Sarah Heil, Ph.D.
Combining Contraceptive Services and Incentives Most Effective to Prevent Unintended Pregnancy
Increases in maternal opioid use have led to an almost doubling in the number of babies born with neonatal abstinence syndrome (NAS) in the U.S. in the past 10 years. This statistic led the Centers for Disease Control and Prevention and American Academy of Pediatrics to call for stepped-up efforts to reduce opioid use during pregnancy, such as ensuring access to contraception to prevent unintended pregnancies among women who use opioids. More than 75 percent of women with OUD report having had an unintended pregnancy, but they are less likely to use effective contraception compared to women who do not use drugs. Results from a multi-year trial found that a two-part intervention featuring co-located contraceptive services in opioid treatment programs and financial incentives could offer an effective solution.
The results of this National Institutes of Health-funded study appear in JAMA Psychiatry.
The trial, led by Sarah Heil, Ph.D., professor of psychiatry at the Vermont Center on Behavior and Health at the University of Vermont’s Larner College of Medicine, tested a novel two-component intervention informed by behavioral economics—combining contraceptive services co-located with an opioid treatment program with financial incentives for attending follow-up visits. The goal of the study was to determine whether co-locating services could effectively remove barriers to initiating contraceptive use (defined as pills, patch, ring, injection, intrauterine device/IUD, and implant), as well as examine the benefits of adding incentives to help ease the burden associated with coming to follow-up visits. Incentives were earned solely for attending follow-up visits and were not dependent on contraceptive use.
“Women with OUD have the same right to decide whether and when to have children as other women, but their persistently high rate of unintended pregnancy suggests that the way contraceptive services are provided does not work for most of them,” said Heil.
A total of 138 women aged 20-44 who were receiving medication for OUD and were at high risk for unintended pregnancy were enrolled between 2015 and 2018. Participants were randomly assigned to one of three conditions: usual care, contraceptive services, or contraceptive services plus financial incentives. The trial’s results showed graded increases in verified prescription contraceptive use at the end of the six-month intervention period (usual care was 10.4%; contraceptive services was 29.2%; and contraceptive plus incentives was 54.8%) and was sustained through the 12-month final assessment, which showed contraceptive adherence at 6.3% with usual care vs. 25% with co-located contraceptive services vs. 42.9% with co-located contraceptive services plus incentives. These numbers also coincided with a graded decrease in unintended pregnancy rates across the 12-month trial (usual care at 22.2% vs. contraceptive services at 16.7% vs. contraceptive services plus incentives at 4.9%). Further, an economic analysis found that each dollar invested yielded a societal cost-benefit of $5.59 for contraceptive services vs. usual care, $6.14 for contraceptive services plus incentives vs. usual care, and $6.96 for contraceptive services vs. contraceptive services plus incentives.
“For women with OUD who do not want to become pregnant, the two interventions we tested provide contraceptive services that better meet their needs and do so in a cost-beneficial way,” said Heil.
While both interventions yielded benefits, the combination of onsite contraceptive services and financial incentives was the more efficacious and cost-beneficial intervention. These results provide promising solutions to help increase access to prescription contraception to prevent unintended pregnancies among women who use opioids.
This study received support from the National Institutes of Health awards No. R01DA036670, R01DA047867, T32DA07242 and P20GM103644