: Closing the health gap is a priority of the Grand Challenges for Social Work, yet reproductive healthcare disparities remain a significant concern in the Appalachian region of the United States, particularly for women who use drugs. To better understand reproductive healthcare access in this context, we examined associations between past-year illicit substance use and reproductive healthcare access and barriers among Appalachian women. Guided by stigma theory (including anticipated, enacted, and structurally produced stigma related to substance use and pregnancy) and a place-based health equity/social determinants of health lens, we conducted a secondary analysis of anonymous, electronic survey data from 357 reproductive-aged women residing in Appalachia. Bivariate tests and logistic regression models were conducted to compare participants who did and did not report past-year substance use. Findings: Appalachian women with a history of drug use reported more barriers to reproductive healthcare, lower engagement in care, and higher rates of unintended pregnancy. Barriers included affordability of care, perceived stigma, discomfort obtaining appointments, and fear of legal consequences. Applications: These findings underscore the potential role for social workers in addressing reproductive health and drug treatment disparities among Appalachian women who use drugs. Applications for regional social workers include building trust between clients and providers, strengthening connections between substance use disorder treatment and reproductive healthcare, and advocating for policies such as Medicaid expansion and restoration of Title X funding. By integrating micro-level support with macro-level advocacy, social workers can help reduce unintended pregnancies, improve access to care, and advance health equity in this historically underserved region.

BACKGROUND:Many people living along the Appalachian mountain region, which spread down the eastern side of the United States, experience limited access to abortion care and report high levels of distrust in health care providers. Therefore, Appalachians are likely to have a unique lens through which to view the use of self-managed abortion. The purpose of this study is to better understand Appalachians' perceptions of self-managed abortions. METHODS:Data was collected via an online survey. Participants were recruited by trusted community partners and boosted ads on social media. Inclusion criteria included pregnancy-capacity, 18+ years old, living in an Appalachian county, and having a history of either considering or attempting self-managed abortion. Open-ended responses were coded using deductive thematic analysis guided by our theoretical framework. RESULTS:Participants [N = 159] representing every Appalachian state responded to the survey. Three themes were identified: (1) self-managed abortion is often a decision made in the absence of choice but can be empowering within these constraints, (2) anticipating failure: the expectation of failure and health complications for those using self-managed abortion, and (3) connection with others is critical to having a more positive self-managed abortion experience. CONCLUSIONS:These findings reveal that self-managed abortion is often pursued not out of preference but due to barriers such as cost, legal restrictions, stigma, or lack of access to clinical care. Improving access to accurate information, emotional support, and follow-up care could greatly enhance confidence in the safety of abortion and improve the well-being of those seeking abortion care in Appalachia.

Very little is known about contraceptive behavior in Appalachia, a large geographic region in the eastern United States where even basic prevalence estimates of contraceptive use/nonuse are lacking. This study characterizes contraceptive behavior among Appalachians, including contraceptive use, reasons for use, and methods used; contraceptive nonuse and reasons for nonuse; and attitudes about contraception, including acceptability. This is a secondary analysis of a subsample of survey data collected on sexual and reproductive health attitudes, behaviors, and needs among reproductive-age women (18–49 years) living in the Appalachian region (n = 332). Results identify rates of contraceptive use (66.6%) and nonuse (33.1%) among Appalachian residents. Methods used most frequently included those that did not require prescription (i.e., external condoms and natural family planning methods) though many reported the use of intrauterine devices (IUDs). Among nonusers, fear of side effects from contraception and ambivalence towards pregnancy were most commonly selected as the most important reason for not using contraception. Contraception was considered acceptable by this sample overall, and these acceptability attitudes were significantly associated with contraceptive behavior.

Good quality patient care requires health care providers to respect the humanity and autonomy of their patients. However, this is not achieved in all settings. This study used cross-sectional survey data including open-ended text responses to explore negative experiences with health care providers among women in Appalachia. We used the Heath Stigma & Discrimination Framework (HSDF) to identify how stigma is created and perpetuated through interactions with health care providers. Survey data from 628 women collected through purposive sampling identified that two out of three participants had had a bad encounter with a provider that made them not want to return for care. One in six participants had a negative experience specifically while seeking contraception. Using the domains of the HSDF framework, qualitative answers to open-ended questions illuminated how health care providers, influenced by social and cultural norms related to religiosity, patriarchal views, poverty, poor health infrastructure, and the opioid crisis, created and perpetuated stigma through dehumanising treatment, low-quality care, and health care misogyny. Because stigma is a driver of health inequity, these findings highlight the important and sometimes problematic role that health care providers can play when they create a barrier to future care through poor treatment of patients.

OBJECTIVE:To investigate the frequency and impact of contraceptive coercion in the Appalachian region of the United States. DATA SOURCES AND STUDY SETTING:In fall 2019, we collected primary survey data with participants in the Appalachian region. STUDY DESIGN:We conducted an online survey including patient-centered measures of contraceptive care and behavior. DATA COLLECTION/EXTRACTION METHODS:We used social media advertisements to recruit Appalachians of reproductive age who were assigned female at birth (N = 622). After exploring the frequency of upward coercion (pressure to use contraception) and downward coercion (pressure not to use contraception), we ran chi-square and logistic regression analyses to explore the relationships between contraceptive coercion and preferred contraceptive use. PRINCIPAL FINDINGS:Approximately one in four (23%, n = 143) participants reported that they were not using their preferred contraceptive method. More than one-third of participants (37.0%, n = 230) reported ever experiencing coercion in their contraceptive care, with 15.8% reporting downward coercion and 29.6% reporting upward coercion. Chi-square tests indicated that downward (χ2 (1) = 23.337, p < 0.001) and upward coercion (χ2 (1) = 24.481, p < 0.001) were both associated with a decreased likelihood of using the preferred contraceptive method. These relationships remained significant when controlling for sociodemographic factors in a logistic regression model (downward coercion: Marginal effect = -0.169, p = 0.001; upward coercion: Marginal effect = -0.121, p = 0.002). CONCLUSIONS:This study utilized novel person-centered measures to investigate contraceptive coercion in the Appalachian region. Findings highlight the negative impact of contraceptive coercion on patients' reproductive autonomy. Promoting contraceptive access, in Appalachia and beyond, requires comprehensive and unbiased contraceptive care.

The reproductive autonomy of persons who can give birth can be impeded through forms of interpersonal violence and coercion. Moreover, macro-level factors (e.g., poverty, discrimination, community violence, legislative policies) may impede the reproductive autonomy of entire communities. This study investigates a form of violence we term perceived contraceptive pressure in Appalachia, an understudied region of the Eastern U.S., regarding reproductive health and decision-making. Through targeted Meta advertising, participants ( N = 632) residing in Appalachian zip codes completed an online survey on reproductive health. The focus of this study was to investigate the prevalence of perceived contraceptive pressure, who was at increased risk of experiencing pressure, and the source(s) of perceived pressure. Binomial regressions were conducted on three different dependent variables: perceived pressure to be sterilized, perceived pressure to use birth control, and perceived pressure not to use birth control. Approximately half of all respondents (49.5%) reported experiencing at least one type of pressure targeting contraceptive decision-making. The most prevalent source of perceived pressure to use birth control was from the healthcare provider (67.4%), and the most prevalent source of perceived pressure not to use birth control was the respondent’s partner (51.1%). Recommendations for providers serving clients in the Appalachian region include pursuing education regarding contraceptive pressure at the individual level and macro-level. In addition, Appalachian residents may benefit from educational programming on reproductive autonomy, healthy relationships, and how to navigate pressure in relationships.

Introduction: African immigrants are a vulnerable population who are seldom seen in the literature, however, the scant research available reports that they experience increased challenges when making family planning decisions. A robust understanding of their specific family planning practices is imperative to providing appropriate, culturally congruent care. Considering this disparity, a scoping review was conducted to synthesize empirical knowledge and identify gaps in the literature around family planning in African immigrant populations in the United States. Methods: Guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) framework, EMBASE, Global Health Database, PsycINFO, CINAHL, and PubMed were searched for literature regarding family planning topics such as decision-making and health care access among African immigrant women in the United States in June 2020. Results: The small number of retrieved studies for the literature review clearly highlights a dearth of research. Available evidence indicates stark disparities in health care access, unmet individual needs, and unacknowledged preferences. Discussion: Ignoring cultural considerations for the growing African immigrant population perpetuates the divide in family planning practices.

Background. In 2015, Tennessee enacted a law requiring a 48-hour wait and two clinic visits to obtain an abortion. Methods. Using data from a Tennessee clinic in 2016, we explore whether abortion seekers from the most economically disadvantaged ZIP codes and those who lived farther from the clinic were less likely to return for the abortion procedure at the second visit. Results. Rates of non-return were 44%- 91% higher among residents of neighborhoods in which _25% of the population was below federal poverty level, >_25% of the female population was below federal poverty level, and median annual household income was <$35,000. Mean clinic distance was also consistently greater among those who did not return. Conclusions. Residents of the most economically disadvantaged ZIP codes may be disproportionately burdened by Tennessee's waiting period law, rendering them less able to return for the abortion procedure than residents of less economically disadvantaged ZIP codes. Furthermore, greater clinic distance may also impede access under this law.

The objective of this article is to describe a secondary data analysis of the 2008 Abortion Patient Survey (APS 2008) data exploring the association between intimate partner violence (IPV) and travel distances in a national sample of patients seeking abortion services in the United States. The researchers used the 2008 APS, which is the most recent publicly available version of this dataset, to conduct chi-square tests to examine the bivariate associations between all independent and dependent variables. Prevalence ratios were calculated to determine the association between physical and sexual violence and distance traveled to get an abortion, controlling for length of pregnancy, age, education, income, poverty category, race, relationship status, insurance type, whether women went to the closest clinic, whether the pregnancy was wanted, and number of previous abortions. Results indicate that approximately 83% of the women traveled between 1 and 50 miles, 11% traveled between 51 and 100 miles, 4% traveled between 101 and 150 miles, and 3% traveled more than 151 miles to get an abortion. Prevalence ratios (PR) reveal that physical violence was significantly associated with distance traveled to get an abortion (PR = 1.15, p < .05) when all control variables were accounted for. Patients in abusive relationships that involve physical violence may have to travel longer distances to access abortion. Repeal of policy that impedes access to abortion is recommended.

Abstract Background Opioid use among reproductive-age women has greatly increased, resulting in high rates of opioid-exposed pregnancies, which are associated with negative outcomes, such as neonatal abstinence syndrome. Prevention of unintended pregnancy among opioid users is a critical pathway to reducing opioid-exposed pregnancies; however, little is known about pregnancy intention in this group. This article estimates the prevalence of unintended pregnancy among opioid-using women, thereby supporting efforts to develop interventions to reduce unintended pregnancy. Methods A systematic literature search was conducted in PubMed, Web of Science, PsycINFO, and CINAHL, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses framework. Reference lists of articles were searched. Eligibility criteria included reported unintended pregnancy rates within a population of opioid-using women of reproductive age. The search was completed in July 2018 and updated in October 2019. Results We identified 115 citations, screened 64 titles/abstracts, reviewed 31 full-text articles, and included 12 articles for this review. Rates of unintended pregnancy in opioid users were estimated in two ways, across the lifetime and for a current pregnancy, depending on study samples. Rates for both groups were high, with rates among currently pregnant opioid-using women (85%) compared with 45% among the general population. Conclusions and Implications Unintended pregnancy rates in opioid-using women were strikingly high, indicating a critical need for intervention. Routine inclusion of pregnancy planning in opioid treatment care is indicated. Education regarding contraception and opioid treatment services is essential for nurses in these settings. Family planning and opioid treatment efforts can be optimized by care coordination, with focus on nurse training for screening and patient education.

Limited research has utilized public abortion narratives to understand how individuals process through their abortion experiences. To address this gap in the literature, this study used thematic analysis to consider the public abortion stories of 39 participants from the Tennessee Stories Project, focusing on how individuals process through these experiences and the context of the abortion experience in a person’s life course. Participants were primarily those who were abortion patients; however, abortion providers and supporters including partners or spouses, family members, and friends of those who received abortion care were also represented. Data analysis indicated that abortion seekers engage in introspection, involving political and religious/spiritual considerations; report specific feelings about their abortion experience, including having no regrets and feeling gratitude; process emotions related to the abortion experience by normalizing emotional responses and using mementos; and position their abortion in the context of their life, both in terms of their family and career opportunities and personal development. These findings provide valuable insight into how individuals process through the abortion experience, before, during, and after the abortion procedure, and suggest possible directions for service providers, advocates, and policy makers in order to better support abortion patients, providers, and family members.

(Abstracted from Contraception 2021;104:265–270) Reproductive coercion is a collection of behaviors intended to maintain power and control in a relationship, typically perpetuated by an intimate partner by interfering with autonomous reproductive decision making. Pregnancy coercion is a form of reproductive coercion wherein threats and pressuring behaviors are exhibited to promote pregnancy.

PURPOSE:From 2009 to 2019, more than 175,000 refugees were admitted into the United States from African countries. What is known about sexual and reproductive health in this population is focused on perinatal outcomes; beliefs and attitudes towards family planning and related behaviors, which can impact perinatal health, have not been explored. Understanding these beliefs and attitudes can guide future work with this population.STUDY DESIGN:A cross-sectional, convenience survey of 100 community-dwelling African refugee women was conducted.RESULTS:The following research questions guided analysis: What are African refugee women's family planning attitudes (pregnancy intention, desired timing, perceived fecundity)? What are African refugee women's family planning behaviors (use vs. non-use of methods, type of methods used)? and What socio-demographic factors and family planning attitudes are related to family panning behaviors (use or non-use of methods)? Almost 49% of participants reported ever using a method of family planning and 35% reported current use. Reasons for non-use included desire for more children (28.8%), infrequent intercourse (22.0%), and fear of side effects (16.9%). Nearly two thirds expressed a desire for a future pregnancy (63.4%), but the majority reported wanting to become pregnant in two or more years (25.7%) or "when God wants" (24.8%). No significant relationship was found between family planning method use and future pregnancy intention, desired timing of future pregnancy, perceived fecundity, marital status, religious affiliation, number of years in the US. Having had any formal schooling decreased the likelihood of using a family planning method.IMPLICATIONS FOR PRACTICE AND RESEARCH:Low family planning method use rates among African refugee women are not completely explained by desires for future pregnancy, perceived fecundity, marital status, or other sociodemographic factors. Concern for future fertility and fear of side effects were identified as potentially modifiable reasons appropriate for community based culturally congruent educational interventions on family planning use.

Reproductive justice is an intersectional social movement, theory, and praxis well aligned with social work's mission and values. Yet, advancing reproductive justice-the right to have children, to not have children, to parent with safety and dignity, and to sexual and bodily autonomy-has not been a signature area of scholarship and practice for the field. This article argues that it is critical for social work to advance reproductive justice to truly achieve the grand challenge of closing the health gap. The article starts by discussing the history and tenets of reproductive justice and how it overlaps with social work ethics. The authors then highlight some of the ways by which social workers have been disruptors of and complicit in the oppression of individuals, families, and communities with regard to their reproductive rights and outcomes. The article concludes with a call to action and recommendations for social work to foreground reproductive justice in research, practice, and education efforts by centering marginalized voices while reimagining the field's pursuit of health equity.

A trauma-informed, thematic analysis that identified stress-related themes evident in 39 personal abortion narratives from the Tennessee Stories Project in the United States is presented in this paper. Using the Braun and Clarke model of thematic analysis, guided by the trauma-informed social work framework, researchers examined these narratives to identify stress related themes. Findings An overall theme of stress and traumatic stress was found to be present throughout the abortion narratives. These themes were categorized into subthemes, including: (a) existing life stressors preceding the abortion experience, (b) stressors while trying to access abortion services, (c) stressors while obtaining abortion services, and (d) stressors arising after the procedure. Applications These results suggest that stress and traumatic stress were reflected in these abortion narratives throughout the abortion seeking experience. This finding supports the need for social work practice responses that are designed to address and eliminate stress during the process of seeking and obtaining an abortion in the United States. A trauma-informed framework is recommended for guiding social work education about abortion, social worker interactions with clients who are seeking abortions, and the development of abortion policy in the United States in order to better align the abortion seeking experience with the principles of trauma-informed care.

Women who use opiates and are involved in the criminal justice system in Appalachia may be prone to adverse health outcomes. In this study, we performed a latent class analysis of risk and protective factors on 400 drug-using women recruited from rural, Appalachian jails. A two-profile solution best fit the data. Both profiles evinced low levels of condom use, reproductive and physical health screens, and STD history. However, the primary substantive difference between the profiles was partner risk behavior: the higher risk class had main male partners with histories of injection drug use and incarceration. Results suggest that interventions need to be tailored to unique profiles of risk and protective factors, which should include taking partner risk into consideration.

This study describes a secondary data analysis of contraceptive use across the lifetime and within the six months prior to incarceration in a sample of 400 currently incarcerated women recruited from rural, Appalachian jails, who were using drugs prior to incarceration. Phase 1 (baseline) data from an NIH funded study were used to examine rates of contraceptive use, reasons for nonuse of condoms, and correlates of condom use. Results indicate that the majority (96.5%) of respondents reported lifetime use of contraceptives, and most (70.5%) had a history of using multiple methods, with male condoms, oral contraceptive pills, and contraceptive injections being the most commonly used methods. Almost 69% of respondents reported nonuse of contraceptives within the last six months, despite high rates of involvement in risky, intimate male partnerships prior to incarceration. Contraceptive use was found to be historically acceptable in this sample, in stark contrast to rates of use within the last six months prior to incarceration, suggesting that reproductive justice-informed, social work interventions to help improve current contraceptive use are warranted as a harm-reduction approach.