“It’s a very nuanced discussion with every woman”: Health care providers’ communication practices during contraceptive counseling for patients with substance use disorders☆,☆☆
Introduction
Each year substance use impacts millions of reproductive-age women in the United States (US). In 2018, 53% and 15% of women aged 15–44 reported past-month alcohol and illicit drug use, respectively [1]. Substance use can be defined along a continuum from abstinence to addiction [2]. Not all individuals who use alcohol or drugs will develop problems of abuse or dependence that meet the criteria for substance use disorder (SUD), defined as repeated unhealthy patterns of substance use that interfere with daily life [3]. Prevalence estimates for lifetime alcohol and drug use disorder among women aged 18 and over are 22.7% [4] and 7.7% [5], respectively.
SUD is chronic relapsing illness similar to other chronic diseases, like diabetes or hypertension [6], that requires ongoing monitoring and treatment. However, unlike people with other chronic conditions, individuals with SUDs have historically been stigmatized for having their disease. People with alcohol and drug use disorders are viewed less favorably, held more to blame for their condition, and are more likely to elicit negative stereotypes and discriminatory attitudes than people with other mental health disorders [7], [8]. Reproductive-age women with SUDs face additional stigma because of entrenched views that women who use substances during pregnancy are unfit to be mothers [9]. Such views have led to women with SUDs being targeted for forced and coerced sterilization by government and other groups. For example, American eugenics programs of the early 20th century facilitated mandatory sterilization of “alcoholics” and “addicts” through the 1950s [10]. More recently, the non-profit organization Project Prevention has been paying women a one-time $300 payment to receive sterilization or use long-acting reversible contraception (LARC) [11].
Although these extreme practices have been used to limit the reproductive freedoms of women who use substances, they are uncommon. More commonly, the stigma associated with substance use in pregnancy may lead health care providers to encourage women with SUDs to use highly effective contraceptive methods, including sterilization, implants, and intrauterine devices (IUDs). Many providers and public health planners seem to have interpreted the higher effectiveness of LARC compared to short-acting reversible contraceptive methods, such as oral pills, patch, or ring [12], to mean that these methods should be best for all women and would have the greatest impact to reduce unintended pregnancy at the population level. Communication strategies that position LARC as first-line contraception, such as tiered-effectiveness and directive counseling, have become widespread in recent years. [13], [14]. Yet despite the benefits and widespread acceptability of LARC, many women will choose not to use implants or IUDs even when financial barriers to obtaining these methods have been removed [15]. In a clinical setting, excessive promotion of LARC methods without accounting for women’s preferences for preventing pregnancy can undermine patient-centered care [16], [17].
Although no research has shown that having a SUD is positively associated with LARC-first contraceptive counseling, there are several reasons why SUD status could influence providers’ recommendations for contraception. More than 75% of pregnancies among women with SUDs are unintended [18], [19], [20]. Many substances of abuse can cross the placenta and adversely impact fetal growth and development [21]. Stigma from clinicians toward people with SUDs is common [22] and stigma is intense surrounding substance use during pregnancy. Moreover, directive counseling has been documented with women with low socioeconomic status and women of color – groups with a similar history of reproductive oppression and coercion as women with SUDs [16].
Currently, there is a paucity of information on contraceptive counseling provision for women with SUDs even as rates of opioid use disorder among reproductive-age women have dramatically increased over the past 20 years [23]. More research is needed to understand how providers are discussing LARC and other contraceptive methods with women who use substances while also understanding women’s preferences for contraceptive counseling. Here we investigate health care providers’ communication practices during contraceptive counseling for women with SUDs.
Section snippets
Sample, recruitment, and data collection
After receiving approval from the Clemson University Institutional Review Board, we purposefully recruited two groups of providers for this study [24]. First, we recruited medical doctors (MDs) from a national group of experts in women’s health and addiction medicine. We contacted MDs by direct email with the assistance of one of their members. The email contained a short recruitment announcement and flyer with the study details and contact information for a project team member (EC).
Results
Characteristics of the sample are displayed in Table 1. A total of 24 providers, including 10 MDs and 14 APNs, participated in the study. Among MDs, 50% specialized in obstetrics and gynecology, 40% in family medicine, and 10% in psychiatry. Nearly all APNs were certified nurse-midwives (43%) or women’s health nurse practitioners (36%). Most providers were female (92%) and aged 35–44 years (46%). On the basis of US Census Bureau-designated regions, most providers resided in the Midwest (29%)
Discussion
This study of health care providers’ communication practices during contraceptive counseling provides insight into how providers build relationships and trust, exchange information, and engage in contraceptive decision-making with women with SUDs. We found that providers used a variety of communication strategies, some of which were grounded in the principles of patient-centered care and others that were more directive, to discuss contraception and pregnancy prevention with their patients with
Conclusion
Substance abuse is a growing concern in the US that can affect women’s reproductive health and has implications for women’s health care delivery. SUD increases the risk for experiencing addiction-related stigma, unintended pregnancy, and barriers to contraceptive access and use. Accordingly, women with SUDs have been the targets of coercive family planning practices and may be vulnerable to LARC-first contraceptive counseling by health care providers. In this study, we found that providers used
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Conflict of interest: The author declares no conflict of interest.
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Declaration of interests:The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.