Date of Award

May 2020

Document Type


Degree Name

Doctor of Philosophy (PhD)


Public Health Services

Committee Member

Rachel Mayo

Committee Member

Khoa Truong

Committee Member

Lori Dickes

Committee Member

Lior Rennert


Substance use disorders (SUD) impact millions of women aged 15-44 in the United States. Unintended pregnancy, which is associated with maternal and infant morbidities, is common among women with SUD. Family planning is a leading strategy to prevent unintended pregnancy, yet women with SUD report low rates of contraceptive use. The goal of this research is to contribute a more nuanced understanding of how women with SUD are provided with and use contraception during the childbearing years.

This dissertation investigates contraceptive provision and initiation trends, patterns, and practices among reproductive-age women with and without SUD. Three chapters make up this dissertation; each chapter is focused on a different aspect of contraceptive care.

The first chapter describes changes in contraceptive provision between 2000-2017 for South Carolina Medicaid-enrolled women with and without SUD aged 15-44 at risk of unintended pregnancy. Clinical performance measures for contraceptive care endorsed by the National Quality Forum were applied to the data to assess annual percentages of women provided most or moderately effective contraceptive methods. Contraceptive provision of long-acting reversible methods increased more for women with SUD than women without SUD over the study period. Provision of most or moderately effective methods was substantially lower among women with SUD than their non-SUD counterparts.

The second chapter compares postpartum contraceptive initiation patterns among reproductive-age women with and without opioid use disorders (OUD) enrolled in South Carolina Medicaid. This study employed a counterfactual framework to balance the distribution of covariates between women with OUD and comparison women without OUD. Having an OUD was associated with decreased contraceptive initiation in the postpartum period, suggesting that women with OUD face increased barriers to accessing postpartum contraceptives than similar women without OUD.

The third chapter investigates health care providers’ self-reported contraceptive counseling practices for their patients with SUD. Interviews were conducted with a national sample of women’s health providers. Providers emphasized the importance of timing contraceptive discussions appropriately, tailoring information based on patient needs and wants, building interpersonal relationships, and prioritizing patients’ autonomy. Some providers perceived that long-acting reversible contraceptives were most appropriate for women with SUD living with instability.



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