Voluntary Pregnancy Screening at Syringe Exchanges: A Feasibility Study

Abstract

The purpose of this study was to explore the feasibility of offering voluntary pregnancy screening at syringe exchange programs, using the National Implementation Research Network Hexagon Discussion and Analysis Tool. We conducted a survey among female syringe exchange clients, which assessed perceived needs, values, and behavioral intentions for parenting and entering treatment if they received a positive pregnancy screen, and surveys among staff and core volunteers to assess organizational fit, capacity, and needed supports. Participants and staff reported that pregnancy screening was needed at syringe exchange and that capacity needs to be expanded to provide services. Pregnancy screening at syringe exchanges holds the potential to lead to early detection of pregnancy. Early detection of pregnancy among women who inject drugs may result in improved prenatal care, including substance use treatment and treatment of infectious diseases, for women who would otherwise be unlikely to receive prenatal care.

Keywords

syringe exchange pregnancy screening injection drug implementation science

Rates of substance use are increasing among women who are pregnant. Maternal opioid use disorder rates at the time of child delivery quadrupled from 1999 to 2014 (Haight et al., 2018). During that same time frame, there were 4 times as many infants born with neonatal abstinence syndrome as a result of exposure to substances in utero (Winkelman et al., 2018). To provide adequate treatment and to prevent some of the consequences of in utero exposure to substance use, including injection drugs, ongoing efforts seek to identify whether a pregnant individual is using substances (Coleman-Cowger et al., 2019; Price et al., 2018). However, women who inject drugs are less likely to know when they first become pregnant (Schmittner et al., 2005; Shen et al., 2014) and, when pregnancy is identified, fear of child welfare involvement and barriers to access limit the amount of prenatal care received (Maupin et al., 2004; Pagnini & Reichman, 2000; Roberts & Pies, 2011). Thus, screening women who inject drugs for pregnancy, rather than screening people who are pregnant for substance use, may enable women to access more timely prenatal care and improve health outcomes for parent and child. Pregnancy can protect against injection drug use among women who previously injected drugs (Girchenko et al., 2015).

The National Implementation Research Network’s Hexagon Discussion and Analysis Tool (Metz & Louison, 2018) provides an ideal framework for understanding whether an innovative practice fits and is feasible in an existing context. For this study, the innovative practice is offering voluntary pregnancy screening and the existing context is syringe exchange programs in the state of Oregon. We used the Hexagon Tool to describe the indicators of need, fit, evidence, capacity, supports for implementation, and usability. Population need characterizes the population as a whole and the needs of individuals within the population. Fit considers whether the program aligns with client needs and with current initiatives in an organization. Evidence for an intervention encompasses existing data on effectiveness, the strength of the evidence, and the specificity of the existing data to the context. Usability of the intervention is whether the program or practice is clearly defined and operationalized and whether there are mature sites for observation. Capacity is defined as an organization’s current staffing, ability to implement the program and collect data, and changes that would need to be made to existing systems. Support is defined as external support (e.g., funding, access to experts) needed to implement the practice.

Need and Fit

The Hexagon Tool can be used to investigate participant needs to ensure that practices selected align with what the client needs. Among those who use injection drugs, common substances injected include heroin and methamphetamine, among others (Kidd et al., 2019). In utero exposure to heroin and methamphetamine is associated with neonatal abstinence syndrome, which consists of symptoms such as infant irritability, feeding difficulties, tremors, and breathing difficulties, and is associated with sudden infant death syndrome (Hudak & Tan, 2012; Minozzi et al., 2013). In addition, opioid use during pregnancy is associated with low birth weight and mortality (Minozzi et al., 2013). Methamphetamine use during pregnancy is associated with a higher risk of preterm birth, low birth weight, stillbirth (Brecht & Herbeck, 2014; Wright et al., 2015), and developmental delays (van Dyk et al., 2014), as well as poor maternal outcomes such as preeclampsia (Gorman et al., 2014). In addition to the risks associated with in utero exposure to substances, people who inject drugs are more likely to have human immunodeficiency virus (HIV) and hepatitis C virus as a result of sharing syringes and risky sexual behavior (Hagan et al., 2005). If a mother is positive for HIV, the child may also contract HIV and hepatitis C virus although risks can be mitigated with early detection of pregnancy (Selph et al., 2019; Syriopoulou et al., 2005).

The theory of planned behavior (Ajzen, 1991) suggests that an individual’s performance of a behavior is a joint function of intentions and perceived behavioral control. The theory of planned behavior provides a framework for assessing whether clients have intentions to change their behavior following pregnancy screening. Intentions may be related to considering various parenting options upon receiving a positive pregnancy screen and intentions to engage in substance use treatment upon receiving a positive pregnancy screen. Perceived control may be assessed by asking about an individual’s perceived ability to make a decision in line with their values (or attitudes) following a positive pregnancy screen.

The Hexagonal Tool factor of fit is whether a practice aligns with client values. As applied here, fit is also whether voluntary pregnancy screening at a syringe exchange site may align with some of the initiatives already offered through the syringe exchange program. For example, screening for HIV and facilitating access to antiretroviral therapy are often provided through organizations that offer syringe exchange services. Antiretroviral therapy substantially reduces the likelihood of transmission of HIV from mother to infant (Connor et al., 1994) and the benefits are optimized when received for a greater duration of pregnancy (Chagomerana et al., 2018). Women may perceive less stigma and fewer barriers at syringe exchange programs because they do not feel judged and feel safe (Stone, 2015). In addition, women already receive services at syringe exchange programs, so providing pregnancy screening at syringe exchange may be an ideal way to engage with people who inject drugs and who may be pregnant.

Evidence and Usability

The Centers for Disease Control and Prevention (CDC) estimates that most syringe exchange programs offer prevention and health services (Des Jarlais et al., 2015), but it is unclear how many offer family planning resources because there are only three published prior studies documenting the provision of family planning services at syringe exchange programs in the United States (Burr et al., 2014; Moore et al., 2012; Tschann et al., 2019). Of the three programs documented in the studies, only two offered pregnancy screening although all offered contraceptive services. When pregnancy screening was offered, one study reported that 15% of client visits were at least partly for pregnancy screening and a quarter of the screens were positive (Burr et al., 2014). Another reported that 75% of client visits were at least partly for pregnancy screening and 3% of the screens were positive (Moore et al., 2012). The third program offered only injection birth control—which was only used by one participant in 6 months—and noted that most women did not desire to become pregnant but were taking few precautions to avoid pregnancy (Tschann et al., 2019). This prior research suggests that women may be inclined to participate in family planning services, including pregnancy screening, at syringe exchange sites. More research is needed to understand whether offering family planning at syringe exchange sites would lead to earlier access to prenatal care and thus improve outcomes for parents and children.

Capacity and Supports

While leveraging the Hexagon Tool, there are gaps remaining to understand the feasibility of offering voluntary pregnancy screening at syringe exchange sites. First, evidence of need and fit were somewhat described by existing literature; however, site-specific data are needed to assess how participants perceive their own needs for family planning services, such as pregnancy screening at syringe exchange sites, and to assess alignment with the population’s values and the existing initiatives of Oregon-specific syringe exchange programs. Moreover, organizational capacity, such as staffing requirements, ability to implement the practice and collect data, and changes to existing systems, can only be adequately assessed by engaging organization stakeholders. In addition, it is important to understand whether there is adequate support within the organization to implement voluntary pregnancy screening at syringe exchange sites.

Present Study

The objective of this study was to use the Hexagon Tool to determine whether offering voluntary pregnancy screening at syringe exchange programs is needed, fits with client values and existing initiatives, has good evidence, is ready to be used by the syringe exchange organization, and whether the organization has the capacity and support to implement this new practice. To address our objectives, we collected surveys from syringe exchange clients and staff and sought to answer the following questions:

Research Question 1 (RQ1): Is there a perceived need for voluntary pregnancy screening at syringe exchange sites among female-identified clients who inject drugs? (clients and staff)

Research Question 2 (RQ2): Would offering family planning services such as pregnancy screening fit with client values and would women be likely to engage in parenting and substance use treatment following a positive pregnancy screen? (clients)

Research Question 3 (RQ3): Does offering family planning services fit with the current initiatives of Oregon syringe exchange programs and are there capacity and adequate support to offer services? (staff)

Method

Setting

We partnered with an organization that provides syringe exchange services to clients across the state of Oregon. The primary mission of the organization is to prevent the transmission of HIV. The organization offers services in offices across the state and at mobile sites where services are provided outside of a van. In addition to opportunities to exchange used for unused syringes, the organization provides condoms, lubrication, cookers (i.e., small metal caps used for heating substances in preparation for injection), alcohol wipes, and other materials to help prevent the transmission of HIV. They also provide case management services to HIV positive clients and have begun providing peer recovery support services at some of their locations. Data were collected during the hours of exchange at five sites across Oregon in four cities (one rural). Two sites were in an office setting, one site was in a community services building, and two sites were on the street using a mobile van.

Participants and Procedures

Client participants

All individuals who identified as a woman and understood English were eligible to complete the survey. Individuals were not screened to avoid unnecessary harms due to stigmatization associated with assuming an individual’s gender identity or reproductive status. We included women who were sterile or not of reproductive age to capture the full range of women who may be receiving syringe exchange services. Women who did not speak English were excluded due to limited study resources; however, we did not encounter any women who did not speak English during data collection. A total of 69 unique individuals completed the client survey. Only one individual did not wish to participate.

We asked syringe exchange clients whether they would like to participate in a survey about adding services to syringe exchange programs, such as pregnancy screening in exchange for a US$10 gift card. Participants who agreed to participate read the informed consent and signed electronically. If a participant did not feel comfortable reading, the principal investigator read consent materials aloud and assisted with survey completion.

Staff participants

To understand staff perspectives on client needs, fit of offering pregnancy screening with current initiatives, current capacity to implement pregnancy screening, and support needed to implement pregnancy screening at syringe exchanges, we emailed a survey link to syringe exchange staff and core volunteers. Surveys were sent to nine syringe exchange staff and 23 past and present core syringe exchange volunteers. These individuals were identified as being highly engaged (either in the past or presently) in the syringe exchange program by the executive director and volunteer coordinator. The survey was available for 1 week and we received a response from eight out of nine (88%) syringe exchange staff and 10 out of 23 (43%) of core syringe exchange volunteers (past or present) for a total of 18 staff and volunteer respondents. No compensations were provided to staff and volunteers for participating.

Measures

Client survey

A survey was created for syringe exchange clients in collaboration with a multisite syringe exchange program in Oregon. Survey creation was an iterative process between the syringe exchange program staff and the researchers. Items were selected based on prior research with female syringe exchange clients (Burr et al., 2014; Moore et al., 2012; Tschann et al., 2019), organizational needs, and alignment with theory of planned behavior (Ajzen, 1991). The survey also used the One Key Question, a tool developed by the Oregon Foundation for Reproductive Health to screen for pregnancy intention (Allen et al., 2017), which asks, “Would you like to become pregnant in the next year?” The client survey had three sections: (a) demographic information, (b) utilization of services at syringe exchange, and (c) family planning needs.

Need

To answer the question whether there is a perceived need by clients for voluntary pregnancy screening at syringe exchange sites, we first solicited a broad inquiry of general client needs. We asked clients to respond to an open-ended question to see whether reproductive health needs were a priority without inadvertently influencing their responses. The question asked, “What is your biggest current health or wellness priority?” All participants provided only one response although they were instructed that they could list multiple responses. The responses were coded by category and summarized as number of individuals whose response was in line with each category. In addition, we asked clients to select which items from a list of additional services they would like to see added to the syringe exchange program. Reponses were summarized as the number of individuals who endorsed each item.

To specifically understand the needs of female exchange clients related to reproductive health, we asked participants about their desire to become pregnant, using the One Key question. Specifically, participants were asked, “Would you like to become pregnant in the next year?” Possible responses included yes, no, okay either way, and unsure. Participants were also asked, “Do you currently have access to family planning and/or contraceptive services?” and they could respond yes or no to whether they had access to family planning services. Finally, participants responded to the questions, “Do you think voluntary pregnancy screening services are needed at the syringe exchange program?” and “Do you think family planning including contraceptive services (birth control) are needed at the syringe exchange program?” Possible responses were very needed, somewhat needed, neutral, not really needed, and not at all needed. A score of 1 corresponded to very needed and a score of 5 corresponded to not really needed.

Fit

To understand whether offering family planning services such as pregnancy screening would fit with client values, we asked, “If you were to become pregnant how likely would you be to consider parenting your child?” “If you were to become pregnant how likely would you be to consider making an adoption plan?” and “If you were to become pregnant how likely would you be to consider termination of pregnancy?” Possible responses were very likely, likely, neither likely nor unlikely, somewhat unlikely, and very unlikely. A score of 1 corresponded to very likely and a score of 5 corresponded to very unlikely. In addition, as a goal of providing pregnancy screening at syringe exchange would be to motivate clients to change their behavior, particularly after a positive screen, we asked, “If you were to become pregnant, how likely would you be to seek medication assisted treatment like methadone or buprenorphine/naloxone (for example, suboxone)?” and “If you were to become pregnant, how likely would you be to seek behavioral treatment (detox, in-patient drug treatment, out-patient drug treatment, etc.)?” Possible responses were very likely, likely, neither likely nor unlikely, somewhat unlikely, and very unlikely. A score of 1 corresponded to very likely and a score of 5 corresponded to very unlikely. Finally, to measure perceived control, we asked, “If you were to become pregnant how confident are you that you could make a decision about your pregnancy in line with your values?” Possible responses were very confident, moderately confident, somewhat confident, slightly confident, and not at all confident. A score of 1 corresponded to very confident and 5 corresponded to not at all confident.

Staff survey

A second survey was developed for syringe exchange staff and core volunteers to understand staff perspectives of client needs, fit of offering pregnancy screening with current initiatives, current capacity to implement pregnancy screening, and support needed to implement pregnancy screening at syringe exchange sites. Surveys were sent through email to nine syringe exchange staff and 23 past and present core syringe exchange volunteers.

Need

We also asked staff and volunteers whether pregnancy screening and contraceptive services were needed at syringe exchange on a scale of 1 (very needed) to 5 (not at all needed), using the same questions from the client survey. However, after staff and volunteers provided their ratings on a scale, they were also asked to describe why they selected that response to receive additional context.

Fit and capacity

To understand whether offering family planning services fit with the current initiatives of Oregon syringe exchange programs and whether there was capacity and adequate support to offer these services, the staff and volunteers were asked, “Do you think it would be feasible to incorporate pregnancy screening and/or contraceptive services into the regular flow of syringe exchange services?” Possible responses were very feasible, somewhat feasible, neutral, not really feasible, and not at all feasible. In addition, they were asked, “Is there capacity at syringe exchange to collect data on whether individuals utilize pregnancy screening or contraceptive services or could there be?” Possible responses were there is plenty of capacity currently, there is some capacity currently, there is no capacity currently but it is likely that there could be capacity, there is no capacity currently and it is very unlikely that there could be capacity, and not at all feasible. Similar to the questions staff and volunteers were asked about client needs, they were given the opportunity to provide additional insights about the response they selected.

Results

Client Participant Demographics

Demographic information is presented in Table 1. The age of individuals was somewhat evenly distributed between age groups and 78% of client participants were below the age of 45 years, which is slightly more than that of the general female-identified exchange clients (66% below the age of 45 years). All but one individual identified as female and one individual identified as nonbinary. Of the participants, 78% were experiencing homelessness and 78% had obtained at least a high school education. The sample we collected included fewer White individuals (80%) compared with the organization’s female-identified syringe exchange client population (85%). Our sample also had a higher proportion of participants who identified as Latinx/Hispanic (12% and 6%, respectively), and had a higher proportion of participants who identified as American Indian/Alaskan Native (12% and 5%, respectively). A total of 36 of the 69 participants (52%) were below the age of 45 years and had not been sterilized (i.e., undergone a tubal litigation or hysterectomy) and are classified as “fertile” throughout the results.

Table 1.

Demographics of Syringe Exchange Clients Who Participated in the Client Survey (n = 69).

Variable	Frequency	%
Age	10	15
Below 24 years	10	15
25–34 years	21	30
35–44 years	23	33
45+ years	15	22
Current gender identity
Female	68	—
Male	0	—
Nonbinary	1	—
Transgender
Yes	4	6
No	65	94
Housing status
Permanent	15	22
Temporary	17	24
Unhoused	37	54
Education
Less than middle school	2	3
Middle school/some high school	13	19
High school (diploma or GED)	28	40
Some college or technical school	24	35
Four-year degree	2	3
Greater than 4-year degree	0	0
Race/ethnicity^a
African American/Black	2	3
Asian	0	0
Native Hawaiian/Pacific Islander	3	4
Hispanic/Latinx	8	12
American Indian/Alaskan Native	8	12
White	55	80
Other	5	7
Number of past pregnancies (n = 67)
0	9	13
1	8	12
2	12	18
3	18	27
4 or more	20	30

The total percentage is greater than 100 because participants could select as many races or ethnicities as applicable. GED = General Educational Development.

Correlations between selected demographic variables and main study variables are provided in Table 2. There were no associations between age, education, or fertility status and any of the main study variables. Of all client participants, those who were unhoused were more likely to report greater need for pregnancy screening at syringe exchange compared with those who were housed, r(67) = .31, p < .05; 83% of those who were unhoused said pregnancy screening was somewhat needed or very needed compared with 46% who had stable housing. There were no differences based on housing status on whether contraceptive services were needed. Participants who expressed that there was a greater need for pregnancy screening at syringe exchange were also more likely to report that there was a greater need for access to contraceptive care at syringe exchange, r(67) = .53, p < .05.

Table 2.

Correlations of Demographics and Main Study Variables (n = 69).

Variable	1	2	3	4	5	6	7	8	9	10	11	12
1. Unhoused
2. Age group	−.01
3. Education	−.15	.39*
4. Fertile	−.09	−.46*	−.09
5. Need for pregnancy screening^a	.31*	−.10	.11	.14
6. Need for contraception^a	−.03	.17	.21	−.09	.53*
7. Number of previous pregnancies	−.06	−.33*	−.19	.18	−.03	−.14
8. Desire to become pregnant	.02	−.05	.00	.22	.12	−.03	.19
9. Parenting likelihood^a	−.09	.13	−.21	.07	−.07	−.02	.03	.26*
10. Adoption plan likelihood^a	.11	.06	.03	.10	−.11	.28*	−.11	−.10	−.24
11. Termination likelihood^a	−.06	.05	.05	.11	.05	.26*	−.14	−.20	−.37*	.65*
12. MAT likelihood^a	.12	.04	.05	.06	.01	.07	−.14	.02	.01	.16	.21
13. Behavioral treatment likelihood	.20	.18	.01	−.03	−.10	.01	−.10	.16	.22	.24	.15	.62*

Note. Unhoused = temporary housing or unhoused; Education = high school education or greater; Desire to become pregnant = yes or okay either way; MAT = medication-assisted treatment.

Rows 5, 6, 9, 10, 11, 12, and 13 were reverse coded for correlations so that higher scores indicated a greater need or likelihood.

p < .05.

Client and Staff Perceived Need for Pregnancy Screening

Table 3 presents client participants’ top health priorities. A chronic health condition such as HIV or liver disease was reported as the primary concern by 39% (n = 27). Of the participants, 13% (n = 9) listed recovery, such as “getting clean,” as a priority.

Table 3.

Top Health Priority of Female-Identified Clients Who Inject Drugs (n = 69).

Health priority	Frequency	%
Chronic health condition	27	39
None	10	14
Recovery	9	13
General health	7	10
Mental health	5	7
Pain	4	6
Harm reduction	4	6
Dental	3	5

Participants were interested in services being added to syringe exchange: 19% were interested in supplies for their children (n = 13), 67% were interested in women’s hygiene products (pads, tampons, and wipes; n = 46), and 14% were interested in child care (n = 10). Data from only the fertile participants are presented in Table 4, in desire to become pregnant and interest in family planning services, because infertile women are very unlikely to need access to pregnancy screening and contraception (other than condoms that are currently provided by the syringe exchange program). Among fertile participants, 39% of the women (n = 14) either desired to become pregnant or were “okay either way” and 53% were interested in having access to family planning services at syringe exchange sites (n = 19). On a scale of 1 (very needed) to 5 (not at all needed), participants who were fertile reported that the need for pregnancy testing was 1.9 (SD = 1.1), which corresponded to somewhat needed. They rated contraceptive services (i.e., birth control), on average, at 1.9 (SD = 1.2), which corresponded to somewhat needed.

Table 4.

Desires and Needs for Family Planning for Fertile Individuals (n = 36).

Question	Frequency	%
Would you like to become pregnant in the next year?
Yes	4	11
No	19	54
Okay either way	11	29
Unsure	2	6
Currently have access to family planning
Yes	29	81
No	7	19
Interested in family planning services (at syringe exchange)
Yes	19	53
No	17	47

Staff and volunteers reported that voluntary pregnancy screening was, on average, somewhat needed: 35% selected very needed, 41% somewhat needed, 24% neutral, and none not really needed or not at all needed. One person highlighted, “it [voluntary pregnancy screening] would definitely be helpful, but not more important than basic needs: food, shelter, warm clothing” and another responded that

in active addiction it’s so easy to feel judged so to go buy a [pregnancy] test can be embarrassing or an overly stressful some may steal them leading them to get charges. People know the [exchange] as a place that doesn’t judge and are there for them.

Others noted that

physical safety seems to be the most pressing need I hear specifically from female-identified clients at syringe exchange. I understand that reproductive services could be a priority for this population, but I haven’t talked with any clients about that specifically.

Staff and volunteers reported that family planning including contraceptive services is, on average, somewhat needed: 53% selected very needed, 29% somewhat needed, 18% neutral, and none selected not really needed or not at all needed. One respondent noted,

Many female-identified clients at needle exchange are at risk for STDs and pregnancy. Needle exchange having the ability to function as a space where one can access their contraceptive needs is extremely important . . . Additionally, unhoused women are highly vulnerable to sexual abuse—and medications such as Plan B provided in a safe, low stigma atmosphere could be helpful.

Another shared,

Access to condoms and lube—which is provided are very important for female clients. If access to other types of birth control, including Plan B could be provided, I could also see this as helpful. Additionally, if domestic violence screening/ referrals were possible in privacy I could see this as helpful—although many clients are very aware of the outside resources available to them. STD screening would be another need that could potentially be included in NEX services.

Alignment With Client Values

On a scale of 1 (very likely) to 5 (very unlikely), participants who were fertile rated their likelihood of considering parenting, an adoption plan, or termination of pregnancy. These women reported their likelihood of considering parenting, on average, as 1.4 (very likely; SD = .94), their likelihood of considering an adoption plan as 4 (somewhat unlikely; SD = 1.3), and their likelihood of considering termination of pregnancy as 4.1 (somewhat unlikely; SD = 1.4). On the same scale, participants who were fertile were asked about their likelihood to engage in medication-assisted treatment (MAT) and behavioral treatment following a positive pregnancy screen. Women reported their likelihood of engaging in MAT at an average of 2.2 (somewhat likely; SD = 1.7), and behavioral treatment as 1.7 (somewhat likely; SD = 1.3). Frequencies for items associated with client values and behavioral intentions are presented in Table 5. To assess individual perceived control, we asked how confident participants felt that they could make a decision in line with their values on a scale of 1 (not at all confident) to 5 (very confident). On average, participants’ score was 4.2 (moderately confident; SD = 1.1; 58% very confident, 19% moderately confident, 12% somewhat confident, 8% slightly confident, 3% not at all confident).

Table 5.

Client Values and Behavioral Intentions Following a Positive Pregnancy Screen Among Fertile Individuals (n = 36).

Variable	Very likely (%)	Likely (%)	Neither likely nor unlikely (%)	Unlikely (%)	Very unlikely (%)
Consider parenting	77	11	6	3	3
Consider an adoption plan	6	8	19	14	53
Consider termination	11	6	14	3	66
Opioid agonist therapy	51	14	9	0	26
Behavioral treatment	61	22	3	3	11

Organizational Fit, Capacity, and Support

Staff and volunteers reported that there was, on average, plenty of capacity currently to collect data on whether women use pregnancy screening or contraceptive services: 64% reported plenty of capacity currently, 18% some capacity currently, 18% no capacity currently but it is likely that there could be capacity, and 0% no capacity and it is unlikely that there could be capacity. A staff member reported, “Currently there is private space during the syringe exchange (the rv) but during the exchange there are doctors utilizing that space. I could start by providing pregnancy screening at lower client volume locations as being feasible.”

Staff and volunteers reported that incorporating pregnancy screening and/or contraceptive services into the regular flow of syringe exchange services was, on average, somewhat feasible: 36% selected very feasible, 43% somewhat feasible, 14% neutral, and 7% not at all feasible. In addition, space limitations, such as limited privacy and no bathroom at mobile sites, were noted, as well as limitations to having a provider on-site to work with clients, having medications on hand, other services that occur at exchange, and funding. One staff member reported,

Distributing pregnancy tests would be very easy at exchange. Having a medical provider who could work with clients on contraceptives would be great. Getting to a pharmacy to fill prescriptions could be tough for clients so we might want to think about ways to have medications on hand or maybe doing depo shots at exchange.

Discussion

Our study provides important insights into the family planning needs of female syringe exchange clients and the unique position of syringe exchange programs to meet this population’s needs. It was important to evaluate the perceived needs of the client population, given the sparse literature on the desire for pregnancy screening among syringe exchange clients (Burr et al., 2014; Moore et al., 2012; Tschann et al., 2019). In addition, we are unaware of any research that uses an implementation science framework to guide the investigation of whether pregnancy screening is feasible at syringe exchange programs. Using the Hexagon Tool to guide our research, we found that there is (a) an actual and perceived need for voluntary pregnancy screening at syringe exchange sites, (b) that offering pregnancy screening would fit with client values and that clients would be likely to engage in parenting and substance use treatment following a positive pregnancy screen, and (c) that offering family planning services does fit with existing initiatives and that there is capacity for implementation of offering voluntary pregnancy screening.

We found that many people who were both of reproductive age and unsterilized, either desired to become pregnant or were “okay either way” and most would be interested in family planning services if they were to be offered at syringe exchange. In addition, participants thought that offering pregnancy screening and contraceptive services were at least somewhat needed. Similar results emerged from staff and volunteer reports of client needs. Given these results, it seems that offering family planning services at syringe exchange is perceived as needed by the client population and by staff and volunteers. However, clients, staff, and volunteers all highlight that, while attending to pregnancy screening and broadly reproductive health is important, it is not as important as basic needs and behavioral/medical health care. For example, no participant identified reproductive health as a top health priority. These findings are not surprising, given the complex health needs of this population (Burr et al., 2014). Thus, it would be useful to combine family planning services with other health services at syringe exchange sites. For example, the syringe exchange sites that were surveyed are part of an organization that aims to reduce the transmission of HIV. Testing and case management to facilitate treatment of HIV and hepatitis C virus are already part of operations and could be incorporated and expanded upon with the provision of voluntary pregnancy screening and contraceptive services.

Staff and core volunteer surveys reinforced that family planning services could be best administered with additional supports such as assistance from a health care professional and providing basic needs services. Assistance from heath care professionals may involve either having physicians or nurses on-site or “warm handoffs” to providers in the community. Additional supports such as food and clothing are also important unmet needs identified by both clients and staff, which should be addressed simultaneously. A more comprehensive approach, such as peer-to-peer case management, may help clients gain access to supports across client needs.

We found that offering pregnancy screening would fit with client values and that clients would be likely to engage in parenting and substance use treatment following a positive pregnancy screen. Specifically, women reported that they would be likely to consider parenting and unlikely to consider making an adoption plan or termination of pregnancy. This was true for both fertile and infertile women, suggesting that the social norms surrounding pregnancy among this population are to attempt parenting. Social norms are proposed by the theory of planned behavior as a driver of behavioral intention (Ajzen, 1991). Although women who inject drugs may intend to parent following a positive pregnancy test, numerous barriers impede this goal as evidenced by high rates of child welfare involvement among mothers with substance use disorders (Taplin & Mattick, 2015). In addition, parent substance use disorders are associated with more complex and severe cases of child maltreatment (Radel et al., 2018).

In line with a desire to parent, participants reported a higher likelihood of engaging in behavioral treatment compared with MAT. Specifically, we found that 83% of women who were fertile said that they would be at least likely if not very likely to engage in behavioral treatment if they received a positive pregnancy screen. However, it is unclear whether this was because many women inject methamphetamine—for which there is no agonist treatment—or due to concern of the possible effects of exposure to MAT in utero on the developing fetus. Given the social norms, values, and behavioral intentions following a positive pregnancy screen for women who inject drugs, early detection is imperative as engaging in injection drug use may make it challenging for women to retain their children (Radel et al., 2018; Taplin & Mattick, 2015). Early prenatal care and case management for women who have intentions to parent following pregnancy may reduce the likelihood of child welfare involvement. Other work has demonstrated the effectiveness of peer support when integrated with behavioral and MAT and general medical access (John McConnell et al., 2020). However, this was for women who were already involved or referred to medical/substance abuse treatment either due to child welfare involvement or self-selection. Additional research is needed to determine the efficacy of peer-led case management at syringe exchange programs for women who are potentially less likely to be connected to necessary and timely prenatal care.

Overall, participants felt confident that they could make a decision in line with their values following a positive screen. This suggests that decision-making around pregnancy and choices to engage in treatment are likely to occur. However, there may be barriers to service entry and treatment retention such as limited access to MAT due to lack of providers or stigma and untreated mental health challenges (Chapman & Wu, 2013; Klaman et al., 2017; Spehr et al., 2017). It is also of note that a substantial majority of participants reported a history of at least one previous pregnancy. To be sensitive to participants’ experiences, we did not ask about the outcomes of previous pregnancies (e.g., pregnancy loss, child death, loss of custody, or termination of pregnancy). However, future research should consider asking about previous outcomes of pregnancies to learn more about client past behavior and to understand when salient points of intervention may have occurred. For example, experiences of loss such as loss of custody, miscarriage, or child death may be associated with acute stress and increased substance use and may also be associated with a greater likelihood of subsequent pregnancies that co-occur with substance use (Brecht & Herbeck, 2014; Coleman et al., 2005). Providing grief and loss support in tandem with substance abuse treatment and medical care in the form of individual counseling, peer support, or group-based support may alleviate distress and prevent substance use and promote reunification and/or future healthy pregnancies.

Our findings also indicated that, at minimum, there is potential for the capacity to implement voluntary pregnancy screening at syringe exchange and that offering family planning services does fit with existing initiatives. However, there are barriers, including limited funding, time, and infrastructure. To move forward with the provision of pregnancy screening at syringe exchange programs, these challenges must be addressed. State and research funding specific to the opioid epidemic could be leveraged to support these efforts as well as funding from local community care organizations and county public health entities. Thoughtful implementation leveraging the Hexagon Tool or other implementation science frameworks is needed for these efforts to ensure that efforts are well designed, sustainable, and paired with other wraparound services to increase the likelihood that clients will have improved long-term outcomes.

Policy and Practice Implications

Policy makers seeking to improve outcomes for communities regarding intravenous drug use should consider removing barriers to pregnancy screening for women who inject drugs. Specifically, women are less likely to seek prenatal care when they know they are pregnant if they fear child welfare involvement; 23 states consider substance use to be child abuse and 25 states require health care professionals to report suspected prenatal drug use (Guttmacher Institute, 2020). Alternative approaches include providing priority access to treatment for pregnant women.

Nonjudgmental screening is crucial for reducing barriers to access and support. A woman seeking pregnancy screening experiences fear of stigmatization and shame (Roberts & Pies, 2011). Motivation to change is more likely to occur if a person feels capable of change rather than demoralized or inadequate (Sim et al., 2009). It is clear from the number of clients who reported considering parenting and behavioral treatment that pregnancy may be an optimal time for change. Providers should capitalize on the moment and use evidence-based strategies such as motivational interviewing to enhance readiness and facilitate action. Researchers and agencies serving syringe exchange clients should pilot test pregnancy screening with and without motivational interviewing to consider the most advantageous approach to providing pregnancy screening services to syringe exchange clients.

Strengths and Limitations

We are unaware of any other studies that have assessed female syringe exchange client’s behavioral intentions following a positive pregnancy screen. Our study provides novel evidence that syringe exchange clients may be likely to consider parenting their child over making an adoption plan or termination of pregnancy. In addition, we are unaware of any studies that have asked syringe exchange clients about behavioral intentions to participate in substance use treatment following a positive pregnancy screen.

Our study was not without limitations. Only half of the volunteers from whom we solicited responses responded to our survey. No compensation and a short time line for participating may have been barriers to soliciting volunteer input. Potential participants had only a week to respond and may not have checked their email during the week of data collection. All but one of the staff members who received an email participated in the study. The population of women we surveyed was relatively homogeneous (80% White); thus, the results may not be generalizable to syringe exchange sites with a greater proportion of individuals who do not identify as White. In addition, this sample was collected exclusively across the state of Oregon. Individuals residing in the state of Oregon may have different values related to reproductive health needs and choices compared with individuals living in other states. The number of female participants we sampled was relatively small. However, our sample size was larger than similar studies with this population (e.g., Tschann et al., 2019) and mirrored the demographics of statewide syringe exchange clients. In addition, 69/70 individuals who were invited to participate agreed, making it unlikely that our results were skewed by participant willingness to contribute to the research. The number of participants who were fertile reduced our sample to approximately half of the original sample size. However, most studies use age as an approximation of fertility status. We estimated fertility status as a combination of age and sterilization, which made it easier to infer the needs of women who were able to become pregnant. Due to our small sample size, our results should be considered preliminary in nature. However, although our results are preliminary, we believe that they do provide sufficient evidence to suggest that it would be useful to pilot pregnancy screening services at syringe exchange programs in Oregon to provide a clearer understanding of the utility of offering such services.

Conclusion

Providing pregnancy screening at syringe exchange sites is feasible, was perceived as needed and in line with the values of female-identified syringe exchange clients, and fits with the current initiatives at Oregon Syringe exchanges. Moreover, women report a high likelihood of engaging in behavioral treatment and parenting following a positive pregnancy screen. The next steps for implementing pregnancy screening at syringe exchange are to (a) consider different approaches for screening, and (b) develop a continuum of care following both positive and negative screens. Approaches to screening may consider who would administer the pregnancy screening, whether by a health care professional or a skilled peer support specialist. Moreover, identifying a safe, convenient space for screening is important (Tschann et al., 2019) and having a continuum of care in place for women following pregnancy screening is crucial for facilitating behavior change. To our knowledge, there is no scientific information on implementing supports following pregnancy screening at syringe exchange sites. However, there are studies on continuums of care at syringe exchange programs, which can be used to help implement supports following pregnancy screening. For example, providing transportation to treatment is key for engaging syringe exchange clients in behavioral treatment (Strathdee et al., 2006). Having a referral network to draw from is also important for developing resources and supports (Burr et al., 2014; Moore et al., 2012; Tschann et al., 2019).

We see an immediate need to pilot test implementing pregnancy screening at syringe exchange sites in Oregon. However, organizations that implement syringe exchange programs must be both structurally and monetarily prepared for implementation. This study highlights a call to action to funding agencies to prioritize the needs of female-identified syringe exchange clients to facilitate improved outcomes for clients, their children, and communities.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The writing of this article was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award No. P50DA048756. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

ORCID iD

Camille C. Cioffi

Author Biographies

Camille C. Cioffi, PhD, is a research associate at the University of Oregon’s Prevention Science Institute, Center on Parenting and Opioids. Cioffi’s research focuses on how to improve health and mental health outcomes and reduce substance use among pregnant and parenting people with substance use disorders. She values community-based participatory research, addressing structural inequities, and meeting people where they are at to help them achieve their personal health and parenting goals.

John R. Seeley, PhD, is a professor in the Special Education and Clinical Sciences department and a core faculty member in the Prevention Science program. His research interests include emotional and behavioral disorders, school-based mental health intervention, research design and program evaluation, and digital health technology.

References

Ajzen

(1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T

Allen

Hunter

M. S.

Wood

Beeson

(2017). One Key Question®: First things first in reproductive health. Maternal and Child Health Journal, 21(3), 387–392. https://doi.org/10.1007/s10995-017-2283-2

Brecht

M. L.

Herbeck

D. M.

(2014). Pregnancy and fetal loss reported by methamphetamine-using women. Substance Abuse: Research and Treatment, 8, 25–33. https://doi.org/10.4137/SART.S14125

Burr

C. K.

Storm

D. S.

Hoyt

M. J.

Dutton

Berezny

Allread

Paul

(2014). Integrating health and prevention services in syringe access programs: A strategy to address unmet needs in a high-risk population. Public Health Reports, 129(Suppl. 1), 26–32. https://doi.org/10.1177/00333549141291S105.

Chagomerana

M. B.

Miller

W. C.

Tang

J. H.

Hoffman

I. F.

Mthiko

B. C.

Phulusa

John

Jumbe

Hosseinipour

M. C.

(2018). Optimizing prevention of HIV mother to child transmission: Duration of antiretroviral therapy and viral suppression at delivery among pregnant Malawian women. PLoS ONE, 13(4), Article e0195033. https://doi.org/10.1371/journal.pone.0195033.

Chapman

S. L. C.

L.-T.

(2013). Postpartum substance use and depressive symptoms: A review. Women & Health, 53(5), 479–503. https://doi.org/10.1080/03630242.2013.804025

Coleman-Cowger

V. H.

Oga

E. A.

Peters

E. N.

Trocin

K. E.

Koszowski

Mark

(2019). Accuracy of three screening tools for prenatal substance use. Obstetrics and Gynecology, 133(5), 952–961. https://doi.org/10.1097/AOG.0000000000003230

Coleman

P. K.

Reardon

D. C.

Cougle

J. R.

(2005). Substance use among pregnant women in the context of previous reproductive loss and desire for current pregnancy. British Journal of Health Psychology, 10(2), 255–268. https://doi.org/10.1348/135910705X25499

Connor

E. M.

Sperling

R. S.

Gelber

Kiselev

Scott

O’Sullivan

M. J.

VanDyke

Bey

Shearer

Jacobson

R. L.

Jimenez

O’Neill

Bazin

Delfraissy

J.-F.

Culnane

Coombs

Elkins

Moye

Stratton

Balsley

(1994). Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with Zidovudine treatment. New England Journal of Medicine, 331(18), 1173–1180. https://doi.org/10.1056/NEJM199411033311801

10.

Des Jarlais

D. C.

Nugent

Solberg

Feelemyer

Mermin

Holtzman

. (2015). Syringe service programs for persons who inject drugs in urban, suburban, and rural areas—United States, 2013. Morbidity and Mortality Weekly Report, 64(48), 1337–12241.

11.

Girchenko

Ompad

D. C.

Bikmukhametov

Gensburg

(2015). Association between pregnancy and active injection drug use and sex work among women injection drug users in Saint Petersburg, Russia. Journal of Urban Health : Bulletin of the New York Academy of Medicine, 92(3), 548–558. https://doi.org/10.1007/s11524-015-9954-3

12.

Gorman

M. C.

Orme

K. S.

Nguyen

N. T.

Kent

E. J.

III Caughey

A. B.

(2014). Outcomes in pregnancies complicated by methamphetamine use. American Journal of Obstetrics & Gynecology, 211(4), 429.E1–429.E7. https://doi.org/10.1016/j.ajog.2014.06.005

13.

Guttmacher Institute. (2020). Substance use in pregnancy. https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy

14.

Hagan

Thiede

Des Jarlais

D. C.

(2005). HIV/hepatitis C virus co-infection in drug users: Risk behavior and prevention. AIDS, 19(Supp. l3), S199–S207. https://doi.org/10.1097/01.aids.0000192090.6175

15.

Haight

Tong

Bohm

Callaghan

(2018). Opioid use disorder documented at delivery hospitalization—United States, 1999–2014. Morbidity and Mortality Weekly Report, 67, 845–849. https://dx-doi-org.web.bisu.edu.cn/10.15585/mmwr.mm6731a1

16.

Hudak

M. L.

Tan

R. C.

(2012). Neonatal drug withdrawal. Pediatrics, 129(2), e540–e560. https://doi.org/10.1542/peds.2011-3212.

17.

John McConnell

Kaufman

M. R.

Grunditz

J. I.

Bellanca

Risser

Rodriguez

M. I.

Renfro

. (2020). Project nurture integrates care and services to improve outcomes for opioid-dependent mothers and their children. Health Affairs, 39(4), 595–602. https://doi.org/10.1377/hlthaff.2019.01574

18.

Kidd

S. E.

Gre

J. A.

Torrone

E. A.

Weinstock

H. S.

(2019). Increased methamphetamine, injection drug, and heroin use among women and heterosexual men with primary and secondary syphilis—United States, 2013-2017. Morbidity and Mortality Weekly Report, 68, 144–148. https://dx-doi-org.web.bisu.edu.cn/10.15585/mmwr.mm6806a4

19.

Klaman

S. L.

Isaacs

Leopold

Perpich

Hayashi

Vender

Campopiano

Jones

H. E.

(2017). Treating women who are pregnant and parenting for opioid use disorder and the concurrent care of their infants and children: Literature review to support national guidance. Journal of Addiction Medicine, 11(3), 178–190. https://dx-doi-org.web.bisu.edu.cn/10.1097/ADM.0000000000000308

20.

Maupin

R. J.

Lyman

Fatsis

Prystowiski

Nguyen

Wright

Kissinger

Miller

J. J.

(2004). Characteristics of women who deliver with no prenatal care. The Journal of Maternal-Fetal & Neonatal Medicine, 16(1), 45–50. https://doi.org/10.1080/14767050412331283913

21.

Metz

Louison

(2018). The hexagon tool: Exploring context. https://nirn.fpg.unc.edu/resources/hexagon-exploration-tool

22.

Minozzi

Amato

Bellisario

Ferri

Davoli

(2013). Maintenance agonist treatments for opiate-dependent pregnant women. Cochrane Database of Systematic Reviews, 12. https://doi.org/10.1002/14651858.CD006318.pub3

23.

Moore

Han

Serio-Chapman

Mobley

Watson

Terplan

(2012). Contraception and clean needles: Feasibility of combining mobile reproductive health and needle exchange services for female exotic dancers. American Journal of Public Health, 102(10), 1833–1836. https://doi.org/10.2105/AJPH.2012.300842

24.

Pagnini

D. L.

Reichman

N. E.

(2000). Psychosocial factors and the timing of prenatal care among women in New Jersey’s HealthStart program. Family Planning Perspectives, 32(2), 56–64. https://doi.org/10.2307/2648213

25.

Price

H. R.

Collier

A. C.

Wright

T. E.

(2018). Screening pregnant women and their neonates for illicit drug use: Consideration of the integrated technical, medical, ethical, legal, and social issues. Frontiers in Pharmacology, 9, 961. https://doi.org/10.3389/fphar.2018.00961

26.

Radel

Baldwin

Crouse

Ghertner

Waters

(2018). Substance use, the opioid epidemic, and the child welfare system: Key findings from a mixed methods study. https://aspe.hhs.gov/system/files/pdf/258836/SubstanceUseChildWelfareOverview.pdf

27.

Roberts

S. C. M.

Pies

(2011). Complex calculations: How drug use during pregnancy becomes a barrier to prenatal care. Maternal and Child Health Journal, 15(3), 333–341. https://doi.org/10.1007/s10995-010-0594-7

28.

Schmittner

Schroeder

J. R.

Epstein

D. H.

Preston

K. L.

(2005). Menstrual cycle length during methadone maintenance. Addiction, 100(6), 829–836. https://doi.org/10.1111/j.1360-0443.2005.01091.x

29.

Selph

S. S.

Bougatsos

Dana

Grusing

Chou

(2019). Screening for HIV infection in pregnant women: Updated evidence report and systematic review for the US Preventive Services Task Force. Journal of the American Medical Association, 321(23), 2349–2360. https://doi.org/10.1001/jama.2019.2593

30.

Shen

Zhang

Y.-S.

Liu

Huang

Chen

Zhou

(2014). Long-Term use of methamphetamine disrupts the menstrual cycles and hypothalamic-pituitary-ovarian axis. Journal of Addiction Medicine, 8(3), 183–188. https://doi.org/10.1097/ADM.0000000000000021

31.

Sim

Wain

Khong

(2009). Influencing behaviour change in general practice Part 2—motivational interviewing approaches. Australian Family Physician, 38, 986–989. http://www.racgp.org.au/afp/2009/december/influencing-behaviour-change/

32.

Spehr

M. K.

Coddington

Ahmed

A. H.

Jones

(2017). Parental opioid abuse: Barriers to care, policy, and implications for primary care pediatric providers. Journal of Pediatric Health Care, 31(6), 695–702. https://doi.org/10.1016/j.pedhc.2017.05.007

33.

Stone

(2015). Pregnant women and substance use: Fear, stigma, and barriers to care. Health & Justice, 3, Article 2. https://doi.org/10.1186/s40352-015-0015-5

34.

Strathdee

S. A.

Ricketts

E. P.

Huettner

Cornelius

Bishai

Havens

J. R.

Beilenson

Rapp

Lloyd

J. J.

Latkin

C. A.

(2006). Facilitating entry into drug treatment among injection drug users referred from a needle exchange program: Results from a community-based behavioral intervention trial. Drug and Alcohol Dependence, 83(3), 225–232. https://doi.org/10.1016/j.drugalcdep.2005.11.015

35.

Syriopoulou

Nikolopoulou

Daikos

G. L.

Theodoridou

Pavlopoulou

Nicolaidou

Manolaki

(2005). Mother to child transmission of hepatitis C virus: Rate of infection and risk factors. Scandinavian Journal of Infectious Diseases, 37(5), 350–353. https://doi.org/10.1080/00365540510032105

36.

Taplin

Mattick

R. P.

(2015). The nature and extent of child protection involvement among heroin-using mothers in treatment: High rates of reports, removals at birth and children in care. Drug and Alcohol Review, 34, 31–37. https://doi.org/10.1111/dar.12165

37.

Tschann

Wright

Lusk

Giorgio

Colon

Kaneshiro

(2019). Understanding the family planning needs of female participants in a syringe exchange program: A needs assessment and pilot project. Journal of Addiction Medicine, 13(5), 366–371. https://doi.org/10.1097/ADM.0000000000000508

38.

van Dyk

Ramanjam

Church

Koren

Donald

. (2014). Maternal methamphetamine use in pregnancy and long-term neurodevelopmental and behavioral deficits in children. Journal of Population Therapeutics and Clinical Pharmacology/Journal de La Therapeutique Des Populations et de La Pharamcologie Clinique, 21(2), e185–e196.

39.

Winkelman

T. N. A.

Villapiano

Kozhimannil

K. B.

Davis

M. M.

Patrick

S. W.

(2018). Incidence and costs of neonatal abstinence syndrome among infants with Medicaid: 20042014. Pediatrics, 141(4), Article e20173520. https://doi.org/10.1542/peds.2017-3520

40.

Wright

T. E.

Schuetter

Tellei

Sauvage

(2015). Methamphetamines and pregnancy outcomes. Journal of Addiction Medicine, 9(2), 111–117. https://doi.org/10.1097/ADM.0000000000000101