Table 3. Adjusted Prevalence Odds Ratios of NAS Delivery, Contraceptive Methods, and Pregnancy Intendedness in Delaware, 2012-201828

Notes: Adjusted prevalence odds ratios (aPOR) with 95% confidence intervals (CI). Models adjusted for maternal age, education, marital status, parity, race and ethnicity, and Medicaid status.

NAS = neonatal abstinence syndrome; International Classification of Diseases – Ninth Revision Clinical Modification (ICD-9-CM) diagnosis of 779.5 and ICD-10-CM diagnosis of P96.1

Using statewide linked PRAMS, birth certificate, and hospital discharge data, our study aimed to assess differences between women who delivered an NAS-affected infant (i.e., a proxy for opioid use) versus those who did not for postpartum contraceptive use and pregnancy intentions in Delaware. Our study found no association between delivery of an NAS-affected infant and use of an effective postpartum contraceptive method. Cornford et al., found lower use of planned contraception in a U.K. cohort of women with OUD.12 Similarly, Krans et al., study of Pennsylvania’s Medicaid enrolled women found that women with OUD were less likely to use highly effective postpartum contraception.13 Heil et al. found that in the experimental group, all women in the OUD treatment program who received free prescription contraceptives, and “financial incentives” initiated prescription contraceptive use following delivery, when compared to the control group who received usual care (i.e., free condoms, received emergency contraception, referral to providers) although such strategies may be coercive.14,30,31

During our 2012-2018 study period, Delaware saw a significant increase in use of long-acting reversible contraceptives in Title X and Medicaid populations.32,33 A statewide data brief indicated that there was 107% increase in reversible contraceptive methods during 2012-2018, and a 17% percent increase in the percent of Delaware women indicating their pregnancy was intended.34 Although our study did not find statistically significant differences in effective postpartum contraceptive use among women with an NAS-affected and non-NAS delivery, the low prevalence of effective postpartum contraceptive methods for both groups suggest that sustained and continued statewide efforts that are non-coercive and culturally appropriate may be needed to increase access to effective methods of contraceptives.

With regard to pregnancy intention, our study found that Delaware women with delivery of an NAS-affected infant had lower odds of indicating that their pregnancy was “intended” as compared to women without an NAS-affected delivery even after we account for maternal characteristics. Our study findings are consistent with Heil et al.’s study who also found that unintended pregnancy was highly prevalent (nine of every 10 women screened) and intended pregnancies were low among women with OUD.15 Unintended pregnancy is associated with increased risk for postpartum depression and lower levels of perceived support,35 and OUD treatment is lower among women who reported unintended pregnancies.36 Women with OUD who already contend with several life stressors, may benefit from treatment for opioid use disorder, increased access to preconception and interconception resources including reproductive health planning.

Limitations

Despite the strength of linked administrative data and PRAMS survey data, the cross-sectional nature of our study limits our ability to draw causal inferences. PRAMS data are based on selfreport and may be subject to recall bias, although this may have been minimized for contraceptive use in our analysis because we focused on contraceptive use at the time the PRAMS survey was completed in the postpartum period (typically 2-6 months after delivery). Our contraceptive estimates did not account for women who were trying to get pregnant and were not sexually active. Identification of NAS was based on administrative data such as HDD and may be prone to coding errors.6 In addition, not all neonates chronically exposed to opioids develop NAS postdelivery.5 Even though PRAMS is a probability-based representative sample from birth certificate generalizable to all Delaware women with a recent live birth, low numbers of total NAS cases during 2012-2018 (n = 169), limited our ability to conduct sub-group analyses to examine effect modification. Linked datasets such as ours from other states may provide a sufficient sample size to allow discernment of how a delivery of an NAS-affected infant (i.e., proxy for opioid use disorder) may be associated with contraceptive use and choices, and pregnancy intentions. Lastly, our dataset was limited as we did not have information on NAS due to appropriate use of prescription opioids, misuse of opioids, or MOUD.

Using representative statewide data, we assessed whether an NAS delivery was associated with effective postpartum contraceptive methods, and pregnancy intendedness. Although we did not find an association among women who delivered an NAS-affected infant and effective postpartum contraceptive method, our data suggests that intended pregnancies were lower in women who delivered an NAS-affected infant as compared with those without a delivery of an NAS-affected infant even after accounting for maternal characteristics. The importance of reproductive counseling to women affected by opioid use disorder has been well-established. However, there is limited research on postpartum contraceptive use and pregnancy intentions in women with and without a NAS delivery. Our findings suggest an opportunity to improve outreach efforts in this population during preconception and interconception periods to develop a reproductive life-plan, counsel women on effective postpartum contraceptive use methods, and increase their access to effective contraceptive methods. Strategies to prevent the incidence of NAS deliveries through CDC’s opioid prescribing guidelines37 and access to preconception and family planning services, pregnancy intention screening, improving access to reproductive counseling and a full-range of contraceptive methods that include long-acting reversible contraception (e.g., intrauterine devices, and implants) may help reduce this disparity in unintended pregnancy. Dr. Hussaini may be contacted at Khaleel.hussaini@delaware.gov

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2 Jansson, L. M., & Velez, M. L. (2019 August). Optimal care for NAS: Are we moving in the wrong Direction? Hospital Pediatrics, 9(8), 655–658 https://doi.org/10.1542/hpeds.2019-0119

3 Jansson, L. M., & Velez, M. (2012, April). Neonatal abstinence syndrome. Current Opinion in Pediatrics, 24(2), 252–258. https://doi.org/10.1097/MOP.0b013e32834fdc3a

4. Kocherlakota, P. (2014 August). Neonatal abstinence syndrome. Pediatrics, 134(2), e547–e561. https://doi.org/10.1542/peds.2013-3524

5. McQueen, K., & Murphy-Oikonen, J. (2016, December 22). Neonatal abstinence syndrome. The New England Journal of Medicine, 375(25), 2468–2479 https://doi.org/10.1056/NEJMra1600879

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32 Boudreaux, M. Choi, Y. S., Xie, L., & Marthey, D. (2019, June). Medicaid expansion at Title X clinics: Client volume, payer mix, and contraceptive method type. Medical Care, 57(6), 437–443.

33 Weiti, K., & Manlove, J. (2021). Estimated reductions in unintended pregnancy among Delaware Title X family planning clients after a contraceptive access intervention. Child Trends.

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37 Frieden, T. R., & Houry, D. (2016, April 21). Reducing the Risks of Relief—The CDC Opioid-Prescribing Guideline. The New England Journal of Medicine, 374(16), 1501–1504 https://doi.org/10.1056/NEJMp1515917