Running head: REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

Reproductive Health Equity:
One Key Question for Women in Recovery
Karen H. Martinot©
Arizona State University

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Abstract
Women in recovery from substance use disorders (SUD) face significant barriers to achieving
reproductive well-being (RWB) and disproportionately experience unintended pregnancy.
Unintended pregnancy can have serious consequences in this population. Equity-informed
approaches promote the integration of reproductive health care (RHC) with recovery programs to
improve both access to and quality of RHC. Arizona’s largest SUD recovery program,
Crossroads, Inc. recently opened an on-site, integrated primary clinic offering RHC. A onemonth pilot demonstration of One Key Question (OKQ), a pregnancy desire screening tool,
was implemented with fidelity at Crossroads to identify clients with RHC needs and offer care.
IRB exempt status was obtained through Arizona State University. All female-bodied clients
aged 18-49 were screened following routine admission assessments. The Institute for Healthcare
Improvement Triple Aim model based on Self-Determination Theory and Motivational
Interviewing was used to prioritize client autonomy. The client experience of care was measured
using an adapted Interpersonal Quality of Family Planning scale. The magnitude of needs and
desires were summarized with descriptive statistics. Sixty-three clients were screened with OKQ.
Needs were identified in 97% of clients. Of those clients, 98% accepted referrals. Ninety
percent of items measuring the client experience of care were rated as “excellent.” OKQ
provided an efficient structure for person-centered screening and referral conversations to
integrate RHC in a large SUD recovery program with excellent care experiences reported by
clients.
Keywords: Family planning, contraception, substance use disorder, pregnancy desire,
motivational interviewing, reproductive health care

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Reproductive Health Equity:
One Key Question for Women in Recovery
Sexual and reproductive health and autonomy have far-reaching implications for the
health of individuals, families, and communities. Individuals experience their own reproductive
health needs as part of an integrated whole. As such, health-related systems should explore ways
to integrate sexual health holistically across a variety of settings (Keller & Sonfield 2019).
Applying the concept of “well-being” to reproductive health may be useful to shift away from
reproductive health paradigms that have been prescriptive, judgmental, and disempowering. The
concept of “well-being” extends beyond the “absence of disease,” and recognizes how people
think and feel about their lives, their relationships, their emotions, and their satisfaction with
their functioning (CDC, 2019). Reproductive well-being (RWB) is a fundamental component of
people’s overall well-being. Significant inequities exist, however, in access to quality
reproductive health education, reproductive health-care (RHC), and family planning. Women
with substance use disorders (SUDs) face unique barriers to RWB and RHC and experience
disproportionate reproductive health burdens. Programs that care for women in recovery may be
opportune settings for integrating holistic RHC to improve the RWB of clients.
Problem
Poor RWB and barriers to RHC may have serious consequences for women with SUDs.
One consequence is unintended pregnancy (Black & Day, 2016; Heil et al., 2011). Pregnancy in
this population presents serious physical and psychosocial risk to the mother including high
blood pressure, placental abruption, hemorrhage, postpartum depression, and death (Black &
Day, 2016; Gemmill, Kiang, & Alexander, 2018; Singer et al., 2002). The American College of
Obstetricians and Gynecologists (ACOG) recommends contraceptive counseling for women with

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SUD and increased access to the most effective, nonpermanent methods, known as long-acting
reversible contraceptives (LARCs) (ACOG, 2012, 2018). Maternal substance use disorder also
presents serious risks to the fetus and newborn, including fetal alcohol spectrum disorders
(FASD), fetal growth restriction, prematurity, stillbirth, and newborn drug withdrawal, referred
to as neonatal abstinence syndrome (NAS) (ACOG, 2011; Whiteman, et al., 2014).
The incidence of NAS grew nearly fivefold over the past decade and costs an estimated
1.5 billion dollars in hospital charges each year (Patrick & Schiff, 2018). The Center for Disease
Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) are calling for
improved primary prevention public health responses to FASD and NAS (Ko et al., 2017; Patrick
& Schiff, 2018). To decrease the incidence of these high-risk, high-cost pregnancies, the World
Health Organization (WHO) encourages contraceptive counseling for women with SUD, with an
emphasis on respecting the patient’s autonomy (WHO, 2014). Yet, in a systematic review of
contraceptive use and method of choice among women with opioid and other substance use
disorders Terplan and colleagues found that this population has unmet needs for contraception,
especially for the most effective methods (Terplan, Hand, Hutchinson, Salisbury-Afshar, & Heil,
2015).
Background and Significance
Threatening policies have perpetuated disempowerment of women with SUDs. Many
well-intentioned programs have contributed to stigma by framing programs in a way that
suggests some women are less deserving than others to have full autonomy in their reproductive
future by prioritizing population health measurements and neglecting to measure the client
experience of care. Unintentional consequences include violations of autonomy and equity and
the stigmatization of women with SUDs. Stigma becomes a health problem when it alienates

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those who need care from those who have the skill to provide care. To be just and effective, any
efforts to reduce the poor health outcomes experienced by women with SUDs, must frame the
delivery of services on the fundamental rights of autonomy, dignity, equity, and justice.
Measurement principles and tools are not well established to promote these protections.
Population Affected
Women who use drugs are less likely to use contraception and more likely to be
ambivalent about pregnancy, with many believing they cannot become pregnant because of their
use of substances (Griffith et al., 2017). Often women in recovery suffer with relationship issues
including intimate partner violence with reproductive coercion, current or past sexual abuse and
trauma, and partner substance use (Griffith et al., 2017). Women can feel embarrassed or
ashamed of these problems and may avoid care to avoid discussing these intimate problems with
providers. System barriers of cost and access present additional hurdles for women with SUDs
(Black & Day, 2016).
Historical treatment of women with SUDs has involved policies that use control efforts
based on criminal justice instead of healthcare. This has increased stigma and fear. Threatening
policies have further discouraged women with SUDs from seeking both RHC and SUD treatment
(Finkelstein, 1994; Howell, Heiser, & Harrington, 1999; Roberts & Nuru-Jeter, 2010; Roberts &
Pies, 2011; Schempf & Strobino, 2009; Stone, 2015). Women have avoided healthcare out of
fear of incarceration or losing custody of children. Not only are these policies ineffective in
reducing substance use, they can erode the therapeutic relationship between provider and patient
(ACOG, 2019).

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Incidence and Prevalence
Approximately 8% of U.S. individuals have a substance use disorder (SAMHSA, 2014).
The gender gap in SUD is narrowing with women now accounting for nearly half of those with
SUD (SAMHSA, 2009). Women additionally account for 30-40% of clients in SUD recovery
programs (Black & Day, 2016). It is estimated that the rate of unintended pregnancies in the
United States is 31%-47%. While these numbers are substantial, that same statistic soars to 86%
for women with SUDs (Heil et al., 2011). While approximately half of women with SUDs report
using some method of contraception, Terplan et al. (2015) found that only 8% of women with
SUDs are using a LARC method. Based on data obtained through a retrospective cohort analysis
of claims and encounter data from 47,902 women in Massachusetts, women with substance use
disorder are less likely to use prescription contraceptives, especially LARCs. However, they are
not less likely to continue using LARCs once prescribed when compared to women without
substance use disorders (Griffith, Kumaraswami, Chrysanthopoulou, Mattocks & Clark, 2017).
Current Practice
Women are accepted as clients at the large majority of SUD programs, however, only a
minority offer programing designed specifically for women (Terplan, McNamara, & Chisolm,
2012). Black and Day (2016) found that family planning services are rarely co-located within
SUD treatment centers. In a qualitative study, Robinowitz and colleagues (2016) explored the
acceptability and feasibility of offering family planning education and services in SUD treatment
centers and found clients were interested in these services while they were in treatment and
preferred to receive these services on-site. According to the U.S. Department of Health &
Human Services Substance Abuse and Mental Health Services Administration (SAMHSA),
women are more likely to enroll, continue, and thrive in recovery care when programs are

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women-centered (SAMHSA, 2009). In 2009, SAMHSA recommended that SUD programs
serving women provide


gynecological care,

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family planning,

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prenatal care,

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educational services about reproductive health,



education about sexually transmitted diseases,

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sexuality education,



assertiveness skills training,



education regarding the effects of alcohol and other drugs on prenatal and child
development,



prenatal education,



trauma-informed services, and



strong female role models in terms of both leadership and personal recovery
(SAMHSA, 2009).

SAMHSA has prepared treatment improvement protocols to address the specific needs of
women and the importance of “one-stop” locations with integrated services (SAMHSA, 2009).
Yet, over a decade later, most SUD treatment facilities do not offer on-site RHC (Black & Day,
2016). The standard practice has been to refer women to outside clinics. However, these referral
sites vary in their ability to offer a full range of contraceptive methods, same day initiation of
contraception, and skill in caring for women with SUD. This current model of care does not
adequately address the needs of this population (Black & Day, 2016). Some experts have argued
that for women who inject drugs, referral is tantamount to service denial (Nasiri, 2013).

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Project Site Internal Evidence
In January 2019, Arizona’s largest residential substance use treatment facility,
Crossroads, Inc., became one of the few programs in the United States to offer on-site primary
care with the opening of a clinic called Crossroads 360 at their largest residential location
serving women. The clinic offers integrated care provided by nurse practitioners specializing in
mental health, adult and family health, and women’s health. Care is available to all residential
clients including those at other locations, with shuttle service provided. Clients can continue to
access care at the clinic after progressing to outpatient or community status. Members of the
community with no other affiliation with Crossroads, Inc. are also welcome to receive care.
Therefore, Crossroads is positioned to serve people recovering from SUD, who may be enrolled
in other programs that do not offer integrated care.
No data was being collected by Crossroads regarding reproductive intent or use of
contraception. The standard admission assessment, developed prior to the clinic opening, did not
explicitly address reproductive health. This is not unusual. A Crossroads client shared that in
her experience of 18 admissions related to SUD over her lifetime- including jails, hospitals,
outpatient treatment centers, and residential treatment centers, “not once” had anyone asked her
if she was interested in or needed help with obtaining contraception. She followed with, “And
it’s so important as I know so many women who have had babies only to have them taken away
and that makes recovery so much harder…. there’s no pain like that.”
The nurse practitioners at Crossroads 360 soon realized that more needed to be done to
fully integrate the new reproductive health care services with the residential recovery program to
ensure clients could access care in a timely manner if desired.

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PICOT Question
This inquiry has led to the clinically relevant PICOT question, “In reproductive aged
women with substance use disorders, who would like to prevent/delay pregnancy (P), does a
formalized integrated family planning program within a residential substance use treatment
center (I), versus the standard practice of referring to an outside clinic (C), affect contraception
initiation and the client’s satisfaction with care received (O), during a typical 30-day length of
stay of residential substance use disorder treatment (T)?”
Search Strategy
Three databases were searched: CINNAHL, PubMed, and PsychINFO. Key words and
Boolean connectors used for SUD were: (substance use disorders or substance abuse or
addiction or recovery or medicated assisted therapy). These terms were combined with key
words: (pregnancy or contraception or family planning or long-acting reversible contraception)
and (barrier or access or health disparities). Articles were restricted to peer reviewed content
written in English. Limits of five years, humans, female, adults, and USA were applied.
The PubMed search yielded 332 articles. PsycINFO yielded 233. CINNAHL yielded
243 articles. Articles were narrowed to those most relevant based on reading titles and abstracts.
A final yield of 56 relevant articles were further evaluated: 15 from CINNAHL 20 from
PsychINFO; and 21 from PubMed. Ten high quality studies were selected based on relevance to
PICOT question and evaluation by rapid critical appraisal tools (Appendix A).
Literature Review Key Themes
The ten studies were chosen for their merit to guide program development for fully
integrating new family planning services with existing SUD treatment programs. All studies
addressed women of reproductive age. Four included a diverse representation of women from

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the general population. Six addressed special subpopulations of women including: American
Indian women with alcohol use disorders, women with SUD, and women at risk for unintended
pregnancy. The settings included a variety of outpatient clinic types: federally qualified health
centers, clinics offering medicated assisted therapy, and primary care clinics. Levels of evidence
included were I, and IV. The studies with the lower level of evidence were included to provide
insight on topics with little published research (Appendix B). Studies described essential
elements of services: education, decisional support, the importance of the interpersonal
relationship between provider and client, and preferred context/setting for the visit.
Interventions
Removing barriers.
The Contraceptive CHOICE Project is one of the largest prospective cohort studies of
women in the United States seeking reversible contraception (Secura, Allsworth, Madden,
Mullersman, & Peipert, 2010). Findings from the project indicate that when the barriers of cost,
access, and knowledge are removed, women choose the most effective and least user-dependent
methods (McNicholas, Madden, Secura, & Peipert, 2014). Not only do women choose these
methods (LARCs), they continue using them and are highly satisfied with their contraceptive
choice (McNicholas et al., 2014). Goodman and colleagues (2017) performed an analysis of the
Contraceptive CHOICE Project database. They concluded that when barriers to cost, access, and
knowledge were removed, there was a reduction in black-white racial disparities in teen
pregnancy rates. Therefore, it is conceivable that disparities in unintended pregnancy rates
would be reduced for women with SUDs using the CHOICE model.
Women were open to a variety of settings/context for family planning counseling, with
convenience of the location being key. Black and Day (2016) reported a few integrated

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contraception services were making promising strides and when co-located with recovery
programs to reduce barriers. Using a naturalistic inquiry, Robinowitz and colleagues (2016)
explored the acceptability and feasibility of offering family planning education and services in
SUD treatment centers and found that clients were interested in these services while they were in
treatment and preferred to receive these services on-site.
Motivational interviewing and tailored counseling.
Tailored education promoting the most effective methods was a major theme of the
studies reviewed. Multiple theories and frameworks were used to guide decision-making
support. Motivational interviewing emerged as an effective theory-based counseling method for
family planning in populations of women with SUDs. This may reflect that women with SUDs
need more time and assistance to clarify their personal goals, understand available options, and
make choices regarding family planning.
Researchers in an integrated behavioral intervention called CHOICES, not to be confused
with the Contraceptive CHOICE Project, used motivational interviewing (MI) and cognitivebehavioral strategies (CBT) targeting adoption of effective contraception and reduction of
alcohol use. The program has been effectively replicated in a variety of settings including
substance abuse treatment settings and urban jails (Floyd et al, 2007; Velasquez, Von Sternberg,
& Parrish, 2013). More recently, the CHOICES program was modified to be culturally and
linguistically appropriate to serve American Indian women and tested in three additional settings.
The researches who developed the CHOICES-based interventions maintained validity,
highlighting the capacity of the intervention to be effectively implemented across settings and
populations (Hanson, Ingersoll, & Pourier, 2015; Hanson et al., 2017).

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Reproductive Justice
Many researchers emphasized the importance of justice. Others highlighted that it must
be appreciated that the choice of a contraceptive method is a personal decision that is highly
contextual; therefore, no form should be promoted as first-line for everyone as effectiveness is
not the only consideration. Authors stressed that efforts to improve access must not lead to
coercion; incentive-based interventions promoting LARCs came under close ethical review
(Downey, Arteaga, Villasenor, & Gomez, 2017; Gomez, Fuentes, & Allina, 2014; Won,
Blumenthal-Barby, & Chacko, 2017). Gubrium et al. (2016) caution of the risks of uncritical
LARC promotion and promote a reproductive justice approach that includes reducing barriers to
accessing LARC while prioritizing patient autonomy. Respecting the decision not to use these
methods or to have these methods removed when requested is foundational. In addition to the
accurate data on method effectiveness, family planning requires providers to engage with women
to consider factors that are important to them. Shared decision making is an approach that
emerged in the literature. Engaging the woman in making a decision that she believes is best for
her accepts the intimate and complex context of contraceptive decision-making and prioritizes
patient autonomy (Chen, Lindley, Kimport, & Dehlendorf, 2019; Downey et al., 2017).
Measuring What Matters Ethically
Leaders in SUD programs desiring to develop or improve RHC services will likely need
to choose outcome measurements to demonstrate program success, justify funding and,
sometimes, reward providers. The items chosen to be measured will have a significant effect on
how programs are implemented and how the autonomy of those served is impacted. Therefore,
there is an ethical imperative to match quality improvement outcomes measurements to the core,
ethical values of family planning care (Dehlendorf et al., 2018). For example, while reducing

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barriers to knowledge, access, and cost is desired, it must be done in an ethical manner that
prioritizes autonomy (Goodman, Onwumere, Milam, & Pelper, 2017). Gubrium and colleagues
(2016) caution against using the number of LARCs placed as an outcome goal as this could lead
to uncritical promotion of LARC methods. Instead, the authors promote a reproductive justice
approach that includes reducing barriers to accessing LARCs while prioritizing patient
autonomy.
While contraceptive effectiveness is an important consideration in contraceptive
counseling, a woman’s lived experience and her own expertise regarding her birth control
preferences need to be elicited and respected (Chen, Lindley, Kimport, & Dehlendorf, 2019;
Downey, Arteaga, Villasenor, & Gomez, 2017; Fox et al., 2018; Gomez, Fuentes, & Allina,
2014). Providers need to be aware of their own biases and prioritize their clients preferences.
The freedom of choice and the absence of coercion regarding method of choice is an essential
component of any family planning program. Additionally, the freedom to readily access care to
change or discontinue a birth control method is essential to ethical contraceptive care.
Many researchers have measured outcomes of contraception initiation and effective
contraception use (Buckel, Maddipati, Goodman, Peipert, & Madden, 2019; Hanson et al., 2017;
Heil et al., 2016; Lopez, Grey, Chen, Tolley, & Stockton, 2016; McNicholas, Madden, Secura, &
Peipert, 2014; Velasquez et al., 2017) (Appendix A).
While these outcomes may be important to record, they must not be used to incentivize
providers as this too has the potential to reward coercive contraceptive counseling. There are
intentionally no set benchmarks for contraceptive use and there is intentionally no goal to reach
100% use (U. S. Office of Population Affairs [OPA], 2020). This reflects the understanding that
many women have personal or religious objections to using contraception. Simply,

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contraceptive counseling is meant to inform all women of their options, not to have all women
on a method.
Other measurements used have included: documentation of screening for pregnancy
desire, documentation of reproductive life planning, and documentation of contraception
counseling (Baldwin, Singhal, & Allen, 2018; Simons & Kohn, 2018; Stulberg, Dahlquist,
Disterhoft, Bello, & Hunter, 2019; Thiel de Bocanegra, McKean, Darney, Saleeby, & Hulett,
2018) (Appendix A). These measures encourage providers to engage more frequently in
conversations about family formation and success can be measured separately from a client’s
choice regarding birth control.
It is important that these measures account for the dynamic nuances of women’s thoughts
about pregnancy. For example, a woman who does not wish to “plan” a pregnancy and would
prefer to “let things happen” should not be recorded as a negative outcome. The outcome
measurement should be positive or negative as she defines it. To achieve this kind of
measurement, Gubrium et al. (2016) argue the primary indicator of quality for family planning
programs should be based on the client’s experience of being truly respected and cared for.
Many researchers used locally produced questionnaires with some risk of bias to assess
contraceptive continuation and substance use. One notable deviation was Dehlendorf and
colleagues. They measured the patient experience using validated measurement instruments:
Interpersonal Quality of Family Planning Score and the Informed Decision and Uncertainty
subscales of the Decisional Conflict Scale (Appendix A).
Person-centered family planning researchers and advocates recommend measuring the
client experience using validated measurement instruments such as the Interpersonal Quality of
Family Planning (IQFP) score (Dehlendorf et al., 2017; Dehlendorf, Henderson, Vittinghoff,

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Steinauer, & Hessler, 2018). In a large prospective study, researchers used the IQFP and
demonstrated that the client experience of the quality of interpersonal care influenced
contraceptive use (Dehlendorf et al., 2016). This measurement focuses the attention on
interpersonal communication and the providers’ skills in eliciting the patient perspective,
establishing trust, building rapport, providing enough information, and supporting informed
decision making (Dehlendorf et al., 2016). The IQFP scale provides a way to “define ‘quality’
from the perspective of an individual member of a defined population” as recommended by the
Institute for Healthcare Improvement (IHI) Triple Aim (IHI, 2020; Mery, Majumder, Brown &
Dobrow, 2017).
Literature Review Conclusion
The evidence from the literature supports the value of family planning services available
on-site in SUD treatment programs. Location is a key feature of convenience and acceptability
for women seeking family planning. Integrating reproductive life planning services with
substance use recovery approaches recovery and overall health goals in a more holistic way.
Staff can modify support and information offered to be sensitive to clients in recovery. Clients
may feel more at ease knowing the provider seeing them already knows they are in recovery. MI
can provide a framework for decision-making counseling for any client needing additional
support to clarify her goals and/or choose among contraceptive options available. Integrating
family planning services into an existing SUD recovery program will require that staff value
reproductive well-being as an integral component of health, well-being, and recovery. To
achieve this, screening conversations about these services should be conducted in a proactive and
routine way. The screening of all clients on admission maximizes the opportunity to provide
care on-site which was a key preference of clients. A non-directive screening that allows for

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women to share their desires for to have or not have a pregnancy will reduce the potential of
coercion if only contraception is routinely discussed. The client experience of care should be a
key consideration with intervention design and measurement of effectiveness.
Theory Application
Motivational interviewing (MI) is a counseling style that has been applied to both
contraceptive counseling and SUD counseling. MI emerged as a leading intervention from the
literature search (Appendix B). It is currently being used at the project site to guide SUD
counseling; it may provide a natural extension of services if used as the underpinnings of new
family planning counseling. MI is defined by Miller and Rollnick (2002) as a “client-centered,
directive method for enhancing intrinsic motivation to change by exploring and resolving
ambivalence.” Markland, Ryan, Tobin and Rollnick (2005) propose that the self-determination
theory (SDT) offers a coherent theoretical framework for understanding the MI process and
efficacy. Fundamental to SDT is the principle that people have an innate tendency towards
personal growth, integration of the self, and the resolution of inconsistency of goals and
behaviors (Markland et al., 2005). Utilizing MI based on SDT can function to support
individuals to reach the SDT goals of competence, autonomy, and relatedness (Appendix C).
Clients can progress towards the SDT concept of competence by understanding options
available to support her reproductive desires using personalized education and MI. Clients can
progress towards the SDT concept goal of autonomy using MI techniques that avoid coercion,
explore options, and support the client to make her own decisions. The SDT concept of
relatedness, or feeling socially supported, can be fostered by exploring client concerns, avoiding
judgement, and demonstrating respect which can result in improved trust.

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The combined MI and SDT model may be better than the technique of MI alone for use
in family planning programs as it emphasizes the importance of autonomy and self-determination
which are ethical essentials. Feelings about pregnancy and contraception are highly contextual
and nuanced, with no “one right path.” MI and SDT may help some clients to resolve
ambivalence by helping to clarify goals and options. MI and SDT may help others embrace their
ambivalence if they genuinely prefer to not plan. Both of these are positive and acceptable
outcomes, particularly when the client does not want to plan her reproductive life can be
connected with well-woman care that can improve her health outcomes whether she becomes
pregnant or not. MI and SDT highlights the importance of a supportive, non-judgmental
provider which may be particularly valued by clients who have formerly avoided family
planning services for fear of judgement, blame, or coercion.
Implementation Framework
The evidence-based practice model chosen to guide implementation is the Institute for
Healthcare Improvement (IHI) Triple Aim Model for Improvement (Appendix D). The Triple
Aim guides health care improvement initiatives to simultaneously pursue three goals: improve
the individual experience of care, improve the health of populations, and reduce per capita cost
of care for the population (Mery, Majumder, Brown, & Dobrow, 2017). The immediate outcome
goal for this project is to offer family-planning screening conversations that provide an excellent
care experience for the client. The long-range (unmeasured) population health goals of this
project include: reduction of disparities in unintended pregnancy rates, reduction of substance
exposed pregnancies, improved birth spacing, and reduction of disparities of preconception and
prenatal care. The cost goals are to mitigate the high-cost per capita associated with unintended
pregnancies in this population by providing ethical and effective primary prevention strategies.

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This model presents three overarching questions: “What are we trying to accomplish?”,
“How will we know that a change is an improvement?”, and “What change can we make that
will result in an improvement?” (IHI, 2019). With initial answers in mind, the change agent(s)
can begin the process of trialing changes. IHI promotes the Plan-Do-Study-Act (PDSA) cycle to
accelerate quality improvement efforts. The steps in the cycle are: plan the intervention,
including a plan for collecting data; do a small-scale test of the intervention; study the data and
results; and act by refining the changes based on what was learned from the tested intervention.
The cycle can be repeated as often and frequently as needed in an upward progression that moves
the organization closer to achieving their aims (IHI, 2019).
Methods
Intervention
A pilot demonstration of a pregnancy desire screening tool, One Key Question, was the
initial PDSA cycle, to trial routine reproductive health conversations on admission to identify
clients with needs and connect them to services offered as desired. OKQ is a patient-centered
tool developed by the Oregon Foundation for Reproductive Health (OFRH) and licensed by the
non-profit organization, Power to Decide. The tool screens for pregnancy desire and then
follows with a conversation algorithm to determine reproductive health care needs and guide
recommendations. It was designed to be used in primary care or other community settings that
have not typically included reproductive healthcare conversations (Bellanca & Hunter, 2013). It
is brief yet has the power to identify those who have straightforward needs and those who need
follow-up with providers skilled in reproductive healthcare. It has been endorsed by ACOG, and
the Association of Maternal and Child Health Programs (ACOG, 2016, Association of Maternal
and Child Health Programs, 2019). The tool is aligned with the Office of Population Affairs and

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the CDC’s Quality in Family Planning service delivery recommendations (Gavin et al., 2014). It
was designed to be non-directional meaning that it can be equally valuable to those who desire
pregnancy, those who don’t, and those who are okay either way or unsure. It is patient-centric,
aimed at understanding intentions, and non-judgmental. It provides guidance for recommended
follow-up care for contraceptive counseling, preconception counseling, or general reproductive
and well-woman care depending on the client response (Power to Decide, 2020). It confines the
context of the conversation to a one-year time frame with an initial question to be asked
verbatim, “Would you like to become pregnant in the next year?”
Measurements and Instruments
Selecting appropriate outcome measurements maintains the focus of the project on the
high-level goals of the organization (IHI, 2019). A modified version of the Interpersonal Quality
of Family Planning Scale-Reduced (IQFP-R) was created to measure the effectiveness the family
planning screening process. The IQFP-R is a parsimonious version of the original IQFP scale
reducing the eleven indicators to four: feeling respected, feeling informed, having preferences
elicited, and having preferences honored (Dehlendorf et al., 2017). This original IQFP is a
validated and reliable tool. It was developed by Dehlendorf and colleagues (2017) to be aligned
with the key client experience measures that have been found to affect contraception choice
(Appendix B).
The IQFP-R is specific to contraception counseling. It was modified version for this
project to be non-directional for the purposes of initial screening conversations. The modification
enables it to be appropriate to for use with those who do or do not desire pregnancy. This
modification was made with the permission and assistance of the original researcher, Christine
Dehlendorf, MD, MS Professor of Family Community Medicine at the University of California,

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San Francisco. A secondary review and further assistance in rewording the tool was provided by
Lisa Callegari, MD, MPH Associate Professor of Obstetrics and Gynecology at the University of
Washington. The resulting tool is a five-point Likert scale like the originals. Face symbols were
added, similar to their use in pain scales, following cultural and literacy appropriateness
principles to allow for easier recognition of the direction of the scale (Appendix F).
Data Analysis
Responses to OKQ and subsequent questions were recorded by the interviewer on a paper
record (Appendix E). Descriptive and summary statistics were tabulated using
IntellectusStatistics to describe the magnitude of healthcare needs, the desires for care at the
on-site integrated clinic, and the client experience of care of the screening process.
Results
Summary statistics were calculated for each interval and ratio variable. Frequencies and
percentages were calculated for each nominal variable.
Participants
The total number of women admitted to Crossroads, Inc. for residential care in the month
of October 2019 was 83. 77 clients were available on the days screenings were conducted; six
were in the hospital. Of the available 77, 65 were of reproductive age defined as 18-49 years
(n=65, 84%). Crossroads, Inc. does not admit people under the age of 18. Two people declined
to participate.
Sixty-three clients agreed to initiate the OKQ conversation. All who initiated the
conversation, completed the conversation. OKQ was not applicable for 18 participants due to

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

21

surgeries or procedures resulting in permanent sterilization. Statistics were compiled to describe
the 45 clients for whom OKQ applied.

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

22

Demographics
The most frequently observed category of race was White (n = 34, 76%). The most
frequently observed category of ethnicity was Non-Hispanic (n = 30, 67%). The most frequently
observed category of gender was female (n = 44, 98%). Client age averaged 30.38 years with a
range of 19 to 45 years of age (SD = 6.59). Findings are presented in Table 1.
Length of Residential Stay at Screening Time
The average number of days in residence for the sample at the time of screening was 4.91
with a range of 1 to 17 days (SD = 3.18). Findings are presented in Table 2.
Individual Screening Duration
The duration of the screening conversations averaged 9.60 minutes; the shortest interview
lasted 3 minutes and the longest lasted 25 minutes (SD = 4.65). Findings are presented in Table
2.
Responses to OKQ
The most frequently observed response to OKQ: “Would you like to become pregnant in
the next year?” was No (n = 31, 69%), followed by Yes (n=7, 16%), Okay either way (n=6,
13%), and Unsure (n=1, 2%). Responses are presented in Table 1 and Figure 1.
Responded “No.”
To describe the subset of clients that answered “No” to OKQ, frequencies and
percentages were calculated for the following variables: folic acid use, birth control method,
level of satisfaction with current birth control method, history of well woman exam in the last 12

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

23

months, offers of well woman referrals, acceptances of well woman referrals, offers of
contraception care, acceptances of contraception care referrals, and other referrals made based on
client request.
None of the women who answered “No” to OKQ were currently taking daily folic acid (n
= 31, 100%). The majority were not using any form of birth control (n = 17, 55%). The next
most frequent response to birth control method use was abstinence (n=4, 13%). Four women
reported they had levonorgestrel implants in situ (13%); all were satisfied with this method. One
respondent had an implant that was expired and she desired a replacement with a new implant.
An IUD was used by two women (6%), one copper device and one levonorgestrel IUD; both
were satisfied with their IUD method. The other methods reported were: withdrawal, natural
family planning, and female partners only (n=1, 3%) for each.
The majority of clients had not had a well woman visit in the last 12 months (n = 21,
68%). Well woman visits were offered to all women who had not had a well woman visit in the
past 12 months and one additional referral was offered in response to a client’s request to have
hers repeated at the integrated clinic (n = 22, 71%). All well woman visit referrals were accepted
(n = 22, 71%). Contraception care referrals were offered to clients who stated they were unhappy
with their current method, not using a method, or using a method that was not in the most
effective category (n = 22, 71%). Of those offered contraception care referrals, 86% were
accepted (n = 19). Frequencies and percentages of variables related to people who answered
“No” are presented in Table 2.

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

24

Responded “Yes.”
Women who desired pregnancy in the next year most frequently answered that they were
not taking folic acid (n = 6, 86%), had not had a preconception care appointment in the last 12
months (n = 6, 86%), and had not had a well woman visit appointment in the last 12 months (n =
4, 57%). All women who were overdue for a well woman visit (n = 4, 57%) were offered
referrals for a well woman visit. All women who desired pregnancy in the next year, but had not
had a preconception care appointment in the last year were offered a preconception appointment
(n = 6, 86%). All referrals offered were accepted (n=10, 100%) Frequencies and percentages of
this subset are presented in Table 3.
Responded “Ok either way.”
None of participants who responded “Okay either way” to OKQ were taking folic acid (n
= 6, 100%). Most had not had a preconception care appointment in the prior 12 months (n = 5,
83%). Condoms were being used as birth control by one participant (n=1, 17%), the others were
not using any form of birth control (n = 5, 83%). Half reported they had had a well woman visit
in the prior 12 months, with the other half reporting they had not, each with an observed
frequency of 3 (50%). All were offered general reproductive care appointments (n = 6, 100%).
All of these referrals were accepted (n = 6, 100%). Well woman visits were offered to all who
were overdue, with an observed frequency of 3 (50%). All well woman visit referrals were
accepted (n=3, 100%). Frequencies and percentages of this subset are presented in Table 4.

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

25

Responded “Unsure.”
Only one client responded to OKQ as “Unsure.” She was not taking folic acid, was
virginal, and planned continued abstinence. However, she was “unsure” about her feelings about
pregnancy in the next year and desired initiating daily folic acid. She had had a recent well
woman visit. A referral was made to the clinic to initiate a multivitamin with folic acid and
receive general reproductive health care and guidance. She accepted the referral.
Including All Participants
Clients for whom OKQ was not applicable, were briefly screened for well-woman visit or
other sexual health appointment needs. The statistics to describe the overall magnitude of needs
and desires for care at the on-site clinic were, therefore, based on the whole participant sample
(n=63). Some clients received more than one referral type. For example, one individual may
have received a referral for well-woman care and contraception care. In all, 83 referrals were
made. The most frequent referral type made was for well-woman care, representing just over half
of all referrals made (n=44, 53%), followed by contraception care (n=21, 25%), preconception
care (n=8, 10%), and general reproductive health appointments offered to women ambivalent
about pregnancy desire (n=6, 7%). Other referrals (n=4, 5%) included: a six-week postpartum
care visit, a follow up regarding abnormal pap results from an outside provider, a request for
multivitamins containing folic acid, and sexually transmitted infection testing. Frequencies and
percentages are presented in Table 6.
Client Experience of Care
Frequencies and percentages were calculated for ratings of interpersonal quality of care
items. The full wording of the items on the scale provided to client were as follows: enough

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

26

information, “giving me enough information about services available related to pregnancy or
birth control;” listened to, “letting me say what mattered to me about desiring or not desiring
pregnancy;” respected, “respecting me as a person;” and taken seriously, “taking my preferences
seriously related to pregnancy or birth control.”
Likert Scale.
All surveys completed (n=54, 100%) had ratings for each interpersonal quality of care
item measured, with no missing data. The overall most frequently observed category of rating
was Excellent (n = 198, 92%). Clients reported their receipt of enough information, most
frequently as Excellent (n = 51, 94%). In regards to being listened to, the most frequently
observed category of rating was Excellent (n = 48, 89%). Most clients rated their experience of
being respected, as Excellent (n = 49, 91%). People felt taken seriously, with the most frequently
rating of Excellent (n = 50, 93%). Frequencies and percentages are presented in Table 7 and
Figure 2.
Qualitative.
The collection of qualitative data was not planned. The client experience of care scale
used did not have a comments section. However, several clients took the initiative to add
unsolicited comments in the margin of the scale. All written comments are listed here, verbatim.


“Thank you!” was written adjacent to the item, “Letting me say what mattered to me
about desiring or not desiring pregnancy”;



“Thank (drawing of heart) You”;



“Y’all the shit!”;

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY


27

“(I liked) having people listen to me, really caring for what I need and explaining all my
tools that I can use! 10/10”;



“I feel very happy with the information I now have that I didn’t before, thank you so
much for talking as well as listening to me. I’m glad you came to see me (drawing of
smiling face)”;



“Thanks for taking time out of your day to come see us”;



“Love it”;



“Very informative. I look forward to 360 health care. I’m glad these services are
offered”; and



“Programs like this should be put into place more often.”
Limitations
There is a discrepancy in the number of clients responding to OKQ and satisfaction

surveys. This is because some clients who responded “Not applicable” to OKQ completed the
satisfaction survey.
Implications
Robust programming to support RWB within recovery programs is a promising way to
improve the overall well-being of clients and population health. The evidence from the literature
and the results of this project highlight the value of family-planning services co-located with
SUD programs. This project identified significant reproductive health needs for this population
consistent with those described in the literature. This project also adds to the small, but growing
body of evidence that demonstrates clients are agreeable to having conversations about their
pregnancy desires, want quality reproductive health care, and express a preference for receiving
that care in an integrated way within their recovery program. Clients expressed feeling more at

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

28

ease, knowing that the provider who would see them for RHC already knows they are in
recovery.
Multidisciplinary, interprofessional collaboration is essential to developing robust
programming that recognizes the multifaceted components of reproductive well-being.
Advocates and healthcare leaders in reproductive health care need to strengthen collaborative
partnerships with SUD recovery programs with a joint aim to improve client well-being.
Interprofessional conferences and education programs that connect nurse practitioners,
physicians, social workers, counselors, and alcohol and drug peer counselors are needed to foster
improved understanding of this population. Innovative programs to support women in recovery
to achieve RWB will likely benefit from the integration of multiple perspectives and skills.
Several pregnancy intention screening guides exist. The OKQ tool is unique in offering a
one-year timeframe to focus the conversation. This may make the tool particularly well suited
for SUD programs that wish to implement screening of all clients. The one-year time frame
makes the conversation more focused on the immediate and near future needs of clients. This
may make the screening more feasible for non-expert family planning conversations. It also may
match the needs of clients in a rapidly evolving state of health. Asking women to consider the
next year only may ease the conversation as we know reproductive life desires or plans are
highly contextual and fluid (Edmonds & Ayres, 2017). Using OKQ does not preclude talking
about goals and feelings about pregnancy beyond the one-year timeframe if raised by clients;
several clients in this sample raised questions or made comments about their long-term plans and
these were easy to address individually within the OKQ framework. However, because the OKQ
tool does not expressly ask people to consider their whole life reproductive plan, women in

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

29

recovery may have accepted this screening tool more readily than others tools. Further research
should be completed to compare OKQ to other screening tools for use with this population.
Recommendations
Full implementation of OKQ was recommended to the leadership team at Crossroads,
Inc. The Crossroads mission to care for the whole person can be enhanced by addressing clients’
RWB as an important part of their overall well-being. Power to Decide offers on-site provider
training and ongoing training and maintenance of certification through “train the trainer” formats
to ensure OKQ is used with fidelity. Full electronic health record (EHR) integration is available
to support billing for services and interdisciplinary communication regarding clients’ desires,
needs, and follow up care plans. Integrating the screening tool into the EHR could be done in a
second PDSA cycle. Integration with the EHR could facilitate use and efficacy, because the
responses and follow up plan could be readily accessed by all providers involved in the client’s
care. Additionally, linking the tool to the EHR would aid outcome measurements.
Other agencies and organizations serving women with SUD are recommended to
consider ways to incorporate reproductive health education and care. Organizations that are too
small or otherwise limited in their capacity to offer a full range of reproductive health care
services, can pilot OKQ to screen and refer clients to known qualified outside resources.
Building partnerships and alliances between reproductive health care providers and recovery
providers can better serve women with SUD bidirectionally in settings where full integration is
not possible. OKQ offers two algorithms to guide conversations. One is designed for clinicians
who can provide the full service, the other is designed for non-clinical staff to use a screening
and referral tool. OKQ maintains fidelity when the question is asked verbatim, “Would you like
to become pregnant in the next year?” and provides four answer options, “Yes”, “No”, “Okay

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

30

either way”, and “Unsure.” Individual organizations can follow one of the two algorithms or
adapt them to fit the setting. This enables a variety of settings to implement this tool with
fidelity.
The client experience of care can be measured and should be a key outcome measurement
in RHC programs. RHC is unlike other areas of health, as positive outcomes are not directional.
Becoming pregnant as soon as possible may be one persons goal. Never becoming pregnant may
be another’s goal. And, of course, there are many other desired personal outcomes between
these two poles. Therefore, it is essential to frame the success of family planning and RHC
programs based on individual care experiences. Programs can use these measurements to ensure
clients goals were taken seriously and clients were given the support and information that
mattered to them. The IQFP is one tool that has been validated to measure the client experience
of care with contraception specific conversations. The adaptation of this tool to be nondirectional was useful to maintain the focus of the client experience for this project. The hope is
more organizations will implement RHC and pregnancy intention screening programs. A tool is
needed to evaluate these programs. The adaptation of the IQFP used in this project may be
useful to other organizations planning to implement pregnancy intention screening routinely to
evaluate how these screening conversations are perceived by clients. As this tool is not specific
to women in recovery, it may be helpful for evaluating family planning screening programs in a
variety of settings.
Conclusion
Empowering women in recovery to consider their reproductive desires and then assisting
them with their reproductive health needs has far reaching implications. Clients can improve
their individual sense of self-determination and reduce their risk of complications associated with

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

31

unintended pregnancies. Integrating RHC in SUD settings has the potential to reduce substance
exposed pregnancies, NAS, and FASD. The financial savings could be substantial. Screening
for pregnancy desire and connecting women to desired reproductive healthcare aligns the
recommendations of key organizations including the AAP, CDC, ACOG, WHO, and SAMSHA.
This primary prevention strategy has the power to simultaneously improve the health and welfare
of two generations.
More work needs to be done to support all women to reach the “highest standard of
sexual and reproductive health as they themselves define it” (Dehlendorf, 2018). Reducing
health disparities for women in recovery requires disrupting the current system of separated care
and reframing reproductive life planning as a priority in substance use treatment programs.
Achieving a greater degree of reproductive well-being is an important aspect of helping women
experience a greater degree of overall wellbeing. Programs for recovery from SUD are a largely
unused setting that have the potential to provide quality RHC in a way that may better support
the priorities and perspectives of women in recovery. These programs may be particularly well
suited to provide RHC in a way that reduces stigma and fears, empowers clients to consider their
desires, and respects individual autonomy. Collaboratively integrating quality RHC within
quality SUD recovery programs has the potential to achieve public health goals by placing the
client experience of care at the heart of the union.

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

32

References
American College of Obstetricians and Gynecologists Committee on Health Care for
Underserved Women. (2019). ACOG Committee opinion no. 473: Substance abuse
reporting and pregnancy: The role of the obstetrician-gynecologist. Obstetrics &
Gynecology, 117, 200-1. http://doi.org/10.1097/AOG.Ob013e31820a6216
American College of Obstetricians and Gynecologists Committee on Health Care for
Underserved Women. (2011). ACOG Committee opinion no. 479: Methamphetamine
abuse in women of reproductive age. Obstetrics & Gynecology, 117(3), 751-755.
http://doi.org/10.1097/AOG.0b013e318214784e
American College of Obstetricians and Gynecologists Committee on Health Care for
Underserved Women and the American Society of Addiction Medicine. (2012). ACOG
Committee opinion no. 524: Opioid abuse, dependence, and addiction in pregnancy.
Obstetrics and Gynecology, 119, 1070-1076. http://doi.org/
10.1097/AOG.0b013e318256496e
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice,
Long-Acting Reversible Contraception Working Group. (2018). ACOG Committee
opinion no. 642: Increase access to contraceptive implants and intrauterine devices to
reduce unintended pregnancy. Obstetrics and Gynecology, 126, e44-48.
http://doi.org/10.1097/AOG.0000000000001106
American College of Obstetricians and Gynecologists. (2016). Committee opinion no. 654:
Reproductive life planning to reduce unintended pregnancy. Obstetrics and Gynecology,
127(2), e66-e69. http:/doi.org/10.1097/AOG..0000000000001314

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

33

Association of Maternal and Child Health Programs. (2019). Innovation station practice
summary and implementation guidance, One Key Question. An innovation station best
practice. Retrieved from
http://www.amchp.org/programsandtopics/BestPractices/InnovationStation/ISDocs/One%
20Key%20Question.pdf
Baldwin, S., Singhal, R., & Allen, D. (2018). Optimizing care for women of reproductive age
with One Key Question. Retrieved from http://rx.ph.lacounty.gov/RxOKQ0718
Bellanca, H. K., & Hunter, M. S. (2013). One Key Question: Preventative reproductive health is
part of high quality primary care. Contraception, 88(1), 3-6.
http:/doi.org/10.1016/j.contraception.2013.05.003
Black, K. I., & Day, C. A. (2016). Improving access to long-acting contraceptive methods and
reducing unplanned pregnancy among women with substance use disorders. Substance
Abuse: Research and Treatment, 10(S1), 27-33. http://doi.org/10.4137/SART.S34555
Buckel, C., Maddipati, R., Goodman, M., Peipert, J. F., & Madden, T. (2019). Effect of staff
training and cost support on provision of long-acting reversible contraception in
community health centers. Contraception, 99(4), 222-227.
http://doi.org/10.1016/j.contraception.2018.12.005
Centers for Disease Control and Prevention. (2016). Providing quality family planning services:
Recommendations of the CDC and the U.S. Office of Population Affairs. Retrieved
from http://www.cdc.gov/reproductivehealth/contraception/qfp.htm.
Chen, M., Lindley, A., Kimport, K., & Dehlendorf, C. (2019). An in-depth analysis of the use of
shared decision making in contraceptive counseling. Contraception, 99(3), 187-191.
http://doi.org/10.1016/j.contraception.2018.11.009

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

34

Dehlendorf, C., Fox, E., Ahrens, K., Gavin, L., Hoffman, A., & Hessler, D. (2017). Creating a
brief measure for patient experience of contraceptive care: Reduction of the interpersonal
quality of family planning scale in preparation for testing as a performance measure.
Contraception, 96, 290. http://doi.org/10.1016/j.contraception.2017.07.106
Dehlendorf, C., Reed, R., Fox, E., Seidman, D., Hall, C., & Steinauer, J. (2018). Ensuring our
research reflects our values: The role of family planning research in advancing
reproductive autonomy. Contraception, 98, 4-7.
http://doi/org/10.1016/j.contraception.2018.03.015
Downey, M.M., Arteaga, S., Villasenor, E., & Gomez, A.M. (2017). More than a destination:
Contraceptive decision making as a journey. Women’s Health Issues, 27(5), 539-545.
http://doi.org/10.1016/j.whi.2017.03.004
Dehlendorf, C., Fitzpatrick, J., Fox, E., Holt, K., Vittinghoff, E., Reed, R., . . . Kuppermann, M.
(2019). Cluster randomized trial of a patient-centered contraceptive decision support
tool, My Birth Control. American Journal of Obstetrics and Gynecology, 220(6), 565e1565e12. http://doi.org/10.1016/j.ajog.2019.02.015
Downey, M.M., Arteaga, S., Villasenor, E., & Gomez, A.M. (2017). More than a destination:
Contraceptive decision making as a journey. Women’s Health Issues, 27(5), 539-545.
http://doi.org/10.1016/j.whi.2017.03.004
Edmonds, S. W. & Ayers, L. (2017). Evolutionary concept analysis of reproductive life planning.
Journal of Obstetric, Gynecologic, & Neonatal Nursing, 46, 78-90.
http://doi.org/10.1016/j.jogn.2016.07.012
Floyd, R.L, Sobell, M., Velasquez, M.M, Ingersoll, K., Nettleman, M., Sobell, L., … Nagaraja, J.
(2007). Preventing alcohol-exposed pregnancies: a randomized controlled trial.

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

35

American Journal of Preventive Medicine, 32(1), 1-10.
http://doi.org/10.1016/j.amepre.2006.08.028
Finkelstein, N. (1994). Treatment issues for alcohol- and drug-dependent pregnant and parenting
women. Health & Social Work, 19(1), 7-15. http://doi.org/10.1093/HSW/19.1.7
Fox, E., Reyna, A., Malcolm, N. M., Rosmarin, R. B., Zapata, L. B., Frederiksen, B. N., …
Dehlendorf, C. (2018). Client preferences for contraceptive counseling: A systematic
review. American Journal of Preventive Medicine, 55(5), 691-702. http://doi.org/
10.1016/j.amepre.2018.06.006
Gavin, L., Moskosky, S., Carter, M., Curtis, K., Glass, E., Godfrey, E.,…Zapata, L. (2014).
Providing quality family planning services: Recommendation of CDC and the U.S.
Office of Population Affairs. Morbidity and Mortality Weekly Report, 63(RR04), 1-29.
Retrieved from https://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
Gomez, A. M., Fuentes, L., & Allina, A. (2014). Women or LARC first? Reproductive autonomy
and the promotion of long-acting reversible contraceptive methods. Perspectives on
Sexual and Reproductive Health, 46(3), 1-5. http://doi.org/10.1363.46e1614
Goodman, M., Onwumere, O., Milam, L., & Pelper, J. F. (2017). Reducing health disparities by
removing cost, access, and knowledge barriers. American Journal of Obstetrics &
Gynecology, 216(382), e1-5. http://doi.org/10.1016/j/ajog.2016.12.015
Gemmill, A., Kiang, M., Alexander, M. (2018). Trends in pregnancy-associated mortality
involving opioids in the United States, 2007-2016. American Journal of Obstetrics and
Gynecology, 220(1), 115-116. http://doi.org/10.1016/j.ajog.2018.09.028

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

36

Griffith, G., Kumaraswami, T., Chrysanthopoulou, S. A., Mattocks, K. M., & Clark, R. E. (2017).
Prescription contraception use and adherence by women with substance use disorders.
Addiction, 112, 1638-1646. http://doi.org/10.1111/add.13840
Gubrium, A., Mann, E., Borrero, S., Dehlendorf, C., Fields, J., Geronimus, A. T., … Sisson, G.
(2016). Realizing reproductive health equity needs more than long-acting reversible
contraception (LARC). American Journal of Public Health, 106, (1), 18-19.
http://doi.org/10.2105/AJPH.2015.302900
Hanson, J.D., Ingersoll, K., Pourier, S. (2015). Development and implementation of CHOICES
group to reduce drinking, improve contraception, and prevent alcohol-exposed
pregnancies in American Indian Women. Journal of Substance Abuse Treatment, 59, 4551. http://doi.org/10.1016/j.sat.2015.07.006
Hanson, J., Nelson, M., Jensen, J., Willman, A., Jacobs-Knight, J., & Ingersoll, K. (2017). Impact
of the CHOICES interventions in preventing alcohol-exposed pregnancies in American
Indian women. Alcoholism: Clinical and Experimental Research, 41(4), 828-835.
http://doi.org/10.1111/acer.13348
Heil, S. H., Hand, D. J., Sigmon, S., Badger, G. J., Meyer, M. C., Higgins, S. T. (2016). Using
behavioral economic theory to increase use of effective contraceptives among opioidmaintained women at risk of unintended pregnancy. Preventive Medicine, 92, 62-67.
http://doi.org/10.1016/j.ypmed.2016.06.023
Heil, S. H., Jones, H. E., Arria, A., Kaltenbach, K., Coyle, M., Fischer, G., … Martin, P. R.
(2011). Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse
Treatment,40,199-202. http://doi.org/10.1016/j.jsat.2010.08.011

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

37

Howell, E. M., Heiser, N., & Harrington, M. (1999). A review of recent findings on substance
abuse treatment for pregnant women. Journal of Substance Abuse Treatment, 16(3), 195219. http://doi.org/10.1016/S0740-5472(98)00032-4
Institute for Healthcare Improvement. (2019). How to improve. Retrieved from
http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
Keller, L. H., & Sonfield, A. (2019). More to be done: Individuals’ needs for sexual and
reproductive health coverage and care. Retrieved from
https://www.guttmacher.org/gpr/2019/02/more-be-done-individuals-needs-sexual-andreproductive-health-coverage-and-care
Ko, J. Y., Wolicki, S., Barfield, W. D., Patrick, S. W., Broussard, C. S., Yonkers, K. A.,
…Iskander, J. (2017). CDC grand rounds: Public health strategies to prevent neonatal
abstinence syndrome. MMWR: Morbidity and Mortality Weekly Report, 66(9), 242-245.
http://doi.org/10.15585/mmwr.mm6609a2
Lopez, L. M., Grey, T. W., Chen, M., Tolley, E. E., & Stockton, L. L. (2016). Theory-based
interventions for contraception. The Cochrane Database of Systematic Reviews,
2016(11), 1-114. http://doi.org/10.1002/14651858.CD007249.pub5
McNicholas, C., Madden, T., Secura, G., & Peipert, J. F. (2014). The Contraceptive CHOICE
project round up: What we did and what we learned. Clinical Obstetrics and Gynecology,
57(4), 635-643. http://doi.org/10.1097/GRF.0000000000000070
Markland, D., Ryan, R. M, Tobin, V. J., and Rollnick, S. (2005). Motivational interviewing and
self-determination theory. Journal of Social and Clinical Psychology, 24(6), 811-831.
Matusiewicz, A.K., Melbostad, H. S., & Heil, S. H. (2017). Knowledge of and concerns about
long-acting reversible contraception among women in medication-assisted treatment for

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

38

opioid use disorder. Contraception, 96, 365-369.
http://doi.org/10.1016/j.contraception.2017.07.167
Mery, G., Majumder, S., Brown, A., & Dobrow, M. (2017). What do we mean when we talk
about the Triple Aim? A systematic review of evolving definitions and adaptations of the
framework at the health system level. Health Policy, 121, 629-636.
http://doi.org/10.1016/j.healthpol.2017.03.014
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change
(2nd ed.). New York, New York: Guilford Press.
Nasiri, B. (2013). Windows of opportunity: adapting services to the needs of people who inject
drugs. International Journal of Drug Policy, 23, 107.
http://doi.org/10.1016/j.drugpo.2011.09.012
Patrick, S. W., & Schiff, D. M. (2018). A public health response to opioid use in pregnancy.
Pediatrics, 139(3),1-7. http://doi.org/10.1542/peds.2016-4070
Power to Decide (2020). One Key Question. Retrieved from https://powertodecide.org/onekey-question
Roberts, S. C. M., & Nuru-Jeter, A. (2010). Women’s perspectives on screening for alcohol and
drug use in prenatal care. Women’s Health Issues, 20(3), 193-200.
http://doi.org/10.1016/j.whi.2010.02.003
Roberts, S. C. M., & Pies, C. (2011). Complex calculations: How drug use during pregnancy
becomes a barrier to prenatal care. Maternal and Child Health Journal, 15(3), 333-341.
http://doi.org/10.1007/s10995-010-0594-7
Robinowitz, N., Muqueeth, S., Scheibler, J., Salisbury-Afshar, E., & Terplan, M. (2016). Family
planning in substance use disorder treatment centers: Opportunities and challenges.

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

39

Substance Use and Misuse, 51(11), 1477-1483.
http://doi.org/10.1080/10826084.2016.1188944
Schempf, A. H., & Strobino, D. M. (2009). Drug use and limited prenatal care: An examination
of responsible barriers. American Journal of Obstetrics and Gynecology, 200(4), 412e1412e10. http://doi.org/10.1016/j.ajog.2008.10.055
Secura, G. M., Allsworth, J. E., Madden, T., Mullersman, J. L., & Peipert, J. F. (2010). The
Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception.
The American Journal of Obstetrics and Gynecology, 203(115), e111-117.
http://doi.org/10.1016/j.ajog.2010.04.017
Singer, L. T., Salvator, A., Arendt, R., Minnes, S., Farkas, K., & Kleigman, R., (2002). Effects of
cocaine/polydrug exposure and maternal psychological distress on infant birth outcomes.
Neurotoxicology and Teratology, 24(2), 127-135. http://doi.org/10.1016/S08920362(01)00208-2
Simons, H. R., & Kohn, J. E. (2019). Examining temporal trends in documentation of pregnancy
intentions in family planning health centers using electronic health records. Maternal and
Child Health Journal, 23, 47-53. http://doi.org/10.1007/s10995-018-2590-2
Stone, R. (2015). Pregnant women and substance use: fear, stigma, and barriers to care. Health &
Justice, 3(1), 2. http://doi.org/10.1186/s40352-015-0015-5
Stulberg, D. B., Dahlquist, I. H., Disterhoft, J., Bello, J. K., & Hunter, M. S. (2019). Increase in
contraceptive counseling by primary care clinicians after implementation of One Key
Question at an urban community health center. Maternal and Child Health Journal,
23(8), 996-1002. http://doi.org/10.1007/s10995-019-02754-z

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

40

Substance Abuse and Mental Health Services Administration. (2009). Substance abuse
treatment: Addressing the specific needs of women: Treatment improvement protocol
(TIP) Series 51. Retrieved from https://store.samhsa.gov/system/files/sma15-4426.pdf
Substance Abuse and Mental Health Services Administration. (2014). Medicaid coverage and
financing of medications to treat alcohol and opioid use disorders. Retrieved from
https://store.samhsa.gov/product/Medicaid-Coverage-and-Financing-of-Medications-toTreat-Alcohol-and-Opioid-Use-Disorders/sma14-4854
Terplan, M., Hand, D. J., Hutchinson, M., Salisbury-Afshar, E., & Heil, S. H. (2015).
Contraceptive use and method of choice among women with opioid and other substance
use disorders: A systematic review. Preventive Medicine, 80, 23-31.
http:/doi.org/10.1016/j.ypmed.2015.04.008
Terplan, M., McNamara, E., & Chisolm, M. (2012). Pregnant and non-pregnant women with
substance use disorders: The gap between treatment need and receipt. Journal of
Addictive Diseases, 31(4), 342-349. http://doi.org/10.1080/10550887.2012.735566
Thiel de Bocanegra, H., McKean, A., Darney, P., Saleeby, E., & Hulett, D. (2018).
Documentation of contraception and pregnancy intention in Medicaid managed care.
Health Services Research and Managerial Epidemiology, 5, 1-5.
http://doi.org/10.1177/2333392817748870
U.S. Office of Population Affairs. (2020). Performance measures. Retrieved from
https://www.hhs.gov/opa/performance-measures/index.html
Velasquez, M. M, von Sternberg, K. L., Floyd, L., Parrish, D., Kowalchuk, A., Stephens, N. S.,
… Mullen, P. D. (2017). Preventing alcohol and tobacco exposed pregnancies: CHOICES

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

41

plus in primary care. American Journal of Preventive Medicine, 53(1), 85-95.
http://doi.org/10.1016/j.amepre.2017.02.012
Velasquez, M., von Sternberg, K., & Parrish, D. (2013). CHOICES: An integrated behavioral
intervention to prevent alcohol-exposed pregnancies among high-risk women in
community settings. Social Work in Public Health, 28, 224-233.
http://doi/org/10.1080/19371918.2013.759011
Whitaker, A. K, Quinn, M. T., Martins, S. L., Tomlinson, A. N., Woodhams, E. J., & Gilliam, M.
(2015). Motivational interviewing to improve postabortion uptake of long-acting
reversible contraception by young women: A randomized controlled trial. Contraception,
92,323-329. http:/doi.org/10.1016/j.contraception.2014.05.066
Won, T., Blumenthal-Barby, J., Chacko, M. (2017). Paid protection? Ethics of incentivized longacting reversible contraception in adolescents with alcohol and other drug use. Journal of
Medical Ethics, 43(3), 135-136. http://doi/org/10.1136/medethics-2015-103176
World Health Organization. (2014). Guidelines for the identification and management of
substance use and substance use disorders in pregnancy. Retrieved from
https://www.who.int/substance_abuse/publications/pregnancy_guidelines/en/

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY

42
Appendix A

Quantitative Studies Evaluation Table
Citation
Buckel et al.
(2019)
Effect of staff
training and
cost support on
provision of
long-acting
reversible
contraception
in community
health centers.
Funding:
PCORG &
Eunice
Kennedy
Shriver NICHD
Conflicts:
Madden serves
on a data safety
board for Bayer
CC. Peipert
receives
research
funding from
Bayer,
& Merck.
Country: USA

Theory/
Framework
Framework:
National
Institutes of
Health
Director’s
Council of
Public
Representatives
Community
Engagement
Plan to guide
partnership
with FQHC
And
Social
determinants of
health
framework

Design

Sample/ Setting

Design:
Controlled timetrend study, a
nonrandomized
study design,
outcomes are
compared before
and after a change
occurs in the
healthcare setting.
This was selected
as the
participating
health centers
were not willing
to be randomized
to “Enhanced
Care”
Purpose: test the
effectiveness of
an adaptation of
the CHOICE
project in
federally qualified
health centers
with the goal of
reducing UP

Sample:
N=1561
407 not interested
113 ineligible
1041 eligible
1008 enrolled
n=502 for enhanced care
n=506 for Complete
CHOICE
Setting:
Three FQHC in the
Midwest
Inclusion: healthcare
appointments at the
participating center, 1545y, spoke English or
Spanish, not pregnant,
VS currently or planned
within 3m, not-sterile/
partner not sterile.

Variables/
Definitions
IV1:
“Enhanced
Care”
IV2:
“Complete
CHOICE”
Enhanced
Care:
CHOICE
counseling
plus usual
care;
Complete
CHOICE:
CHOICE
counseling,
HCP
education, inclinic
stocking of
LARC, and
no-cost
LARC for
uninsured
DV1: UP
DV2: SDP

Measurement/
Instruments
Baseline
questionnaire and
post-appointment
survey

Data
Analysis
REDCap
electronic data
capture tools
Fisher’s exact
test
Univariate
and
multivariable
Poisson
regressions

Findings
Women in
“Complete
CHOICE”
were more
likely to
choose LARC
(54.0% vs.
30.5%, p<0.01)
and almost 5
times more
likely to
receive a sameday IUD or
implant (RRadj
4.73;95%CI
3.20-6.98)

Application
to practice
LOE: IV
Limitations:
possible
conflicts of
interest
Strengths:
Provides
insight in an
area with little
research
Application:
Provider
education is an
important
element of
LARC
initiation,
particularly
SDP.
Cost is an
important
determinant of
LARC
initiation.

Key: AEP: alcohol exposed pregnancy; APRN: advanced practice registered nurse; ARR: absolute risk reduction; PBTL: post bilateral tubal ligation; CC: contraceptive;
CHOICES: Changing High-risk alcohOl use and Increase Contraception Effectiveness Study; d: days; DV: dependent variable; DS: databases searched; FQHC: federally
qualified health centers; HCP: health care provider; IHS: Indian Health Services; IUD: intrauterine device; IRR: incidence risk ratio; IV: independent variable; JDM: joint
decision making; LARC: long-acting reversible contraception; LOE: level of evidence; los: length of study; m: months; MAT: medication assisted therapy; ME: medically
eligible; MI- motivational interview; N: number of studies; n: number of participants, NICHD: National Institute of Child Health and Human Development; NIH: National
Institutes of Health; OST: Oglala Sioux Tribe; PCORI: Patient Centered Outcomes Institute; PH: post hysterectomy; PM: postmenopausal; PP: postpartum; PR: participant
report; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; SCT: social cognitive theory; SDP: same-day
placement; SR: systematic review; STI: sexually transmitted disease; SUD: substance use disorder; TAB: therapeutic abortion; TEP: tobacco exposed pregnancy; UP: unintended
pregnancy; UPT: urine pregnancy test; USPSTF: United States Preventative Services Task Force VS: heterosexual vaginal sex; y: years

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY
Citation
Dehlendorf et
al. (2019)
Cluster
randomized
trial of a
patient-centered
contraceptive
decision
support tool,
My Birth
Control.
Funding:
PCORI
Conflicts: none
recognized
Country: USA

Theory/
Framework
Decision
Conflict
Theory and
Ecological
Rationality

Design

Sample/ Setting

Design: Cluster
Randomized
Trial; randomized
at the provider
level.

n=758
28 providers participated
and 758 patients enrolled

Purpose: to
evaluate the effect
of My Birth
Control on
contraceptive
continuation,
experience of
contraceptive
care, and decision
quality

Racially/ethnically
diverse; <25% identified
as white
Setting: 4 outpatient
clinics in San Francisco
Bay area
1) Family
planning clinic
2) Department of
Health clinic
3) College student
health clinic
4) Hospitalaffiliated
outpatient clinic

43
Variables/
Definitions
IV1:
interaction
with My
Birth Control
decision tool
prior to their
family
planning visit
DV1: CC
continuation
DV2: patient
experience of
care
DV3: UP

Measurement/
Instruments
Interpersonal
Quality of Family
Planning score
Informed decision
and uncertainty
subscales of the
Decisional Conflict
Scale
Post visit survey

Data
Analysis
Mixed effects
logistic
regression
models with
multiple
imputation for
missing data

Findings
No effect on
7m CC
continuation
(56.6% and
59.6% for I and
C, odds ratio,
0.89; 95% CI,
0.65-1.22)
Intervention
did enhance the
experience
(66.0% vs.
57.4%, odds
ratio, 1.45;
95% CI, 1.032.05) as
Informed
decision scores
(50.5% vs
43.2%, odds
ratio, 1.34;
95% CI, 1.01.80)
No significant
effect on
pregnancy
outcomes

Application
to practice
LOE: I
Strengths:
Addresses
importance of
patientcentered care
and patient
preferences
Limitations:
potential for
contamination
between arms
if providers at
same clinic
shared
experiences.
Patients and
providers were
not blinded.
Application:
Intervention
effect on
patient
experience is
important
given the
personal
nature of
contraceptive
decision
making

Key: AEP: alcohol exposed pregnancy; APRN: advanced practice registered nurse; ARR: absolute risk reduction; PBTL: post bilateral tubal ligation; CC: contraceptive;
CHOICES: Changing High-risk alcohOl use and Increase Contraception Effectiveness Study; d: days; DV: dependent variable; DS: databases searched; FQHC: federally
qualified health centers; HCP: health care provider; IHS: Indian Health Services; IUD: intrauterine device; IRR: incidence risk ratio; IV: independent variable; JDM: joint
decision making; LARC: long-acting reversible contraception; LOE: level of evidence; los: length of study; m: months; MAT: medication assisted therapy; ME: medically
eligible; MI- motivational interview; N: number of studies; n: number of participants, NICHD: National Institute of Child Health and Human Development; NIH: National
Institutes of Health; OST: Oglala Sioux Tribe; PCORI: Patient Centered Outcomes Institute; PH: post hysterectomy; PM: postmenopausal; PP: postpartum; PR: participant
report; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; SCT: social cognitive theory; SDP: same-day
placement; SR: systematic review; STI: sexually transmitted disease; SUD: substance use disorder; TAB: therapeutic abortion; TEP: tobacco exposed pregnancy; UP: unintended
pregnancy; UPT: urine pregnancy test; USPSTF: United States Preventative Services Task Force VS: heterosexual vaginal sex; y: years

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY
Citation
Fox et al.
(2018).
Client
preferences for
contraceptive
counseling: A
systematic
review
Funding:
Office of
Population
Affairs, U.S.
Department of
Health and
Human
Services and
Atlas Research,
Inc.
Conflicts: none
recognized
Country: USA

Theory/
Framework
Client-centered
care

Design

Sample/ Setting

Design: SR
Purpose:
Updating the
Systematic
Reviews used to
develop the US
Recommendations
for Providing
Quality Family
Planning Services,
adding key
question to prior
SR.

N=26
DS: 16 electronic
databases
Inclusion: 1)All study
designs, 2)US, Canada,
Australia, New Zealand,
or European countries
categorized as “very
high” on the Human
Development Index,
3)written in English,
4)available as full-test,
5)women studied age 1545y, 6)study related to
client preferences for
contraceptive counseling

44
Variables/
Definitions
1 Key
question:
“What are
clients’
preferences
with regard to
contraceptive
counseling
approaches in
the family
planning
setting?”
4 domains:
Contraceptive
Information,
The
DecisionMaking
Process, The
ProviderClient
Relationship,
The Context
in which
Contraceptive
Counseling is
provided

Measurement/
Instruments
Not addressed

Data
Analysis
PRISMA,
USPSTF
rating of
evidence
strength

Findings

Application
to practice
LOE: I
Limitations:
small sample
sizes, limited
evidence from
incarcerated
women,
women with
SUD, risk for
bias among
recruitment
methods for
qualitative
research.
Strengths:
comprehensive
inclusion of
studies of any
design;
includes rich
qualitative
data.
Application:
Personalized,
comprehensive
counseling in a
variety of
settings is
desired

19 articles
reported
preferences for
the information
received, 13
reported
preferences for
the decisionmaking
process, 13 the
relationship
between
providers and
clients, and 11
about context
in which CC
counseling is
delivered.
Clients prefer
comprehensive,
personalized
counseling that
prioritizes
client
autonomy,
positive
relationships
with providers,
and diverse
preferences for
the
context/setting.
Key: AEP: alcohol exposed pregnancy; APRN: advanced practice registered nurse; ARR: absolute risk reduction; PBTL: post bilateral tubal ligation; CC: contraceptive;
CHOICES: Changing High-risk alcohOl use and Increase Contraception Effectiveness Study; d: days; DV: dependent variable; DS: databases searched; FQHC: federally
qualified health centers; HCP: health care provider; IHS: Indian Health Services; IUD: intrauterine device; IRR: incidence risk ratio; IV: independent variable; JDM: joint
decision making; LARC: long-acting reversible contraception; LOE: level of evidence; los: length of study; m: months; MAT: medication assisted therapy; ME: medically
eligible; MI- motivational interview; N: number of studies; n: number of participants, NICHD: National Institute of Child Health and Human Development; NIH: National
Institutes of Health; OST: Oglala Sioux Tribe; PCORI: Patient Centered Outcomes Institute; PH: post hysterectomy; PM: postmenopausal; PP: postpartum; PR: participant
report; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; SCT: social cognitive theory; SDP: same-day
placement; SR: systematic review; STI: sexually transmitted disease; SUD: substance use disorder; TAB: therapeutic abortion; TEP: tobacco exposed pregnancy; UP: unintended
pregnancy; UPT: urine pregnancy test; USPSTF: United States Preventative Services Task Force VS: heterosexual vaginal sex; y: years

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY
Citation

Theory/
Framework
MI

Design

Sample/ Setting

45
Variables/
Definitions
Program
Intervention:
modified
CHOICES
program.
Outcomes:
1)Alcohol
intake
2)CC correct
use

Measurement/
Instruments
National Institute
on Alcohol Abuse
and Alcoholism,
screening tool

Data
Analysis
One-way
ANOVA and
Proc Glimmix
was used to
run negative
binomial
models with
random
intercepts
generalized
estimation
equation
model

Findings

Application
to practice
Hanson et al.
Average 51%
LOE: IV
Design:
Sample:
(2017)
Cohort study
n=193
completed both Strengths:
Impact of the
n=99
3m and 6m
vulnerable
Purpose:
CHOICES
Present data on
follow-ups.
population
Setting:
intervention in
the impact that the Oglala Sioux Tribe
Weaknesses:
preventing
OST CHOICES
communities, two on
Significant
no control
alcoholProgram had on
reservation, one off
decrease in
group
exposed
risk for AEP
reservation
AEP risk from
>20% loss of
pregnancies in
among American
Inclusion: Race: AI,
baseline at both participants,
American
Indian women
Age: 18+y, high risk for
3 and 6m
sample size
Indian women.
AEP defined as: VS with
follow-ups.
did not allow
Funding: IHS
males, not using any CC
for nesting by
and NIH,
or using a method
Women in
site or a
National
incorrectly/inconsistently
program were
random slope
Institute on
and exceed low risk
more likely to
Application:
Minority
alcohol intake defined
reduce risk of
CHOICES
Health and
as: 4 or more drinks per
AEP via CC
program can
Health
occasion or 8 or more
vs. reduced
be modified to
Disparities
drinks per week.
drinking
be culturally
Conflicts: none
Exclusion: PM, PH,
and
recognized
PBTL
linguistically
Country: USA
appropriate for
high-risk
populations.
Feasibility:
Intervention
was effective
in 2-4
sessions.
MI by trained
community
members.
Key: AEP: alcohol exposed pregnancy; APRN: advanced practice registered nurse; ARR: absolute risk reduction; PBTL: post bilateral tubal ligation; CC: contraceptive;
CHOICES: Changing High-risk alcohOl use and Increase Contraception Effectiveness Study; d: days; DV: dependent variable; DS: databases searched; FQHC: federally
qualified health centers; HCP: health care provider; IHS: Indian Health Services; IUD: intrauterine device; IRR: incidence risk ratio; IV: independent variable; JDM: joint
decision making; LARC: long-acting reversible contraception; LOE: level of evidence; los: length of study; m: months; MAT: medication assisted therapy; ME: medically
eligible; MI- motivational interview; N: number of studies; n: number of participants, NICHD: National Institute of Child Health and Human Development; NIH: National
Institutes of Health; OST: Oglala Sioux Tribe; PCORI: Patient Centered Outcomes Institute; PH: post hysterectomy; PM: postmenopausal; PP: postpartum; PR: participant
report; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; SCT: social cognitive theory; SDP: same-day
placement; SR: systematic review; STI: sexually transmitted disease; SUD: substance use disorder; TAB: therapeutic abortion; TEP: tobacco exposed pregnancy; UP: unintended
pregnancy; UPT: urine pregnancy test; USPSTF: United States Preventative Services Task Force VS: heterosexual vaginal sex; y: years

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY
Citation
Heil et al.,
(2016).
Using
behavioral
economic
theory to
increase use of
effective
contraceptives
among opioidmaintained
women at risk
of unintended
pregnancy.
Funding:
National
Institute on
Drug Abuse
Conflicts: none
recognized
Country:
USA

Theory/
Framework
Behavioral
economic
theory

Design

Sample/ Setting

Design:
RCT
Purpose:
Examine
behavioral
economic theory
to reduce barriers
to effective CC,
increase initiation
and continuation
of effective
methods, and
reduce UP in
women in MAT
for SUD

n=31
Inclusion criteria:
Age: 18-44y, VS in past
3 m, 6+ m PP, not
planning pregnancy in
next 6 m, ME to use CC,
in MAT 30+ d, English
speaking
Exclusion criteria:
PM, PH, BTL, or
imminent incarceration
Setting: co-located with
MAT clinic

46
Variables/
Definitions
IV 1-JDM
with an
APRN using
the WHO
Contraceptive
DecisionMaking Tool
IV 2- 13
follow-up
visits over 6
m, vouchers
of approx.
$15 for
attending
follow up
visits
DV 1participantreported
contraceptive
use
DV 2unintended
pregnancy

Measurement/
Instruments
Screening:
1)Time-Line
Followback
2)Risk Assessment
Battery- Sexual
practices section
3)Addiction
Severity IndexFifth edition
4)Beck Depression
Inventory
5)Barrett
Impulsivity Scale
Version 1
Outcomes:
DV 1- PR of
effective use as
defined by
guidelines for use
DV 2- clinic UPT

Data
Analysis
Fisher’s exact
test

Findings
Initiation of
CC (100% vs.
29%, p<0.01).
Continuation
of CC
1m: (63% vs.
13%, p<0.01)
3m: (88% vs.
20%, p<0.001)
6m:(94% vs.
13%, p<0.001)
UP in
experimental
vs. usual care
(0% vs 20%,
p=0.10)

Application
to practice
LOE: I
Limitations:
Small sample
Strengths:
Setting similar
to project
setting
Application:
Removing cost
can increase
initiation.
Close followup can
improve CC
continuation.
Incentives can
increase
attendance.
Using WHO
Contraceptive
DecisionMaking Tool
can assist joint
decision
making

Key: AEP: alcohol exposed pregnancy; APRN: advanced practice registered nurse; ARR: absolute risk reduction; PBTL: post bilateral tubal ligation; CC: contraceptive;
CHOICES: Changing High-risk alcohOl use and Increase Contraception Effectiveness Study; d: days; DV: dependent variable; DS: databases searched; FQHC: federally
qualified health centers; HCP: health care provider; IHS: Indian Health Services; IUD: intrauterine device; IRR: incidence risk ratio; IV: independent variable; JDM: joint
decision making; LARC: long-acting reversible contraception; LOE: level of evidence; los: length of study; m: months; MAT: medication assisted therapy; ME: medically
eligible; MI- motivational interview; N: number of studies; n: number of participants, NICHD: National Institute of Child Health and Human Development; NIH: National
Institutes of Health; OST: Oglala Sioux Tribe; PCORI: Patient Centered Outcomes Institute; PH: post hysterectomy; PM: postmenopausal; PP: postpartum; PR: participant
report; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; SCT: social cognitive theory; SDP: same-day
placement; SR: systematic review; STI: sexually transmitted disease; SUD: substance use disorder; TAB: therapeutic abortion; TEP: tobacco exposed pregnancy; UP: unintended
pregnancy; UPT: urine pregnancy test; USPSTF: United States Preventative Services Task Force VS: heterosexual vaginal sex; y: years

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY
Citation
Lopez et al.
(2016).
Theory-based
interventions
for
contraception.
Funding:
NICHHD &
U.S. Agency
for
International
Development
Conflicts: none
recognized
Country: USA

Theory/
Framework
Behavioral
theory

Design

Sample/ Setting

Design: SR of
RCTs

N= 25
DS: MEDLINE via
PubMed, Cochrane,
POPLINE, Web of
Science,
ClinicalTrials.gov,
ICTRP

Purpose: review
RCTs that tested a
theoretical
approach to
inform
contraceptive
choice and
encourage or
improve
contraceptive use.

Inclusion criteria: RCT
that tested an
intervention with an
explicit theoretical basis
for improving
contraceptive use.
Exclusion: trial purpose
preventing STI or HIV
not pregnancy
prevention, trials
focusing on high-risk
groups

47
Variables/
Definitions
IV:
behavioral
theory-based
interventions
to improve
CC use
DV1:CC use
DV2:
pregnancy

Measurement/
Instruments
UPT, PR
pregnancy, PR use
of CC

Data
Analysis
MantelHaenszel odds
ratio with
95%
confidence
interval

Findings
SCT and MI
had strongest
evidence of
effectiveness.
MI was
effective
addressing
needs of
special
populations of
adults in 1-5
sessions.
MI was
effective in
preventing
AEP and
pregnancy after
TAB.

Application
to practice
LOE: I
Limitations:
excluded trials
that focused
on high-risk
groups
Strengths:
Interventions
with a
theoretical
base help
explain/
motivate
behavior
change
Application
to practice:
The MI format
may be
appropriate for
clinic or SUD
typical length
of stay

Key: AEP: alcohol exposed pregnancy; APRN: advanced practice registered nurse; ARR: absolute risk reduction; PBTL: post bilateral tubal ligation; CC: contraceptive;
CHOICES: Changing High-risk alcohOl use and Increase Contraception Effectiveness Study; d: days; DV: dependent variable; DS: databases searched; FQHC: federally
qualified health centers; HCP: health care provider; IHS: Indian Health Services; IUD: intrauterine device; IRR: incidence risk ratio; IV: independent variable; JDM: joint
decision making; LARC: long-acting reversible contraception; LOE: level of evidence; los: length of study; m: months; MAT: medication assisted therapy; ME: medically
eligible; MI- motivational interview; N: number of studies; n: number of participants, NICHD: National Institute of Child Health and Human Development; NIH: National
Institutes of Health; OST: Oglala Sioux Tribe; PCORI: Patient Centered Outcomes Institute; PH: post hysterectomy; PM: postmenopausal; PP: postpartum; PR: participant
report; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; SCT: social cognitive theory; SDP: same-day
placement; SR: systematic review; STI: sexually transmitted disease; SUD: substance use disorder; TAB: therapeutic abortion; TEP: tobacco exposed pregnancy; UP: unintended
pregnancy; UPT: urine pregnancy test; USPSTF: United States Preventative Services Task Force VS: heterosexual vaginal sex; y: years

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY
Citation

Theory

Design

Sample/ Setting

McNicholas et
al. (2014). The
Contraceptive
CHOICE
Project round
up: What we
did and what
we learned.
Country: USA
Funding:
anonymous
foundation
grant,
Washington
University
Institute of
Clinical and
Translational
Science, &
Eunice
Kennedy
Shriver NICHD
Bias: none
recognized

Behavioral
economic
theory

Design:
Prospective
Cohort Study
Purpose: Remove
barriers to
obtaining CC.
Promote the most
effective CC
methods to
reduced UPR on a
population level.

n=9256
Inclusion:
age: 14-45y, reside in St.
Louis, not desiring
pregnancy for at 12+m,
desires reversible CC,
VS in past 6m or
planned in next 6m,
willing to start a new CC
method of choice.
Exclusion: PH, BTL
Setting: St. Louis

48
Variables/
Definitions
IV-reversible
CC method of
choice at no
cost for 3y,
SDP offered
when ME,
able to
change
method as
frequently as
desired.
Participant
contact by
phone at 3m
and then
every 6m for
study
duration
Outcome1CC method
chosen
Outcome2CC
continuation
DV3- teen
pregnancy
DV4-repeat
abortion rate

Measurement/
Instruments
Counseling based
on GATHER
process:
CC education was
delivered with a
script, CC in order
of effectiveness of
the method.

Data
Analysis
Obtained from
linked reports:
Chi-square,
Students ttest, logistic
regression for
multivariable
analysis,
Poisson
regression
with robust
error variance.

Findings
 LARC use
(5% at
baseline vs.
75% at end of
study)
continuation
in LARC users
 sexual risktaking
behaviors, # of
partners in
program
participants
UPR

Application
to practice
LOE: IV
Strengths:
Large
representative
sample. 9y
study. Robust
linked website.
Weaknesses
No control
group
Application
When the
barriers of
cost, access,
and
knowledge are
removed,
women choose
the most
effective and
least userdependent
methods, they
continue using
them, and are
highly
satisfied with
their choice

Key: AEP: alcohol exposed pregnancy; APRN: advanced practice registered nurse; ARR: absolute risk reduction; PBTL: post bilateral tubal ligation; CC: contraceptive;
CHOICES: Changing High-risk alcohOl use and Increase Contraception Effectiveness Study; d: days; DV: dependent variable; DS: databases searched; FQHC: federally
qualified health centers; HCP: health care provider; IHS: Indian Health Services; IUD: intrauterine device; IRR: incidence risk ratio; IV: independent variable; JDM: joint
decision making; LARC: long-acting reversible contraception; LOE: level of evidence; los: length of study; m: months; MAT: medication assisted therapy; ME: medically
eligible; MI- motivational interview; N: number of studies; n: number of participants, NICHD: National Institute of Child Health and Human Development; NIH: National
Institutes of Health; OST: Oglala Sioux Tribe; PCORI: Patient Centered Outcomes Institute; PH: post hysterectomy; PM: postmenopausal; PP: postpartum; PR: participant
report; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; SCT: social cognitive theory; SDP: same-day
placement; SR: systematic review; STI: sexually transmitted disease; SUD: substance use disorder; TAB: therapeutic abortion; TEP: tobacco exposed pregnancy; UP: unintended
pregnancy; UPT: urine pregnancy test; USPSTF: United States Preventative Services Task Force VS: heterosexual vaginal sex; y: years

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY
Citation

Theory

Design

Sample/ Setting

Matusiewicz et
al., (2017).
Knowledge of
and concerns
about longacting
reversible
contraception
among women
in medicationassisted
treatment for
opioid use
disorder.

Health Belief
Model

Design:
Convenience
sample of women
who completed an
eligibility
screening for an
ongoing RCT
evaluating family
planning
interventions for
this population

n= 83 for survey; of
these, 51 (61%),
completed the
supplemental survey

Funding:
National
Institutes of
Health
Bias: none
recognized
Country: USA

Survey of
contraceptive use
attitudes and
knowledge,
supplemental
survey regarding
LARC methods

Inclusion:
Age: 18-49y, in MAT
Exclusion: not at risk
for unintended
pregnancy, or missing
data
164 completed the
eligibility screen, 61
were excluded-not at risk
for unintended
pregnancy and another
20- missing data
Setting: co-located with
MAT clinic

49
Variables/
Definitions
“Familiarity
with different
methods”
“Past use of
methods”
“Likelihood
of future
method use”
“Perceived
method
knowledge”
Knowledge
of “relative
effectiveness”
of methods

Measurement/
Instruments
Locally-developed
structured
interview to collect
sociodemographic,
clinical, and
sexual/reproductive
histories.
National Campaign
to Prevent Teen
and Unplanned
Pregnancy’s
Survey of
Reproductive and
Contraceptive
Knowledge plus
15-item locally
developed
supplement to
assess likelihood of
future use or
knowledge-related
items with regard
to implants

Data
Analysis
Descriptive
Statistics,
Frequencies

Findings
Likelihood of
future use:
IUD- 42%
unlikely to use;
cited concerns69% side
effects, 46%
infection risk,
37% negative
anecdotal
reports.
Implants: 33%
unlikely to use
implant;
concerns- 59%
removal
process, 53%
insertion
process, 41%
menstrual
changes, 29%
side effects

Application
to practice
LOE:IV
Weaknesses
Potential bias
in the sample
selection,
Small sample
Strengths:
Provides
insights in area
with limited
evidencelikelihood of
LARC use
among women
in treatment
for SUD
Application
Women with
SUD may trust
peers>HCP,
may benefit
from
knowledge
about LARC
risk/benefit
implant
insertion and
removal

Key: AEP: alcohol exposed pregnancy; APRN: advanced practice registered nurse; ARR: absolute risk reduction; PBTL: post bilateral tubal ligation; CC: contraceptive;
CHOICES: Changing High-risk alcohOl use and Increase Contraception Effectiveness Study; d: days; DV: dependent variable; DS: databases searched; FQHC: federally
qualified health centers; HCP: health care provider; IHS: Indian Health Services; IUD: intrauterine device; IRR: incidence risk ratio; IV: independent variable; JDM: joint
decision making; LARC: long-acting reversible contraception; LOE: level of evidence; los: length of study; m: months; MAT: medication assisted therapy; ME: medically
eligible; MI- motivational interview; N: number of studies; n: number of participants, NICHD: National Institute of Child Health and Human Development; NIH: National
Institutes of Health; OST: Oglala Sioux Tribe; PCORI: Patient Centered Outcomes Institute; PH: post hysterectomy; PM: postmenopausal; PP: postpartum; PR: participant
report; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; SCT: social cognitive theory; SDP: same-day
placement; SR: systematic review; STI: sexually transmitted disease; SUD: substance use disorder; TAB: therapeutic abortion; TEP: tobacco exposed pregnancy; UP: unintended
pregnancy; UPT: urine pregnancy test; USPSTF: United States Preventative Services Task Force VS: heterosexual vaginal sex; y: years

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY
Citation
Terplan et al.
(2015).
Contraceptive
use and method
choice among
women with
opioid and
other substance
use disorders:
A systematic
review
Funding:
National
Institute on
Drug Abuse
Conflicts: none
recognized
Country: SR
conducted in
USA. Studies
reviewed
conducted in:
USA, Australia,
England,
Canada,
France,
Finland, and
Russia

Theory/
Framework
Social
determinants of
health
framework

Design

Sample/ Setting

Design: SR
Purpose: to
describe
contraceptive use
and method of
choice among
women with
SUDs

N=24
n=5000
DS: PubMed and
PsychINFO
580 abstracts reviewed,
105 articles given full
review
Inclusion: human
studies, English
language. PubMed years
1948-2014; PsychINFO
years 1806-2014,
reported contraceptive
use & a population of at
least 50% women with
SUDs

50
Variables/
Definitions
First aimdescribe
prevalence of
contraceptive
use among
women with
opioid and
other
substance use
disorders
Second aimdescribe
method of
choice among
contraceptive
using women
in this
vulnerable
population

Measurement/
Instrumentation
National Health
surveys

Data
Analysis
PRISMA

Findings
Contraception
prevalence:
Very effective
methods:
median use 7%
(range: 2-29%)
across 8 studies
Most used
method:
condoms, 62%
(range: 3-87%)
across 17
studies

Application
to practice
LOE: I
Women with
substance use
disorders have
an unmet need
for
contraception,
especially for
the most
effective
methods.
Offering
contraception
services in
conjunction
with substance
use treatment
and promoting
use of more
effective
methods could
help meet this
need and
reduce
unintended
pregnancy

Key: AEP: alcohol exposed pregnancy; APRN: advanced practice registered nurse; ARR: absolute risk reduction; PBTL: post bilateral tubal ligation; CC: contraceptive;
CHOICES: Changing High-risk alcohOl use and Increase Contraception Effectiveness Study; d: days; DV: dependent variable; DS: databases searched; FQHC: federally
qualified health centers; HCP: health care provider; IHS: Indian Health Services; IUD: intrauterine device; IRR: incidence risk ratio; IV: independent variable; JDM: joint
decision making; LARC: long-acting reversible contraception; LOE: level of evidence; los: length of study; m: months; MAT: medication assisted therapy; ME: medically
eligible; MI- motivational interview; N: number of studies; n: number of participants, NICHD: National Institute of Child Health and Human Development; NIH: National
Institutes of Health; OST: Oglala Sioux Tribe; PCORI: Patient Centered Outcomes Institute; PH: post hysterectomy; PM: postmenopausal; PP: postpartum; PR: participant
report; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; SCT: social cognitive theory; SDP: same-day
placement; SR: systematic review; STI: sexually transmitted disease; SUD: substance use disorder; TAB: therapeutic abortion; TEP: tobacco exposed pregnancy; UP: unintended
pregnancy; UPT: urine pregnancy test; USPSTF: United States Preventative Services Task Force VS: heterosexual vaginal sex; y: years

REPRODUCTIVE HEALTH FOR WOMEN IN RECOVERY
Citation
Velasquez et al.
(2017)
Preventing
alcohol and
tobacco
exposed
pregnancies:
CHOICES Plus
in primary care.
Funding: CDC
Conflicts: none
recognized
Country: USA

Theory/
Framework
MI

Design

Sample/ Setting

Design: RCT with
two intervention
groups
Purpose: Test the
effectiveness of a
modified
CHOICES
program: using 2
sessions instead of
4 and adding
tobacco as a target
behavior to
reduced AEP and
TEP

11, 470 women
screened, 4.9% were
eligible, 46.7% of those
consented.
N=261
CHOICES Plus n=131
Brief advice n=130
Settings: 12 primary
care clinics in a large
Texas public healthcare
system
Inclusion criteria: 1844y, non-sterile, nonpregnant, drinking more
than three drinks per day
or more than seven
drinks per week,
sexually active, and not
using effective
contraception.

51
Variables/
Definitions
IV1: Brief
Advice
(standard of
care)
IV2:
CHOICES
Plus
intervention
DV1: AEP
risk
DV2: TEP
risk
DV3: risky
drinking
DV4: current
smoking
DV5:
ineffective
contraception

Measurement/
Instrumentation
Alcohol Use
Disorder
Identification Test
and Brief Symptom
Inventory:
readiness to
change, pros and
cons for changing,
experiential and
behavioral
processes of
change, and
temptation and
confidence
assessed for each
behavior.
Timeline followback to produce
record of daily
drinking, VS, CC
use.
NicAlert saliva
assay to assess
tobacco use

Data
Analysis
Power
analysis
(logistic
regression
model
approach)
using
GEESIZE
Poisson
multilevel
models (SAS,
version 9.3
Proc
GLIMMIX)
with HuberWhite
sandwich
estimators
Sensitivity
intervals
created to
account for
women lost to
follow-up

Findings
CHOICES Plus
group members
were more
likely to reduce
risk of AEP:
(IRR= 0.620,
95% CI=0.511,
0.757) and
ARR of -0.233
(95% CI = 0.239, -0.226)
CHOICE Plus
group members
at risk for both
exposures were
more likely to
reduce TEP
(IRR = 0.597;
95% CI=0.424,
0.840 and
ARR, -0.233;
95% CI=0.019, -0.521).

Application
to practice
LOE: I
Strengths:
Streamlining
of the original
CHOICES
intervention
for application
in busy urban
health-care
setting
Limitations:
reliance on
self-reported
outcomes
Application:
CHOICE Plus
reduced AEP
and TEP in
fewer visits,
improving
feasibility.
Demonstrates
the CHOICES
program can
be effective
with
modifications
to target TEP.

Key: AEP: alcohol exposed pregnancy; APRN: advanced practice registered nurse; ARR: absolute risk reduction; PBTL: post bilateral tubal ligation; CC: contraceptive;
CHOICES: Changing High-risk alcohOl use and Increase Contraception Effectiveness Study; d: days; DV: dependent variable; DS: databases searched; FQHC: federally
qualified health centers; HCP: health care provider; IHS: Indian Health Services; IUD: intrauterine device; IRR: incidence risk ratio; IV: independent variable; JDM: joint
decision making; LARC: long-acting reversible contraception; LOE: level of evidence; los: length of study; m: months; MAT: medication assisted therapy; ME: medically
eligible; MI- motivational interview; N: number of studies; n: number of participants, NICHD: National Institute of Child Health and Human Development; NIH: National
Institutes of Health; OST: Oglala Sioux Tribe; PCORI: Patient Centered Outcomes Institute; PH: post hysterectomy; PM: postmenopausal; PP: postpartum; PR: participant
report; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT: randomized controlled trial; SCT: social cognitive theory; SDP: same-day
placement; SR: systematic review; STI: sexually transmitted disease; SUD: substance use disorder; TAB: therapeutic abortion; TEP: tobacco exposed pregnancy; UP: unintended
pregnancy; UPT: urine pregnancy test; USPSTF: United States Preventative Services Task Force VS: heterosexual vaginal sex; y: years

Appendix B

Interventions

Lopez et al.

McNicholas et al.

Matusiewicz et al.

Terplan et al.

Velasquez et al.

2018

2017

2016

2016

2014

2017

2015

2017

I
SR
N=26
G
MCT

IV
CH
n=292
AI/SUD
AICS

I
RCT
N=31
ARUP
MAT

I
SR
N=25
G
MCT

IV
PCH
n=9256
SUD
MCT

IV
CS
n=83
SUD
MAT

I
SR
N=24
SUD
MCT

I
RCT
n=261
SUD
PCC

X

CHOICE program

X

GATHER
WHO DMT

X

X

X
X

X

X

X

MBC DMT

X

Train provider
Remove cost

X

Education



X

X

X
X

X





















Provider/Peer







Context/Setting



































LARC-C







SEP risk



Decision support

Findings

Heil et al.

2019
I
RCT
n=758
G
MCT

Hanson et al.

Design
Sample Size
Population
Setting
CHOICES/MI

2019
IV
CTTS
n=1008
G
FQHC

Fox et al.

Year
LOE

Dehlendorf et al.

Overview

Studies

Buckel et al.

Synthesis Table

CC-I




CC-C
LARC-I



UP
PE




































Key: : reported increase; : reported decrease; : important feature of study; AI: American Indian; AICS: American Indian
community setting; ARUP: at risk of unintended pregnancy; C: continuation; CC: contraception; CH: cohort; CHOICES/MI:
Changing High-risk alcohOl use and Increase Contraception Effectiveness Study using motivational interviewing; CS: convenience
sample; CTTS: controlled time trend study; DMT: decision making tool; FQHC: federally qualified health center; G: general
population reproductive age women; I: initiation; LARC: long-acting reversible contraception; LOE: level of evidence; MAT: colocated with medicated assisted therapy clinic; MBC: “My birth control”; MCT: multiple clinic types; PCC: primary care clinic;
PCH: prospective cohort study; PE: patient experience/satisfaction; RCT: randomized controlled trial; SEP: substance exposed
pregnancy; SR: systematic review; SUD: substance use disorder; UP: unintended pregnancy; WHO: World Health Organization.

Appendix C
Motivational Interviewing and Self Determination Theory

(Markland, Ryan, Tobin, & Rollnick, 2005)

Appendix D
Institute for Healthcare Improvement (IHI) Triple Aim Model for Improvement

(IHI, 2019)

Appendix E
One Key Question Conversation Guide and Client Response Record: Page 1

One Key Question Conversation Guide and Client Response Record: Page 2

One Key Question Conversation Guide and Client Response Record: Page 3

One Key Question Conversation Guide and Client Response Record: Page 4

Appendix F
Client Experience of Care Scale: Modified version of IQFP-R

Client Experience of Care:
Think about the talk you just had about family planning with _________________ at________________ on _______________
Please read the statements on the left. For each statement, please circle the number under the face that matches how you feel about the talk.
Poor (1)
Fair (2)
Good (3)
Very Good (4)
Excellent (5)

Respecting me
as a person
Letting me say
what mattered
to me
about desiring
or not desiring
pregnancy
Taking my
preferences
seriously
related to
pregnancy or
birth control
Giving me
enough
information
about services
available
related to
pregnancy or
birth control

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

This scale is a modified version of the IQFP-R developed by Dr. Christine Dehlendorf. It is been reviewed by her and used with her permission. It was modified to be appropriate for screening and referral for reproductive health care.

Tables
Table 1
Frequency Table for Demographic Variables and Answer to OKQ
Variable
Race
American Indian/Alaskan Native
Asian
Black
Declined
Multiracial
White
Missing
Ethnicity
Declined
Hispanic
Non-Hispanic
Missing
Gender
Declined
Female
Non-binary
Missing
OKQ
No
OK Either Way
Unsure
Yes
Note. Due to rounding errors, percentages may not equal 100%.

n

%

5
0
4
0
1
34
1

11
0
9
0
2
76
2

0
14
30
1

0
31
67
2

0
44
1
0

0
98
2
0

31
6
1
7

69
13
2
16

Table 2
Summary Statistics Table for Interval and Ratio Variables
Variable

M

SD

N

Min

Max

30.38

6.59

45

19.00

45.00

Days in Residence

4.91

3.18

45

1.00

17.00

Screening Duration (minutes)

9.60

4.65

45

3.00

25.00

Age (years)

Table 3
Subset Frequency Table for Variables for People who Responded “No” to OKQ
Variable
Taking folic acid
No
Missing
Birth control method
None
Abstinence
Nexplanon
Mirena
Expired Nexplanon
Withdrawal
Natural Family Planning
Condoms
Paragard
Female partners only
Missing
Happy with birth control method
No
not applicable
Yes
Somewhat
Missing
Well woman exam in last 12m
No
Yes
Missing
Well woman referral offered
Yes
No
Missing
Well woman referral accepted
Yes
not applicable
No
Missing
Contraception care offered
Yes
No

N

%

31
0

100
0

17
4
3
1
1
1
1
1
1
1
0

55
13

1
18
10
2
0

3
58
32
6
0

21
10
0

68
32
0

22
9
0

71
29
0

22
8
1
0

71
26
3
0

22
9

71
29

10

3
3
3
3
3
3
3
0

Missing
Contraception referral accepted
Yes
not applicable
No
Missing
Note. Due to rounding errors, percentages may not equal 100%.

0

0

19
8
3
1

61
26
10

3

Table 4
Subset Frequency Table for Variables for People who Responded “Yes” to OKQ
Variable
Taking Folic Acid
No
Yes
Missing
Preconception appointment in last 12 months
No
Yes
Missing
Well woman exam in last 12 months
No
Yes
Missing
Well woman offered
No
Yes
Missing
Well woman accepted
not applicable
Yes
Missing
Preconception offered
No
Yes
Missing
Preconception Accepted
not applicable
Yes
Missing
Note. Due to rounding errors, percentages may not equal 100%.

N

%

6
1
0

86
14
0

6
1
0

86
14
0

4
3
0

57
43
0

3
4
0

43
57
0

3
4
0

43
57
0

1
6
0

14
86
0

1
6
0

14
86
0

Table 5
Subset Frequency Table for Variables for People who Responded “Okay either way” to OKQ
Variable
Taking folic acid
No
Missing
Preconception appointment in last 12m
Yes
No
Missing
Birth control method
None
Condoms
Missing
Well woman in last 12m
No
Yes
Missing
General reproductive care referral offered
Yes
Missing
General reproductive care accepted
Yes
Missing
Well woman exam offered
Yes
No
Missing
Well woman exam accepted
Yes
not applicable
Missing
Note. Due to rounding errors, percentages may not equal 100%.

n

%

6
0

100
0

1
5
0

17
83
0

5
1
0

83
17
0

3
3
0

50
50
0

6
0

100
0

6
0

100
0

3
3
0

50
50
0

3
3
0

50
50
0

Table 6
Frequency Table for Nominal Variables
Variable
Appointment type
Well Woman
Contraception
Other
General Reproductive Health
Preconception
Missing
Group
Accepted
Declined
Missing
Note. Due to rounding errors, percentages may not equal 100%.

n

%

44
21
4
6
8
0

53
25

79
4
0

95

5

7
10

0

5

0

Table 7
Frequency Table for Ratings of the Interpersonal Quality of Care Items
Variable
enough information
listened to
respected
Rating
Excellent
51 (94%)
48 (89%)
49 (91%)
Very Good
3 (6%)
5 (9%)
4 (7%)
Good
0 (0%)
1 (2%)
1 (2%)
Fair
0 (0%)
0 (0%)
0 (0%)
Poor
0 (0%)
0 (0%)
0 (0%)
Missing
0 (0%)
0 (0%)
0 (0%)
Note. Due to rounding errors, column wise percentages may not equal 100%.

taken seriously
50 (93%)
4 (7%)
0 (0%)
0 (0%)
0 (0%)
0 (0%)

Figures

Figure 1. The pie chart depicts a summary of responses to One Key Question

Figure 2. The stacked bar plot depicts referral types made. Referrals accepted are represented in blue.
Referrals declined are represented in black.

Figure 3. The stacked bar plot depicts the client experience of care scores using an adaptation of the
IQFP Scale developed by Dehlendorf.