Unplanned pregnancy and contraceptive use in women attending drug treatment services

Transcription

1 Australian and New Zealand Journal of Obstetrics and Gynaecology 2012; 52: DOI: /j X x Original Article Unplanned pregnancy and contraceptive use in women attending drug treatment services Kirsten I. BLACK, 1 Christine STEPHENS, 2 Paul S. HABER 2,3 and Nicholas LINTZERIS 3,4 1 Discipline of Obstetrics, Gynaecology and Neonatology, Central Clinical School, Royal Prince Alfred Hospital, University of Sydney, Camperdown, 2 Drug Health Services, Sydney Local Health, District, 3 Discipline of Addiction Medicine, Faculty of Medicine, University of Sydney, Sydney, and 4 Drug and Alcohol Services, South East Sydney Local Health District, c/o The Langton Centre, Surry Hills, NSW, Australia Background: At an international level, there are calls for a greater focus on women and harm reduction in recognition that female drug users have a unique set of issues that are not routinely assessed in drug treatment programs. Aims: To assess the pregnancy history, current pregnancy risk and contraceptive use of nonpregnant women attending opioid treatment programs (OTPs). Methods: This study involved a structured questionnaire survey of 204 women attending outpatient OTP services within the Sydney South West Area Health Service. Results: Two hundred and four women of 302 (67.5%) enroled in OTPs at the time completed surveys. Key findings were high pregnancy rates, with 28.9% of women reporting six or more pregnancies, high rates of adverse pregnancy outcomes (miscarriage, termination and stillbirth) compared with national data and poor uptake of contraception, with only 54.7% of sexually active women not wanting to get pregnant using a method. Women expressed diverse preferences for the type and location of women s health services they felt would meet their needs. Conclusion: Women in OTP clinics have unaddressed reproductive health issues, particularly around contraception. Addressing these will potentially minimise the risk of material deprivation and social exclusion in these women and improve their well-being through greater control and choice over their fertility. Current women s health service provision in OTP programs involves referral to external services, but an integrated model of care may best address the unmet contraceptive needs of these women. Key words: contraception, substance-related disorders, unplanned pregnancy. Introduction Women account for approximately 30 40% of clients attending alcohol and drug treatment services, yet women s sexual and reproductive health is not routinely addressed by services. 1 Regular substance use can have a myriad of effects upon women s sexual health including patterns of contraception, irregular menstrual history, sexually transmitted diseases, sexual abuse and increased risk of cervical neoplasia. 2 6 These may be a result of the effects of substance use (eg dependence or regular Correspondence: Dr Kirsten I Black, Discipline of Obstetrics, Gynaecology and Neonatology, Central Clinical School, University of Sydney, Level 4, Building 63, Royal Prince Alfred Hospital, Camperdown, NSW, Australia. kirsten.black@sydney.edu.au Received 14 July 2011; accepted 25 December intoxication upon alcohol, stimulants, benzodiazepines or opioids), social determinants of health (socio-economic status, ethnicity and education status), and/or poor access or utilisation of appropriate health services. The maternal and fetal impact of drug use in pregnancy has received substantial research attention, 7 13 yet to date there has been little assessment of the health needs of nonpregnant women attending drug and alcohol treatment services. A survey of 40 female narcotic addicts attending a methadone clinic, undertaken in 1977, found that compared with university students these women had a history of poor reproductive health outcomes, poor contraception use and general health impairment. 5 A more recent study, undertaken in rural Australia, found that of 23 women on a methadone program, 14 were sexually active and four of these used no contraception. 14 A number of barriers to women in substance use treatment accessing contraception services have been identified. One barrier is that women erroneously believe The Authors The Australian and New Zealand Journal of Obstetrics and Gynaecology

2 Reproductive health of women in drug treatment that opioids such as methadone will consistently impair their fertility. There is also misinformation about the suitability of different methods in this population. 15 Women with substance abuse issues also report difficulties using conventional systems of care for several reasons including a mistrust of healthcare services, fear of forced treatment or fear of losing custody of children, guilt, denial or embarrassment regarding their substance use, stigma, and the costs and difficulty of accessing services. 16,17 At a national and international level, there is a lack of research regarding the unique health needs of women in substance misuse programs and this study aimed to identify the reproductive health needs of women attending public opioid treatment program (OTP) clinics in southwest Sydney. Normative data of general population were available in Australia, enabling age-matched comparison between substance abuse treatment and general populations. Materials and Methods The study involved a questionnaire survey of women enroled in public OTP within Sydney South West Area Health Service between May and November The questionnaire was designed to investigate the reproductive health characteristics of women, and the design was informed by the existing literature, by our preliminary work in this field and by an established research instrument. 18 Many of the questions were based on the National Survey of Sexual Attitudes and Lifestyles (NATSAL) in the United Kingdom, which sought information about contraceptive knowledge from a representative sample of British women. 18 Ethics approval was obtained from the Sydney South West Area Health Service. The project was funded by NSW Drug and Alcohol Research Grants Program Potential participants were referred by healthcare professionals or were recruited in response to advertisements at participating opioid treatment clinics. Participants were recruited voluntarily under conditions of informed voluntary consent. Assistance was provided with the self-complete questionnaires for those participants who had poor literacy levels from a staff member. Subjects were reimbursed $10 voucher for participating in the project. Women who identified as having reproductive and sexual health issues were referred to either a general practitioner or sexual health service for follow-up. No participant identity was linked to the questionnaire. Data were entered into SPSS 14.0 (IBM, New York, NY, USA) database for analysis. Data analysis was performed by using one- and two-sided chi-square analyses. For the one-sided chi-square test, we report the 95% confidence intervals calculated for the proportions with the Wilson score method without continuity correction. We used univariate analysis with chi-square to explore the relationship between contraceptive use and demographical and risk-taking behaviours. We considered a P value of <0.05 as significant. Where the cell size was <5, we used Fisher s exact test. Results Of 302 women enroled in treatment at the time, 204 (67.5%) completed surveys over the six-month recruitment period. The socio-demographical characteristics of the participants matched those of all OTP clients. 19 The participants were recruited from five clinics in the Sydney South West Area Health service. The response rate varied between 80 and 95% for any given question. Most women on OTP were receiving methadone (83.3%; 170) with 16.4% (34) on buprenorphine. Over half (57.4%) had been in treatment for more than five years. All women were of reproductive age: 17 (8.3%) were under 25, 75 (36.8%) were 25 34, 83 (40.7%) were and 29 (14.2%) were years old. The majority were unemployed (n = 142, 69.6%) or on a pension (44, 21.6%). We did not collect ethnicity data. Pregnancy history, planning and outcomes One hundred and eighty-three women (89.7%) reported a past and/or current pregnancy. Women reported a mean number of 4.6 lifetime pregnancies (SD = 2.7) with 59 women (28.9%) reporting six or more pregnancies and 11 (6.0%) women reporting ten or more. Overall, this sample of women reported higher rates of births, stillbirths and termination of pregnancy than national data for Australian women as documented by Smith et al. 20 (Table 1). Most of the participants reported their first pregnancy at a young age: 87 (47%) were under the age of 18 and 80 (44%) were between 18 and 24 years. Only 29 (15.8%) of first pregnancies were planned. The woman s age at the time of her first pregnancy significantly affected the unplanned pregnancy rate. Of the women who had first been pregnant under the age of 18, 90.8% of these pregnancies were reported as unplanned. Women aged years and those who were over 25 at the time of their first pregnancy, respectively, reported unplanned pregnancies in 81.3 and 57.1% of cases (P < 0.004). Of the 163 women who had been sexually active in the last year, 45 women had been pregnant in the last 12 months. Of these 45 pregnancies, eight were planned (17.7), three (6.7%) didn t mind, and 34 (75.5%) were unplanned. Sexual activity One hundred and sixty-three women (79.9%) reported that they had had sex with a man in the last year. Of those, 30 reported having sex for money (18.4%), 19 (11.6%) for drugs and close to half whilst intoxicated (72; 44.1%). Most women reported only one male sexual partner within the past 12 months (n = 107, 65.6%), The Authors 147

3 K. I. Black et al. Table 1 Pregnancy outcomes of women in opioid treatment compared with national data from Smith et al. 20 Smith et al. [95% CI] (n = 6838) 16 Our sample % [95% CI] (n = 183) One-sample chi-square df = 1 Level of significance Ever had a birth 91.6 [ ] (6264) 82 [ ] (150) <0.01 Ever had a miscarriage 33.4 [ ] (2284) 42.1 [ ] (77) 6.19 <0.05 Ever had a stillbirth 2.6 [ ] (178) 7.1 [ ] (13) <0.01 Ever had an abortion 22.6 [ ] (1545) 57.9 [ ] (106) <0.01 reported 2 5 male partners (20.2%), and 15 (9.2%) reported more than five partners within the past year. Contraception use There were 116 women of reproductive age not trying to get pregnant who reported sexual activity in the month prior to the study. For 10 women the data were missing (data not completed in these sections), for 42 (36.2%) they reported no contraceptive use, and only 64 (54.7%) reported using a method of contraception. Women could report use of several methods, but the single most reliable of the methods they used were condoms in 29 of the 64 women (45.3%), followed by the oral contraceptive pill in 10 of the 64 women (15.6%). Twenty-four of the 64 women using contraception (37.5%) used one of the longacting reversible methods (intrauterine devices, implants and injectables) or had been sterilised. One woman did not specify (1.6%). Factors associated with use and nonuse of contraception Of the 116 women not trying to conceive, data were complete for 106 cases. The relationship between demographical and risk-taking behaviours of these 106 is documented in Table 2. Women s preference for accessing women s health services Women completing the survey were asked where they would most prefer to have their women s health needs addressed. Although they expressed a diversity of preferences, 24.5% (n = 50) said that they would like a clinic within drug services. Other preferences were to attend their general practitioners (21.6%, n = 44), sexual health clinics (20.6%, n = 42), family planning clinics (4.9%, n = 10) and to see a gynaecologist (5.4%, n = 11). No response was documented for 47 women (23.0%). Discussion This is the first detailed contemporary study of women s reproductive health needs in an opioid treatment population in Australia. The study examined women Table 2 Factors associated with use and nonuse of contraception in women not wanting to conceive Non contraceptive use in the past month (n = 42) Contraceptive use in the past month (n = 64) P value Age (years) <25 6 (50) 6 (50) 0.08* (26.7) 33 (73.3) (44.7) 21 (55.3) (63.6) 4 (36.4) Marital status Single 14 (42.4) 19 (57.6) 0.815* Married/de facto 22 (40) 33 (60) Widowed/ 6 (33.3) 12 (66.7) separated/ divorced Sex for drugs Yes 2 (15.4) 11 (84.6) No 40 (43.0) 53 (57.0) Sex for money Yes 4 (16.7) 20 (83.3) No 38 (46.3) 44 (53.7) Sex whilst intoxicated Yes 19 (37.3) 32 (62.7) 0.631* No 23 (41.8) 32 (58.2) *Pearson s chi-square. Fisher s exact. Data shown as n (%). attending public OTPs. Most women were aged between 25 and 44 years of age, were treated with methadone (83%) and were on benefits (94%). Most women had been pregnant (89.7%) with a median number of three pregnancies each, but 28.9% of women reported six or more pregnancies. Compared with nationally representative data, women in OTP services are at higher risk of unplanned pregnancy at an earlier age. Of the participants, 47% had experienced their first pregnancy under the age of 18 and 84% of these were said to have been unplanned. The women in our study who had been pregnant reported increased risk of adverse pregnancy outcomes (miscarriage and stillbirth) compared with nationally representative data. Addiction specialists in the United Kingdom working with pregnant women documented The Authors

4 Reproductive health of women in drug treatment similar findings in an audit of specialist perinatal outreach addictions services. The authors found that the women in drug treatment presenting in the second trimester for antenatal care had higher rates of miscarriage (3 vs <1%), low birthweight (28 vs 9%) and preterm babies (20 vs 9%) compared with the local maternity population in Importantly, our study found that almost half of sexually active women in OTP treatment do not use contraception. Further 27.6% reported a pregnancy in the year prior to the survey, and 75.5% of these pregnancies were unplanned. As a group they had had more abortions compared with the national sample and reported high-risk sexual behaviours of having sex whilst intoxicated and having sex for drugs or money. This finding is in keeping with international data from different settings that links substance use and unplanned pregnancy. 21,22 Women expressed a diverse preference about where they would like to access their women s health services, but given that there are recognised barriers to their access of mainstream services, one possible approach is to integrate contraceptive services into drug treatment clinics. Integrated services have been shown to improve outcomes through facilitated access in an environment that is more familiar and less threatening. 23,24 Evidence from studies on maternal mental health services suggests that programs integrated into drug treatment may be associated with enhanced maternal mental health compared with external referral. 24 We have evidence from one published study that integrating a contraceptive service is feasible. In this study, in Philadelphia, 958 women accessed integrated family planning clinics in drug treatment services. Both staff and the clients preferred the model whereby on-site family planning services operated separately from, yet in collaboration with, drug treatment services. 23 The study s limitations include the possibility of inaccurate reporting and selection bias. We believe that there was potentially underreporting of sex work and sexual history relating to the fact that honest disclosure may have been difficult for women requiring assistance from their case worker to complete the questionnaire. The population of women attending regular specialised drug and alcohol services as opposed to general practice and pharmacy services are a particularly high-risk group of patients who may not represent the reproductive health of all women in substance abuse treatment. The comparison with national data is limited in which the sample was not matched for social and economic indicators; nevertheless, the large differences are likely to remain after adjustment. Conclusion This research suggests that screening for women s health issues should be routinely performed with all women in OTP programs with a particular focus on women s contraceptive needs. Improving access to fertility control methods will assist in reducing the personal and health system costs of unplanned pregnancy that are particularly great for women in substance misuse programs. We believe that on-site services may be an effective way of ensuring uptake of contraception in those women not wanting to conceive and we are planning a trial investigate this. Pregnancy is often considered a unique opportunity to encourage positive health behaviours amongst drug using women, yet a preventative strategy of addressing the reproductive health needs in non pregnant women deserves more consideration. Acknowledgement This study was funded by the NSW Health Drug and Alcohol Research Grants Program References 1 Sherman SG, Kamarulzaman A, Spittal P. 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