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Boosting contraception uptake among female substance misusers

A service aiming to increase contraception uptake among hard-to-reach female substance misusers is showing signs of success, writes Dr Bernadette Hard.

The aim is to empower women to choose the right time to become mothers (image: iStock)
The aim is to empower women to choose the right time to become mothers (image: iStock)

I am a GP specialist in addictions, working with Kaleidoscope Drug Project, a national charity that provides a broad range of addiction services.

Coming from a primary care background, it has always been my aim to provide holistic care for my clients. One area in particular which caught my interest,was reproductive health in female opiate-using clients.

Recurring theme

A recurring theme in my clients’ stories is that they have had their children removed from their care. As a mother myself, I can fully understand the level of trauma this must inflict, which, in many cases, fuels on-going drug use in an attempt to block out the pain.

Ironically, keeping their children is often the biggest motivating factor my clients have to stay away from drugs and move forward in their recovery.

As I came to know my client group better, I heard a familiar story: that they themselves had experienced shattered childhoods which, in part, led them to seek out drugs to deal with their emotional distress.

This led me to believe that, by empowering clients to make healthy choices about their use of contraception, and to delay conceiving while in the turmoil of active addition, I could help them to break the cycle.

In 2010, I carried out an audit in the Gwent area of Wales which revealed that only 36% of our female client group was using any form of contraception, with 19% using a long acting reversible method (LARC). This contrasts with around 75% of the general female population of childbearing age.

This low uptake of reliable contraception in this vulnerable client group has been echoed in other studies, and some of the reasons explored. Many women believe using drugs can prevent them from getting pregnant, particularly if their periods have stopped.

Some women are in controlling, abusive relationships that can hinder their decision-making around use of contraception. Many women simply have not got around to addressing their contraception, as they are caught up in the daily grind of survival.

If you are homeless and trying to support a drug habit costing £40 per day, attending the local family planning service or being on time for a booked GP appointment may not feature high on the list of priorities. Some studies also reveal that women find having to discuss their sexual history traumatic and shameful, particularly if they have been victims of abuse or work in the sex industry.

Some clients who have had difficult childhoods, and feel alone and isolated, project hope into a pregnancy, believing it will offer a way out of their current situation. All too often, if the addictive process is not addressed first, the outcome is not good for mother or baby.

Addressing access

All women should have easy access to impartial and informed contraceptive advice. It appears that, for many reasons, our client group makes poor use of existing services such as their own GP or sexual health clinic.

Because, in our service, all clients are seen regularly by a prescriber, it seems the ideal setting in which to offer contraceptive advice and also perhaps some increased access to reliable contraception. So in 2011, a service was launched offering this.

We have employed a ‘health promotion nurse’ who works alongside the prescribing clinics, consulting opportunistically with clients as they attend their medical review.

The safest and most effective methods of contraception available are choices from the LARC range. This includes Implanon, IUD/IUS and progesterone-only injections.

Clients can now access DMPA injections on site as well as condoms. In addition, we signpost to the local sexual health service for all types of sexual health support.

We are currently also running a pilot study offering screening for chlamydia and gonorrhoea infections.

Since the service started, rates of LARC uptake have increased from 19 per cent to 44 per cent, in a recent audit cycle, indicating encouraging findings that we are having an impact on uptake of LARC in this hard to reach group.

Funding stream

This service is not about stopping this group of women becoming mothers. Our mission is to empower women to choose the right time to become mothers, and to support them in recovery from active addiction.

A next step in expanding our service would be to offer the contraceptive implant Nexplanon within our clinic setting.

We have had to be very innovative in securing a funding stream to run this service.  One of the barriers we have faced is lack of flexibility. The authorities are keen to ensure that criteria for accessing various funding pots are strictly adhered to. So, for example, monies granted for substance misuse services should be spent only on that and not contraception and sexual health which isn’t in our core service specification.

Yet a year’s supply of DMPA for one client costs £20. If you compare the cost of that to the cost of an unplanned pregnancy and the child potentially going into care the difference would fund our service for life.

We have gained support from the local public health team at the Aneurin Bevan Health Board and Public Health Wales, both of which have supplied one off funding contributions that have allowed us to offer these services. It has been recognised that reducing rates of unintended pregnancy in vulnerable groups is a key public health priority, and Public Health Wales recognises the valuable work we are doing with this hard to reach client group.

My ultimate goal would be that contraception and sexual health services be made a core part of all tier-three prescribing provision in order that substance misusers’ general health needs are better addressed.

Key points:

  •  This client group is often very traumatised so you have to engage with them and take a non-judgmental approach. It takes time but trust can be built.
  • Be opportunistic. The key to reaching this client group is to be flexible and to reach out to them rather than set up a service and wait for them to arrive.
  •  Dr Bernadette Hard is a GP specialising in addiction at the Kaleidoscope Project in Gwent, Wales.


  • This initiative was shortlisted in the 2013 GP Enterprise Awards.

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