“It’s not a top priority”: A qualitative analysis of provider views on barriers to reproductive healthcare provision for homeless women in the United States

Abstract

Women experiencing housing insecurity are at an elevated risk for adverse reproductive health outcomes due to the prevalence of chronic health conditions and higher risk behaviors. Social service and healthcare providers are front line in addressing women’s needs when they seek support. Thus, we sought to explore reproductive healthcare barriers using in-depth interviews with 17 providers at 11 facilities serving housing-insecure women in Salt Lake County, Utah, USA from April to July 2018. Providers noted a number of system-, provider-, and individual-level barriers. Dominant themes include reliance on unstable funding, lack of provider training on reproductive health, and perceived logistical challenges to care. Due to the prevalence of immediate needs among housing-insecure women, providers attest that reproductive health needs often do not emerge as their urgent concern. Our findings suggest that addressing policy and funding challenges to prioritizing reproductive needs among housing-insecure women can help mitigate the potential for long-term adverse reproductive outcomes.

Introduction

Homelessness—defined by the U.S. Department of Housing and Urban Development as the lack of fixed, regular, and adequate nighttime residence—is a complex social and economic problem. According to the National Housing Inventory Count (HIC) conducted in January 2018, an estimated 552,830 individuals were homeless on a single night in the U.S. (Henry M et al., 2018). Perhaps surprisingly, 39 percent of the nation’s homeless population is comprised of women or girls, and the number of homeless women is on the rise (Henry M et al., 2018). Homeless women have unique issues and needs when compared to homeless men. For example, domestic and sexual violence is the leading cause of homelessness for women and families (Jasinski JL et al., 2005; Zorza J.,1991) and homeless women are far more likely to experience various forms of violence compared with women who are not homeless, due to a lack of personal security while living outdoors or in shelters (Zlotnick C and Zerger, 2009). Domestic violence shelters report limited client information and likely underestimate the number of women and families seeking shelter as a result of domestic violence. Because the number of homeless women in the U.S. is growing, researchers and healthcare providers need more information and evidence-based approaches to better address this population’s unique health needs.

Given that treatment and preventive services can be difficult to secure while experiencing homelessness, homeless women have reduced access to medical care. Such barriers result in reliance on emergency medical services and homeless clinics for chronic disease management (ACOG, 2013). Further, the multitude of complications that can accompany homelessness—including inadequate income, mental health issues, substance use, and lack of insurance—may make accessing medical care a low priority for this population. (National Coalition on Homelessness, 2019) When it comes to sexual and reproductive health, the rate of unintended pregnancies is higher among homeless women compared to other women in the U.S. (Crawford DM et al., 2011; Saver BG et al., 2012). Additionally, these women are at high risk for unintended pregnancy at a time when chronic conditions may be poorly controlled. (Zlotnick C and Zerger, 2009). Homeless women also experience a higher number of adverse birth outcomes, including preterm delivery and low infant birth weights, even after adjustment for other risk factors such as maternal age, number of previous pregnancies, and smoking (Little M et al., 2005; Stein JA et al., 2000).

Unintended pregnancy may present a challenge for any woman, but an unintended pregnancy in a housing-insecure situation could be especially difficult. Women experiencing homelessness and/or housing instability face unpredictable access to basic shelter, food, safety; thus, having autonomy and resources to prevent an unintended pregnancy can positively impact individuals. Previous studies of sheltered housing-insecure women found that while they desired a future pregnancy (or expressed ambivalence toward becoming pregnant), none of the women desired a pregnancy while homeless (Kennedy S et al., 2014; Gelberg L et al., 2004). Complicating this dilemma is the fact that homeless healthcare clinics often have limited contraceptive methods available and may only be capable of offering barrier or short-acting methods, such as condoms or the birth control pill. Long-acting reversible contraceptives (LARC), such as intrauterine devices (IUD) and the contraceptive implant, are more effective and safer for many women with chronic conditions but are more expensive for both clinics and patients (Dasari M, et al., 2016). Additionally, the ethical history of LARC and sterilization should be considered in order to safeguard against coercive and unjust uses in the homeless population. (ACOG, 2017)

Despite current research on homeless women and reproductive health, there is still insufficient understanding of why reproductive healthcare continues to be limited for this population. In this study, we take a unique approach by focusing on the providers’ points of view regarding the family planning needs of homeless or housing-insecure women. This work expands on the current provider-specific literature by utilizing in-depth interviews with providers to discuss comprehensive reproductive care, including abortion services (Saver BG, et al 2012). Providers’ views are important because these individuals serve as gatekeepers and care coordinators when it comes to homeless women’s sexual and reproductive services. The views of providers can illustrate both the barriers they face in their work, as well as their understanding of the potential barriers facing homeless women. This study sought to understand provider perceptions of the varying processes that work to enhance and limit reproductive healthcare to homeless women.

Materials and Methods

Study population and recruitment.

We recruited healthcare and social service providers associated with eleven organizations serving women who reported housing insecurity or homelessness in Salt Lake County, UT, U. S. between April and July 2018. Participant affiliations at the time of the interviews included shelters, clinics, a refugee/immigrant center, and a Veterans Affairs (VA) health center. We employed snowball sampling (Biernacki and Waldorf 1981) in which initial contacts of the researchers helped find additional participants. Ultimately, we were able to capture providers and personnel with diverse levels of training and roles in their organizations. All participants provided verbal consent before the interview. We did not provide incentives for interview completion. The first author’s institutional review board approved the study.

Qualitative interview.

We developed an interview guide through input from reproductive health experts and healthcare providers in homeless organizations. We sought to capture participant demographic characteristics, descriptions of facilities, descriptions of the populations supported by facilities, provision of reproductive health services, and barriers to providing/accessing reproductive healthcare. Each interview utilized the interview guide with standardized questions (Appendix A), but followed a semi-structured flow (Lune and Berg 2017). Two people from the study team, including the first author, conducted all pre-scheduled interviews via telephone.

Data Management and Analysis.

The study team audio recorded all interviews, transcribed them verbatim and checked transcripts for accuracy. We uploaded the transcripts to Dedoose online qualitative software and employed thematic analyses in the coding process (Braun and Clarke, 2006). Two team members independently coded four transcripts during codebook development through constant content comparative analysis, resolving any discrepancies in the process. The primary coder then completed the remaining transcripts. We assigned all participants a pseudonym to protect confidentiality and provide anonymity.

Results

A total of 17 providers from 11 facilities participated in interviews. The majority of participants identified as white, non-Latinx women (Table 1). Most participants were social service providers (n=11) working at shelters, temporary housing, or a refugee center and included educators, social workers, case managers, and program coordinators. The remaining six participants worked at clinics, including a mobile clinic, hospitals, and the VA. Those involved in direct medical care included an obstetrician/gynecologist, advance practice clinicians, and registered nurses. Three of the medical providers had credentials to prescribe and administer comprehensive reproductive care, while the remaining three did not provide comprehensive reproductive care due to scope of practice (e.g. registered nurse). From the interviews, we discerned that participants identified barriers to meeting homeless women’s health needs at three levels: the system-, provider-, and individual- levels (see Figure 1). We discuss each of these levels (or domains) below.

Table 1.

Sociodemographic and professional characteristics of healthcare and social service providers in facilities serving homeless and housing-insecure women in Salt Lake County, UT, USA (N=17)

		n (%)
Gender*	Male	1 (6)
	Female	14 (82)
Race*	White Non-Latinx	11 (65)
	Latinx	3(18)
	Middle Eastern	1 (6)
Professional characteristics	Health Care Provider that can provide comprehensive contraceptive care	3 (18)
	Health Care Provider that cannot provide comprehensive contraceptive care	3 (18)
	Social Service Provider	11 (65)
Proportion of Providers reporting specific reproductive services offered at their facility	Pap smears	10 (59)
	STI screening/treatment	11 (65)
	Sexual trauma screening/assessments	8 (47)
	Contraceptive services	10 (59)
	Prenatal care	3 (6)

^*2 participants did not report their gender or race

Figure.

Schema of Barriers to Contraceptive Access in Women Facing Homelessness or Housing Instability

Domain 1. Health System Barriers.

System-level factors such as cost of services, reliance on federal funding and politics, and insurance all influence the capacity of staff to provide comprehensive reproductive healthcare services, including abortion care services, to homeless or housing-insecure women. Providers described how poverty and housing insecurity can result in women accessing care later in their pregnancy. The later gestation leads to increased cost and limited access to abortion services:

The farther along in gestation, the increase in difficulty. And then once you get to 13 weeks, that starts increasing by week, and that's just a matter of paying for skill level, paying for clinic time, [and] additional medications such as misoprostol, IV sedation.

[Jane, healthcare provider]

Another provider describes how cost impacts access to LARC contraceptive services:

I think one of our challenges as far as reproductive healthcare, [is] that if our patients are underinsured or they become uninsured in the course of the time we’re seeing them, we cannot provide them low cost contraception. Because if they’d like a long-term method we can get them the lowest cost of an IUD; however, the facility requires us to charge a rather large fee for placement service.

[Teresa, healthcare provider]

Unaffordable prices for reproductive services, such as contraception and abortion, could lead to women declining services, which could result in an undesired pregnancy.

Multiple providers noted that federal funding and federal tax exemptions improved access to services. However, relying on federal funding also fostered feelings of uncertainty. If their funding was reduced or cut due to politics, underserved populations (such as homeless women) would receive fewer services. Additionally, the majority of providers shared that, in their experience, funding for other kinds of health programs took priority over reproductive healthcare services. For example, one provider shared, “We just don't have the additional funding to just be like, ‘Oh, okay. You're homeless, but you need an abortion. We've got this covered.’ We just don't have that funding.” (Jane, healthcare provider)

The role of insurance in the healthcare system, and homeless women’s lack of insurance, also proved barriers. As one provider explained, “We don’t have any uninsured women because I’m not allowed to take care of them [due to clinic policies].” [Karen, healthcare provider] Another shared:

So, even as a provider, if you’re willing to take the time to see them for a full annual as well as place their IUD, you have to continue to explain, ‘I don’t know what happens with your insurance.’

[Teresa, healthcare provider]

As one provider described, this population often is uninsured and therefore they can have the perception that they are unable to receive care. Thus, they might avoid seeking care:

I feel like a lot of people don't have insurance, so they feel like they can't come to the doctor until its worst case scenario, or they don't have insurance so they don't get on birth control until they're pregnant, or think they're pregnant.

[Jane, healthcare provider]

Additionally, scheduling issues at individual clinics also impacted women’s ability to access reproductive services. Many clinics had limited hours, and other point of care establishments for homeless women or women with housing instability only offered services at particular times during specific days. As one provider exemplified, this fragmented schedule and clinic wait times could lead to women who require services falling through the cracks:

We're at the mercy of our doctors as far as clinical, surgical days. Anywhere from two and a half to three days, but they're split up based on our doctors' schedules. If a homeless person is saying, “I need some birth control,” you don’t say, “Okay, well, I can see you in two months.

[Jane, healthcare provider]

Overall, the structural setup of the healthcare system complicated providers’ ability to deliver comprehensive healthcare services to homeless women. As one provider stated:

The focus on healthcare as an industry rather than healthcare as a service is probably the biggest barrier. People are always looking at numbers.

[Diane, healthcare provider]

Domain 2. Provider Barriers.

In addition to systemic issues, interviews highlighted a number of provider-specific barriers as well, including: language and cultural barriers, lack of training, and provider bias/focus. For example, multiple providers described limited access to effective reproductive services because of barriers in language and/or communication:

Part of the reason why they also avoid going to the doctors [is] because they’re not going to understand what the doctor is telling them. The language sometimes that the doctors use, even if it will be in Spanish… a lot of the clients do not understand.

[Elaine, social service provider]

In another example, one provider discussed the difficulty navigating language and cultural barriers with some homeless clients:

I see fear in a lot of these women, just …“What do you mean? What is that?” Even trying to have to explain to a woman from Iraq the importance of having a pap smear and her eyes being the size of golf balls, like, “What the hell?” So, I think there is that fear factor, but I think there is also just, again, lack of [understanding].

[Laura, social service provider]

Providers’ issues navigating communication with a variety of clients sometimes proved to be a challenge in delivering care to homeless women who spoke languages or came from cultural backgrounds that were different from the medical staff.

In addition to language and cultural barriers, more general gaps in the training of some providers exacerbated issues between provider and clients. One participant described her concerns about whether providers who act as the first point of care for homeless women have sufficient training:

I don’t think there are enough providers serving women with housing instability…I know from first-hand that they’re not all trained. So, [a client] may be able to access [services] because now she has insurance coverage that will allow her to access [them]. But, I feel quite nervously confident that the person they may access initially [will not] meet their reproductive healthcare needs.

[Teresa, healthcare provider]

Providers’ approaches were also informed by their belief that reproductive healthcare was not necessarily a priority for homeless women and was secondary to women’s other immediate concerns. Providers commonly responded that housing stabilization should be the top priority, “My bias is that people need housing just to be able to then focus on other things as opposed to just if they don’t have a place to go or a safe place to be.” [Molly, social service provider] Another provider described how the attention of their work turned to a “housing first model” before focusing on other aspects of women’s needs, “We’ve been working a lot of housing first because if a client feels safe in a specific place, then they can be able to work and branch out, and work on the different aspects of their needs.” [Elaine, social service provider] Social service providers in particular shared that they only addressed reproductive healthcare if a client initiated the conversation.

Provider bias also further limited access to abortion services. With some providers, the decision to refer a patient for an abortion was determined by providers’ personal beliefs. As one provider recalled:

[I tell women] “It’s your decision, but I cannot help you with abortion because it’s against my religion.” But like I said, if she was forced, if she’d been raped, or she made a mistake or something, and her life is going to be in danger—because trust me, her life will be in danger if they [domestic violence perpetrator] find out. And so [with] that client I remember I did the referral.

[Savannah, social service provider]

Especially around the topic of abortion, some providers struggled to set personal biases and beliefs aside in order to support clients.

Domain 3. Patient-level Barriers.

Lastly, providers perceived a number of patient-level barriers to accessing reproductive healthcare, including: competing needs, transportation, domestic violence, distrust of the system. For example, many providers shared that they believed their clients did not view preventive medicine as a top priority due to the myriad issues facing them while homeless. One provider shared that her clients are often “trying to figure out their next meal or safety rather than [saying] ‘You know what, I should probably get a mammogram.’” (Molly, social service provider) Providers typically conceptualized women’s preventative healthcare as a less urgent need of homeless women. One provider exemplified this common view with a story about a patient:

One patient in mind comes back to me. She came into Planned Parenthood when she was 20 weeks pregnant and was assaulted when she was sleeping under an underpass but didn't realize she was pregnant until she was about 20 weeks along. Missing her period wasn't even a thought that occurred to her. She just figured it was from stress or not eating enough or not sleeping, things like that…when you're still trying to focus on [immediate concerns], missing a period doesn't really throw up a red flag necessarily.

[Maria, healthcare provider]

When asked where reproductive healthcare falls in terms of priority for homeless women, the majority of providers felt it was not a priority. As one provider stated, “To be sincere, I think it will be one of the last [priorities]. I don’t know. I feel like a lot of women focus on what is needed right now.” [Elaine, social service provider]

In addition to providers’ beliefs about women’s priorities, multiple providers also commented on how clients struggle with logistical issues—such as a lack of sufficient transportation. Many providers cited lack of adequate transportation as a major barrier. One provider exemplified this common view, stating:

“A lot of [homeless clients] sometimes have appointments, even regular appointments, and they want access to the medical system, but they don’t have a means to get to the hospital, for example. The [light rail] costs money. The bus costs money…and sometimes they don’t have money for that.”

[Paula, social service provider]

Besides transportation issues, other personal struggles—such as substance abuse, intimate partner violence, and distrust of institutions—could inhibit women’s ability to access services. Providers often commented how substance use took precedence over seeking reproductive healthcare. One provider illustrated this common perception by stating:

They are out on the street and addicted to heroin and also trying to get a motel room for the night so they have a place to sleep because they don’t want to be on the street where they could get raped. So they are working throughout the day doing whatever they do…Then they feel they don’t have any more time [in the day] to take care of any other needs, like going to a clinic.

[Steve, healthcare provider]

In addition to substance use, providers commented on how domestic violence affects their patients. For example, one provider stated how fear of seeing their perpetrators keeps women from seeking services at the local clinic for people experiencing homelessness, “They [victims of sexual violence] don't like to come here [community clinic for people experiencing homelessness], because the fear of running into their abuser down here.” (Alice, social service provider) Another provider described how a woman who recently left a violent relationship did not have the financial capabilities to seek out reproductive services, “[A] woman comes in who’s been under control of her husband her entire life and has never had a job and has never had a bank account, has never dealt with any of that kind of stuff.” [Laura, social service provider]

In addition to struggles with drugs or domestic violence, multiple providers commented on how homeless women or those facing housing instability may not seek out services because of a distrust in government and/or fear of healthcare systems. Often, patients are unwilling to undergo this engagement because of a past trauma or mistreatment within a system. One provider shared:

The health care system first of all is complex. It is difficult to navigate. These people have often been in really negative situations in systems—government systems, for example. Foster care system, a lot of them didn’t like that so they are done with that. …They’ve either been in jail or in prison, are being harassed by the police… They don’t like systems [and] these contraceptives, reproductive health is provided to them through a system and sometimes that’s a big turnoff…They feel like they’ve been violated by the system before so they are not very trusting.

[Steve, healthcare provider]

Discussion

This study explored how both social service and healthcare providers in facilities serving homeless and housing-insecure women in Salt Lake County, UT view the complex and interconnected barriers to reproductive healthcare provision. Participating providers identified three domains—structural-, provider-, and individual client-level—that serve as opportunities for interventions to address reproductive health disparities. We found organizations’ reliance on federal funding and the structure of health insurance serve as systemic factors that affect the provision of reproductive healthcare services. Simultaneously, provider issues such as language and cultural differences, a lack of appropriate training, and personal biases are potential barriers to care. Lastly, providers perceived that a woman’s ability to receive effective reproductive healthcare may be inhibited by competing needs, transportation issues, domestic violence and distrust in social institutions and organizations due to previous traumatic experiences (Figure 1). While care teams believe reproductive healthcare is often deprioritized due to more pressing issues, they acknowledge that a lack of comprehensive reproductive services can exacerbate housing destabilization, intimate partner violence, and negative financial, emotional, and physical outcomes for homeless or housing insecure women (Crawford DM et al., 2011; Saver BG et al., 2012; Little M et al., 2005; Stein JA et al., 2000).

This study has implications for both local and broader policies and practices. First, our findings highlight the structural vulnerabilities of clinics who serve homeless women. These clinics often have severe financial limitations, and thus, are somewhat constrained in the services they offer clients due to the requirements of federal funding and the ever-shifting political climate. Providing more comprehensive care would require additional financial resources that are more stable and/or that recognize the importance of reproductive health as preventative care. In addition, providers voiced a desire for additional training at all sites, which would mitigate some of the provider-level issues cited above. This training could include educating administrators and staff on the particular reproductive health needs of homeless women, initiating protocols assessing for sexual and reproductive health needs at intake, training clinicians on initiation and continuation of contraception, educating staff and strengthening referral links between clinics and agencies that provide services to homeless persons, and assisting sites in developing reproductive healthcare-specific outreach and follow-up programs as well as techniques to cope with specific hindrances to treating homeless patients. Specifically, strategies to support women facing intimate partner violence (IPV) is of particular importance to this population. The incorporation of family planning services into IPV programs should be a strategy to support women’s reproductive goals during this vulnerable time. Finally, while this study occurred prior to the onset of the COVID-19 pandemic, research has shown that the expansion of virtual reproductive services, including mail-order contraception and “no-touch” medication abortion protocols (Raymond EG et al., 2020), overcame many of the systemic-, provider-, and patient-level barriers expressed in this study and preparing resources for future situations is essential (Radanliev and De Roure, 2021). Unfortunately, while telehealth and mail-order options expand access and address lack of reproductive health education by providers in shelters and other settings, this is not a complete solution, as many reproductive health needs require in-person services.

Limitations

We evaluated homeless health care access points, including shelters and clinics from across the geographic catchment area, in an effort to provide a comprehensive picture of the perceived need experienced by homeless and housing insecure women in Salt Lake County, Utah. However, this sample was one of convenience and thus is not representative of the views of all providers in the county or state. It is also important to point out that we recognize the distinction between providers’ own perspectives and their descriptions of clients’ perspectives. We are mindful that expression from the provider does not necessarily reflect the true perspectives of the women they care for—a perspective that should be included in future research.

Conclusion

Barriers to comprehensive family planning services for women experiencing housing insecurity and homelessness are complex and interconnected, but opportunities exist to prioritize these essential needs and avert unwanted pregnancy during a time of upheaval. At a systemic level, devoting more attention and resources that are currently focused primarily on “housing first” to reproductive health services for housing insecure women could help reproductive outcomes. Further, providers of homeless services desire, and would benefit from, additional education and information around meeting housing insecure clients’ needs.Lastly, several additional strategies—such as the use of telehealth or mobile providers—may helpovercome the patient-level barriers to accessing care that we have highlighted here. In sum, fostering homeless women’s reproductive health and autonomy, as well as supporting the providers tasked with helping women meet their goals, will be essential to improving health outcomes for this growing group of women in the United States.