone who is in recovery and can share their own experiences and what they learned about birth control.

“They can talk about what women have heard and what’s not true,” Stancil adds. “They can talk about LARC, side effects, efficacy, and what makes things effective and less effective.”

The challenge is finding peers. “We need to harness women who are invested in serving this role,” Stancil says.

Another way to improve reproductive counseling is to use shared decision-making. “We’re understanding from more research that shared decision-making is more important to improve health around the continuum,” she says.

For all patients seeking reproductive healthcare, but especially for women with OUD, clinicians should provide trauma-informed care. “There’s a broader framework for how to engage with patients and their families,” Stancil says. “Assume everyone who comes in your door, clinic, hospital has undergone some sort of trauma.”

Any patient could be struggling because of something that occurred in their lives. “There’s likely something in their background that impacts their response,” she explains. “How do you meet them where they are?”

One answer is open, nonjudgmental communication. “Viewing patients as having trauma reduces the unconscious bias that most folks have,” Stancil says. “Maybe you grew up in a family or setting where substance use was considered someone’s choice, but what does the evidence suggest?”

The goal is to view patients as having potentially experienced trauma and determine how to help them become healthy.

“The provider or healthcare worker who is engaging with that patient needs to be intentional about the position they’re coming from and what they’re trying to say,” Stancil explains. “If you have the desire to meet the patient where they’re at, are you intentional in body language, verbal language? What approach are you taking overall?”

Keep in mind that everyone makes mistakes. Healthcare practitioners can learn from their patients and even apologize to patients when they realize their approach displayed bias.

“You can say, ‘I apologize. I’m trying to be intentional about getting this right,’” Stancil says.

Providers also can use motivational interviewing. “It’s a technique used commonly to promote contraceptive service uptake and family planning, making goals mutually,” Stancil says. “One of the benefits of the framework is there often are scripts, even brief phrases, that a clinician can find and adopt.”

For instance, a reproductive health provider could say, “Help me understand when you would like to start a family,” she says.

“The other thing is open-ended questions. Rather than asking a question with ‘yes’ or ‘no’ answers, ask questions that cannot be answered [simply],” she explains.

A better approach is to ask for help to understand what the patient wants. “We know time is of the essence, and not everyone has time to do this every time, but try to integrate one or two of these tools,” Stancil says.

REFERENCE

  1. Stancil SL, Miller MK, Duello A, et al. Long-acting reversible contraceptives (LARCs) as harm reduction: A qualitative study exploring views of women with histories of opioid misuse. Harm Reduct J 2021;18:83.