Pregnancy and family planning choices of birthing people in the Parent and Child assistance Program (PCAP)

Abstract

Little research exists surrounding vulnerable birthing people and their relationships with planning and preventing pregnancy. This study aims to better describe services and barriers that impact family planning choices, including housing, primary care provider accessibility, and insurance access among participants in the Parent Child Assistance Program (PCAP). Participant data was derived from 59 participants enrolled in PCAP, a case management program for birthing people who use substances. Amongst the participants who were recently pregnant, 7/59 (12%) were using birth control around the time of conception of that pregnancy. Of the participants who were not recently pregnant, 53% of clients were using birth control upon intake. This figure rises incrementally by 24 months. Data showed that those with health insurance are almost twice as likely to be using contraceptives at intake. The low prevalence of birth control use even after a recent pregnancy suggests significant barriers still exist in terms of education and access to family planning resources for birthing people. This indicates the need for targeted interventions and supports that empower birthing people to make decisions about their reproductive health.

Background

The World Health Organization (WHO) defines family planning as "the ability of individuals and couples to attain their desired number of children and the space and timing of their births" [1]. Contraceptive use is a key method in achieving family planning. In Canada, 79.9% of women (aged 15–49) who want to avoid pregnancy report using contraception within the past year [2]. Non-use or misuse of contraceptives contributes to unintended pregnancies resulting in greater reliance on social supports and reduced quality of life for both parent and children [3–5]. Family planning may also enhance autonomy and promote overall wellness [3].

McCartin et al. [6] suggested that birthing people with substance use disorders (SUDs) have lower contraceptive use, likely contributing to higher unintended pregnancy rates. Charron et al. [7] also found this population is more likely to experience unintended pregnancies and adverse prenatal and perinatal outcomes.

Evidence shows that SUDs impair interpersonal capabilities, potentially hindering parent–child attachment and negatively affecting the child's relational development [8]. The complex interplay of substance use, trauma, and poverty increases the risk of social and health-related problems for both the birthing person and baby, especially when substance use continues during pregnancy [9, 10].

Birthing people who use substances face numerous systemic barriers to preventing unintended or substance-exposed pregnancies. These include limited access to primary care, lack of insurance for prescription drug coverage, missing identification (e.g., Medicare Cards), and unstable housing [11]. Many lack a consistent primary care provider, disrupting continuity of care, knowledge of contraceptive options, and understanding of substance use impacts during pregnancy [7]. Moreover, fear of stigma or prior negative healthcare experiences may lead some to avoid the healthcare system altogether, further reducing contraceptive uptake [7].

In the U.S., low-income birthing people are seven times more likely to face barriers in acquiring prescription medications due to lack of medical insurance [12]. Nearns [13] found higher uptake of prescription contraceptives among those with private insurance or Medicaid. In Canada, the oral contraceptive pill can cost up to $300 annually without insurance, while a hormonal intrauterine device (IUD) typically costs $350–500 [14]. Birthing people living in poverty may not have the purchasing power to prioritize contraception, leading to reduced use [15–17]. Nethery et al. [17] found that cost, inconsistent care, and lack of education on contraception options may reduce access to effective long-term contraceptives, like the IUD. Programs that reduce financial barriers have been shown to increase contraceptive use and reduce unintended pregnancy rates [15]. Unstable housing, stigma in healthcare, and logistical challenges further reduce contraceptive access among vulnerable groups, including homeless youth and women [18–20].

The federal government allocates additional healthcare funding through the Canada Health Transfer (CHT). To receive full CHT payments, provinces must comply with The Canada Health Act’s principles [38]. Recently, New Brunswick’s CHT payments were reduced due to regulations requiring out of pocket payment for medical abortions outside of hospitals, violating the Act by charging for services typically covered by Medicare [21].

Medicare is Canada’s public healthcare system, granting access to hospital visits, primary care, physician services, and diagnostics with a Medicare card [22]. However, it excludes most prescription drugs, dental, and vision care [23]. These are often covered by purchasing additional private insurance through employers or paid out of pocket [22]. Many low wage, part-time, or casual workers lack private coverage. Those on social assistance or with no income may have prescription costs covered by provincial plans, such as New Brunswick’s “white card” [22].

Neonatal abstinence syndrome (NAS) refers to withdrawal symptoms in newborns exposed to substances in utero. Rates of NAS have sharply increased in Canada, particularly in New Brunswick, where substance use in pregnancy remains a serious concern [24, 39].

In response to the rise of NAS cases, New Brunswick Social Pediatrics launched the Parent–Child Assistance Program (PCAP) in 2018 to support birthing people who used substances during their pregnancy. Originally piloted in Washington State in the early 1990 s with positive results, PCAP has since been implemented at numerous sites across the U.S. and Canada with comparable success. This 3-year, in-home case management program has significantly improved outcomes in areas such as substance use management, stable housing, child guardianship, prevention of subsequent substance exposed births, and increased use of family planning [37]. PCAP advocates work one-on-one with clients to understand and support their goals around family planning and other life areas, coordinating care and connecting them with appropriate resources [36].

The present study

Understanding the pregnancy and family planning experiences of this population, specifically the barriers they face, is essential. Interventions targeting high risk birthing people with babies and young children can benefit both parent and child across multiple domains beyond health. [25]. This study aims to descriptively analyze pregnancy and family planning among substance-using birthing people enrolled in the PCAP program. We will also report on barriers to access and their status over time. Hypothesized barriers include limited access to primary care providers, unstable housing, lack of an NB Medicare card, and no insurance. We expect increased use of family planning methods and improvement in healthcare access, insurance coverage, and housing stability at 24 months compared to intake.

Methods

Study population

This study employed a repeat cross-sectional design where we examined 59 voluntarily consented PCAP registry participants that were enrolled in the PCAP program from 2018–2022 in Saint John, New Brunswick. Participants have either been referred to PCAP by community health providers and social service agencies or have self-referred to the program. To refer a potential participant, the referral source called the PCAP office and completed the Community Referral Screening Questionnaire (CRSQ) form or completed it online on the website. All participants have had their referrals reviewed to make sure they meet all the inclusion criteria. The inclusion criteria for PCAP are noted below:

• Pregnant or up to twenty-four months postpartum. (The updated PCAP program inclusion criteria extended to up to 5 years postpartum, if space is available.)

• Self-report of alcohol or drug use, including opioid replacement therapy, during the index pregnancy.

• Ineffectively engaged with community service providers.

• The potential participant must be 19 years of age or older. (The updated inclusion criteria is 16 years of age or older.)

• Provide Voluntarily Informed Consent to be part of the registry.

Study procedure

If the potential participant’s eligibility was confirmed through the CRSQ form, the Clinical Supervisor scheduled the intake interview meeting. During this meeting the PCAP advocate explained the PCAP program, obtained voluntary research consent and conducted the intake interview using the Addiction Severity Index (UW-ASI) tool. Every six months the PCAP advocate completed biannual forms that captured the client’ progress across various domains (e.g. substance use, treatment use, child custody, legal involvement, service connection, housing situation, birth control use, and employment and income). Data were extrapolated from the PCAP primary intake tool, an adapted version of the University of Washington Addiction Severity Index (UW-ASI), and the Biannual Documentation of Client Progress Form.

Addiction Severity Index (ASI) edition 5

The 5th Edition of the Addiction Severity Index (ASI) is a standardized tool developed in 1992, with accepted validity and reliability, designed to provide important information about aspects of a participant’s life which may contribute to their substance use [26, 27]. In 1997, the ASI was adapted by the Parent Child Assistance Program of Seattle, Washington, for use with pregnant and postpartum women by including questions on childhood experiences, substance use during pregnancy, or use of local services [28]. This updated ASI, referred to as the UW-ASI, is the version used in this study. The semi-structured interview is divided into several sections. These sections assess various psychosocial domains, but for the purposes of the current investigation we focussed on the following sections: General Information, Family/Social Relationships, Family Planning & Other Children and Community Services. Each of these categories were scaled from 0 (no issue) to 3(urgent need for support) to assess the level of need or urgency for addressing a problem or issue. Variables of interest included age, family planning method (if applicable), adherence to method, participant’s current pregnancy status, current housing situation, healthcare provider accessibility, family planning service accessibility, valid New Brunswick Medicare card and private insurance. This assessment is completed at intake into the program. An author developed the Housing stability index from interview responses. A copy of these measures is available upon request from the contact author.

Biannual documentation of progress form

The biannual documentation of Client Progress is a briefer assessment of the factors assessed in the ASI. The information was documented by the PCAP advocates and was based on the advocate’s knowledge of their client’s situation. The biannual is completed every six (6) months throughout the three years, beginning at 6 months in the program. The purpose of the biannual is to provide a status update on the client’s substance use, treatment use, child custody, legal involvement, service connection, housing situation, birth control use, and employment and income. This process was taken from the Washington PCAP procedure manual and adapted for our local use by the study team [37].

Data analysis

Demographic variables from the UW-ASI interview at intake and from the Biannual Assessment form at 24 months were analyzed. Frequencies and percentages were calculated for all variables of interest. Varying degrees of missing data were observed throughout the variables, only valid percentages were reported.

Results

Data from 59 voluntarily consented PCAP registry participants enrolled in the PCAP program from 2018–2022 in Saint John, New Brunswick were analyzed. The mean age at intake was 27 years old (SD = 6.25). Over half of all participants (61.0%) reported lack of access to health insurance and 89.8% of participants reported having a valid Medicare card.

Around the time of conception for this most recent pregnancy, seven (11.9% or 7 out of 59) participants were regularly using birth control (Table 1). Upon intake to PCAP, 40.7% of participants were pregnant (and therefore excluded). Of those who were not pregnant, 53.1% were regularly using contraception, and 46.9% were not regularly using contraceptives at intake (Table 1). At 24 months (post intake) 18 out of 30 non pregnant participants (60%) reported using birth control regularly (Table 1). Depo Provera initially was the most used form of contraception at intake (28%) among the women who were not pregnant at the time but at 24 months post intake, the IUD was tied as the method of contraception most used (20%) (Table 1).

Table 1.

PCAP clients use of birth control (N = 59

Contraceptive use	At time of conception	Intake	24 months
	% (n)	% (n)	% (n)
Regular use	11.9 (7)	53.1 (17)	60.0 (18)
Oral Contraceptive	42.9 (3)	9.4 (3)	3.3 (1)
Depo Provera Shots	28.6 (2)	28.1 (9)	20.0 (6)
IUD	28.6 (2)	3.1 (1)	20.0 (6)
Tubal ligation	0 (0)	12.5 (4)	16.7 (5)
No regular use	88.1 (52)	46.9 (15)	40.0 (12)

Contraception data at intake and 24 months excludes women who were pregnant, abstinent, or whose information was unknown

During intake, 33 of the 59 (55.9%) participants reported stable housing and at 24 months 25 out of the 38 participants (65.8%) reported stable housing (Table 2). Access to a regular healthcare provider or family planning service is reported to decrease during time spent in the program (Table 2).

Table 2.

Social determinants of health (N = 59)

Domain	Intake	24 months
	% (n)	% (n)
Housing Stability
Stable	55.9 (33)	65.8 (25)
Precarious	28.8 (17)	18.4 (7)
Unstable	15.3 (9)	15.8 (6)
Access to Healthcare Provider
Yes	83.1 (49)	70.0 (28)
No	16.9 (10)	30.0 (12)
Access to Family Planning Service
Yes	40.7 (24)	29.4 (10)
No	59.3 (35)	70.6 (24)

Various patterns were noted when contraception-use is examined by client access to health insurance (Table 3). Among those with private medical insurance at intake 4 out of 13 (30.8%) did not regularly use any contraception. Among those without private insurance at intake, 11 out of 19 (57.9%) did not regularly use any contraception (Table 3). At intake, 1 out of 13 (7.7%) participants with private medical insurance reported use of an IUD (Table 3). Among those without private insurance at intake, 0 out of 19 (0%) report use of an IUD (Table 3). Of clients that chose to use IUD’s as their contraceptive choice at 24 months, 3 out of 11 (27.3%) participants had private insurance and 3 out of 19 (15.8%) reported not having private insurance (Table 3). Additionally, use of oral contraceptives is only reported in clients without private medical insurance at 24 months (5.3%) (Table 3).

Table 3.

Contraceptive use based on presence of private medical insurance

Contraception use	Private medical insurance		No private medical insurance
	Intake	24 months	Intake	24 months
	% (n)	% (n)	% (n)	% (n)
Regular use	69.2 (9)	45.5 (5)	42.1 (8)	68.4 (13)
Oral Contraceptive	15.4 (2)	0 (0)	5.2 (1)	5.3 (1)
Depo Provera Shots	38.5 (5)	9.1 (1)	21.1 (4)	26.3 (5)
IUD	7.7 (1)	27.3 (3)	0 (0)	15.8 (3)
Tubal ligation	7.7 (1)	9.1 (1)	15.8 (3)	21.1 (4)
No regular use	30.8 (4)	54.5 (6)	57.9 (11)	31.6 (6)

Contraception data for intake and 24 months excludes women who were pregnant, abstinent, or whose information was unknown. Barrier methods were not included as a form of contraception in Biannual Reports

At 24 months, for those with access to a healthcare provider, which is n = 24, 14 or 58.3% reported regular contraceptive use (Table 4). For those without access to a healthcare provider at 24 months, n = 2 or 33.3% report regular contraceptive use (Table 4).

Table 4.

Contraceptive use based on access to a healthcare provider

Contraceptive use	Healthcare provider		No Healthcare provider
	Intake	24 months	Intake	24 months
	% (n)	% (n)	% (n)	% (n)
Regular use	53.6 (15)	58.3 (14)	50.0 (2)	33.3 (2)
No regular use	46.4 (13)	41.7 (10)	50.0 (2)	66.7 (4)

Contraception data for intake and 24 months excludes women who were pregnant, abstinent, or whose information was unknown

At intake, 52.6% or 10 out of 19 participants who report stable housing, used contraceptives regularly (Table 5). At 24 months, 66.7% or 14 out of 21 clients with stable housing reported regular birth control use (Table 5). As for those who report precarious living at 24 months (n = 7), 5 or 71.4% report not regularly using birth control (Table 5).

Table 5.

Contraceptive use based on housing stability

Contraception use	Stable housing		Precarious housing		Unstable housing
	Intake	24 months	Intake	24 months	Intake	24 months
	% (n)	% (n)	% (n)	% (n)	% (n)	% (n)
Regular use	52.6 (10)	66.7 (14)	57.1 (4)	28.6 (2)	50.0 (3)	100 (1)
Oral Contraceptive	15.8 (3)	4.8 (1)	0 (0)	0 (0)	0 (0)	0 (0)
Depo Provera Shots	21.5 (4)	23.8 (5)	57.1 (4)	14.3 (1)	16.7 (1)	0 (0)
IUD	5.3 (1)	19.0 (4)	0 (0)	14.3 (1)	0 (0)	100 (1)
Tubal ligation	10.5 (2)	19.0 (4)	0 (0)	0 (0)	33.3 (2)	0 (0)
No regular use	47.4 (9)	33.3 (7)	42.9 (3)	71.4 (5)	50.0 (3)	0 (0)

Contraception data for intake and 24 months excludes women who were pregnant and abstinent, or whose information was unknown

Discussion

The ability to choose a preferred method of family planning remains central to patient autonomy. The ability to plan pregnancies contributes to better health and social outcomes for both the birth giver and the infant [1, 3, 5]. The WHO maintains that “family planning will have a direct impact on achieving the Sustainable Development Goal (SDG) themes of people, planet, prosperity, peace, and partnership” [29]. However, access to contraception remains a barrier to many, including individuals with substance use disorder [7, 11]. Prior research shows that birthing people with substance use disorders have higher rates of unintended pregnancies than the general population and face unique barriers when it comes to contraceptive use and choice [6, 7]. Additionally, neonate health challenges caused by substance use during pregnancy contribute to increased health cost expenditures, for example, increased length of stay in hospital and the treatment and diagnostic costs associated [24].

In the present study we explored a selection of proposed barriers to this demographic group. Our results raise concern that birthing people with substance use disorders encounter specific barriers when accessing and choosing contraception in keeping with past research. As most of the participants had a valid NB Medicare Card, this was not as much of a barrier as originally proposed. However, lack of private medical insurance, housing stability and access to a regular healthcare provider or family planning service may have impacted use of regular contraception and the choice in type of contraception.

Regular birth control use increases throughout time spent in the PCAP program rising from 53.1% at intake to 60.0% at 24 months, suggesting a positive shift in contraceptive behaviour among participants. However, the low prevalence of use even after 24 months (60.0%) in the program could suggest that significant barriers in terms of education and access to family planning resources remain to exist for people with substance use disorders. This indicates the need for diverse and targeted interventions and supports that empower women to make decisions about their reproductive health.

As discussed, those with limited financial resources may not have the capacity to divert money to regular contraceptive use [40]. Hulme et al. [30] found that cost was reported as the greatest barrier to regular contraception use and suggested that subsidized family contraception may be one way to make access more equitable. Initially, more participants with private medical insurance report regular contraceptive use which is in keeping with findings from previous studies [13, 15–17]. This could indicate that when the financial barrier of regular contraceptive use is removed, participants will use contraceptives more effectively. Interestingly, at 24 months in those without private insurance, there were higher rates of regular use than in those with private insurance. This may be reflective of qualifying participants being connected to the provincial drug plan as a result of time spent in PCAP. At intake, IUD use was only reported in one participant that had private medical insurance. This could suggest that contraceptive choice is more inclusive for those with private insurance. The NB Prescription Drug Program currently only covers specific types of contraceptive options which does not include an IUD. As an IUD involves a large upfront cost, often even for those with some type of medical insurance, it remains inaccessible to most despite it being one of the more effective contraceptives on the market [31].

Tubal ligation appeared to be a more popular contraceptive method in individuals without insurance. Given tubal ligation is covered under Medicare, this preference could reflect desire to avoid the ongoing financial responsibility for contraceptive options like oral contraceptives or injectable Depo-Provera. This is of note as it would mean that the most permanent contraceptive would be the most affordable financially. Although it may be the most accessible contraceptive option financially, there remains barriers to uptake including provider attitudes about tubal ligation in younger individuals, access to specialist care and lack of operating room time allocated to gynecological procedures in New Brunswick. This preference could also suggest lack of education on alternative long term contraceptive options such as IUD’s or the birth control implant.

Being able to make an informed choice about your health requires that an individual has access to all the relevant information and ideally a healthcare provider to engage in discussion not just about options and possible side effects but also about patient values. There was more reported use of methods, such as IUDs, and a decrease in reported use of methods such as oral contraceptives. This change could reflect improvements in contraceptive counselling surrounding other options. Depo Provera use is relatively unchanged from intake at the 24 months mark which may represent a comfort/familiarity aspect to this particular contraceptive option.

Housing stability increased at similar increments to regular contraceptive use. This could be because time spent in the program helped address other needs in the client’s life allowing them to better prioritize contraception. PCAP has been shown not only to improve client contraceptive use but also improve access to services which includes housing programs and initiatives [37].

Unfortunately, reported access to a primary care provider (PCP) decreased as time went on. This is likely because once the client has given birth, they no longer have consistent access to a PCP through PCAP. Although the child is matched with a PCP even after clients have completed PCAP, there remains a gap in regard to care for the birthing individual once they have delivered.

Additionally, data were gathered during the COVID-19 pandemic when the healthcare system experienced significant pressures which may have exacerbated GP wait times and caused delays in access to care [32].

Study limitations and future directions for research and policy

This study has potential limitations. One of which includes a small sample size which can be attributed to data collection taking place in the early years following PCAP’s initiation. This limited the data analysis that could be performed as it would have lacked statistical power. This study also relies on self-reported data which although having many advantages, patient recall may be subject to bias. Additionally, because of the nature of how data was collected, there were unknown data values which may have underestimated true values for specific data points examined. This can be attributed to several factors including the fact that attrition is a known problem in research with continued assessment, impacts of the COVID-19 pandemic and the transient nature of the population studied often results in loss to follow-up and, therefore, missing data.

Future directions include inferential statistics on contraceptive use and its barriers as the number of PCAP participants increases the longer the program is available in Saint John. A follow up study to explore rates of regular contraceptive use some time after completion of the PCAP program could be beneficial to see if the same barriers once again play into contraceptive choice or if graduated participants face new and different challenges regarding contraception use. Qualitative research based on data collected during focus groups with enrolled PCAP participants could also explore attitudes towards contraceptive options, the barriers we proposed during our present study and any additional barriers individuals may have experienced. As family planning encompasses planned pregnancy or desire for such, a qualitative study could also give further insight into those not using contraceptives for this purpose. Research has been done on primary provider attitudes towards birthing people with low socioeconomic status and how stigma plays into care. Future studies may want to engage in a similar exploration within an Atlantic Canada or broader context.

British Columbia recently became the first province or territory in Canada to provide free contraception for residents in the hopes of eliminating financial barriers for those who wish to obtain contraception [33]. The AccessBC Campaign was founded in 2017 to help achieve this goal through advocacy and research. Comparable countries such as the United Kingdom, the Netherlands and France have publicly funded access to contraception and other medical prescriptions, while this remains a barrier for a large percentage of Canadians [34]. The campaign argues that the implementation would promote better health outcomes through reducing unintended pregnancy, promote equality and autonomy and save taxpayer dollars in the long run [34]. Recently, in 2024, the Government of Canada passed a bill, Bill C-64, in collaboration with Canada’s provinces and territories, to support universal access to contraceptives [35]. Conversations on how this will be tangibly implemented remain ongoing [35].

Conclusion

This study adds to the growing research emphasizing the importance of reproductive choice. Access to, and engagement in family planning services and birth control is a complex issue in birthing people that use substances. PCAP helps participants begin to address some of the possible barriers to family planning and works with each client individually to better understand their needs, perceptions and goals thus allowing for prioritization of the client’s autonomy regarding family planning.

Abbreviations

ASI

Addiction Severity Index

CHT

Canada Health Transfer

CRSQ

Community Referral Screening Questionnaire

IUD

Intrauterine devices

NAS

Neonatal abstinence syndrome

NB

New Brunswick

PCAP

Parent Child Assistance Program

PCP

Primary Care Provider

REB

Research Ethics Board

SUDs

Substance Use Disorders

SDG

Sustainable Development Goal

WHO

World Health Organization

Authors’ contributions

AN and SG devised the project and main conceptual ideas. AN, NF, KF, SC, DC and SL analyzed and interpreted the results. AN was a major contributor in writing the manuscript. All authors participated in manuscript feedback and edits. All authors read and approved the final manuscript.

Funding

Funding was received through the Dalhousie University Research in Medicine Summer Studentship as part of their Research in Medicine (RIM) Program.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due possible compromise of individual privacy but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study received approval by the institutional Research Ethics Board (REB) at the Horizon Health Network. Reference Number: RE: ROMEO File #: 10133 Event # 27946.

RS #: 2018–2657. Informed consent was obtained from all 59 PCAP participants in the present study.

The Human Research Protection Program (HRPP), which includes the Horizon Research Ethics Board, through which our research was approved is accredited by Human Research Accreditation Canada, which is based on international and national standards for human research.

It is the responsibility of the Principal Investigator that this study is conducted in accordance with the Declaration of Helsinki and in compliance with the International Conference on Harmonization Good Clinical Practice. In addition, the study was conducted to according to the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans – TCPS 2.

The Principal Investigator will ensure that all staff members assisting with the study are adequately qualified and informed about the study procedures.

Consent for publication

Not applicable (N/A).

Competing interests

The authors declare no competing interests.