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. Author manuscript; available in PMC: 2023 Mar 11.
Published in final edited form as: Subst Use Misuse. 2022 Mar 11;57(6):999–1006. doi: 10.1080/10826084.2022.2046100

Miscarriage and Abortion among Women Attending Harm Reduction Services in Philadelphia: Correlations with Individual, Interpersonal, and Structural Factors

Joy D Scheidell a, Janna Ataiants b, Stephen E Lankenau b
PMCID: PMC9101319  NIHMSID: NIHMS1799751  PMID: 35277115

Abstract

Background:

Reproductive health research among women who use drugs has focused on pregnancy prevention and perinatal/neonatal outcomes, but there have been few investigations of miscarriage and abortion, including prevalence and associated factors.

Methods:

Using cross-sectional data from a sample of non-pregnant women receiving harm reduction services in Philadelphia in 2016–2017 we examined lifetime miscarriage and abortion (n=187). Separately for both outcomes, we used modified Poisson regression to estimate prevalence ratios (PR) and 95% confidence intervals (CI) for associations with each correlate. We also explored correlates of reporting both miscarriage and abortion.

Results:

Approximately 47% experienced miscarriage, 42% experienced abortion, and 17% experienced both. Miscarriage correlates included: prescription opioid misuse (e.g., OxyContin PR 1.82, 95% CI 1.23, 2.69); 40% increase in prevalence associated with housing instability, 50% increase with survival sex, and two-fold increase with arrest. Abortion correlates included: mental health (e.g., depression PR 2.09, 95% CI 1.18, 3.71), stimulant use (e.g., methamphetamine PR 1.83, 95% CI 1.22, 2.74), and drug injection (PR 1.76, 95% CI 1.03, 3.02); partner controlling access to people/possessions, physical and emotional violence; and a two-fold increase associated with survival sex and arrest. Experiencing both reproductive outcomes was correlated with mental health, opioid and simulant use, housing instability, survival sex, and arrest.

Conclusion:

Miscarriage and abortion was common among women with history of drug misuse suggesting a need for expanded access to family planning, medication-assisted therapy, and social support services, and for the integration of these with substance use services. Future research in longitudinal data is needed.

Keywords: Reproductive health, miscarriage, abortion, women, drug use

Introduction

Women who use drugs are at elevated risk of poor sexual and reproductive health, and have a high prevalence of sexual risk behaviors, and subsequently, high rates of sexually transmitted infections (STIs; Benotsch et al., 2011; Cheng et al., 2016; Edelman et al., 2014; Flom et al., 2001; Jessell et al., 2017; MacAfee et al., 2020; Marchand et al., 2012; Mateu-Gelabert et al., 2015; Meade et al., 2014; Tross et al., 2009). STIs are a risk factor for adverse reproductive outcomes including miscarriage, defined as spontaneous loss of a pregnancy (Baud et al., 2011; Baud et al., 2008; Bunyavejchevin et al., 2003; Centers for Disease Control and Prevention, 2018; Dugas & Slane, 2021; Giakoumelou et al., 2016; Westrom, 1980). Moreover, sexual risk behaviors may lead to unintended pregnancy (Reardon et al., 2004), a risk factor for abortion, which is often defined as induced termination of a pregnancy (Dugas & Slane, 2021; Finer & Zolna, 2011). However, most research among women who use drugs has focused on HIV/HCV, contraception use, and neonatal outcomes (Collier et al., 2019; El-Bassel & Strathdee, 2015; Heil et al., 2019; Rey et al., 2020; Sinha et al., 2007; Smith et al., 2019; Sweeney et al., 2000), and there has been little examination of other reproductive outcomes in this population (Edelman et al., 2014; MacAfee et al., 2020).

The few studies assessing miscarriage and abortion among women who use drugs indicate that approximately half have experienced at least one of these events (Dasgupta et al., 2018; Edelman et al., 2014). Most research has examined substance use as a driver of miscarriage or abortion (Lind et al., 2017; Martino et al., 2006; Roberts et al., 2012; Yazdy et al., 2015), although limited evidence suggests that there may be other contributors among women who use drugs (Dasgupta et al., 2018). There is a high prevalence of individual- (e.g., mental health, polysubstance use; Committee on Obstetric Practice, 2017), interpersonal- (e.g., partner violence, social support; Lawson et al., 2013; Office of Women’s Health, 2017), and structural-level (e.g., incarceration, housing; Office of Women’s Health, 2017), factors among women who use drugs, which may be associated with miscarriage and abortion. It is important to examine a broad range of factors that may be linked to these reproductive outcomes to identify potential intervention targets.

Guided by a social ecological framework (McLeroy et al., 1988), we aimed to fill gaps in the literature by assessing the prevalence of lifetime miscarriage and abortion and exploring individual-, interpersonal-, and structural-level factors that may be associated with these pregnancy outcomes in a sample of women who attend harm reduction services and use drugs.

Materials and Methods

We conducted a secondary analysis of data collected as part of a mixed methods study among women receiving harm reduction services in Philadelphia, Pennsylvania, in 2016–2017. Briefly, the parent study enrolled 220 adult, non-pregnant women with a history of illicit drug use who participated in interviewer-administered surveys (Ataiants, Mazzella, et al., 2020; Ataiants et al., 2021; Ataiants, Roth, et al., 2020). The parent study procedures were approved by the Drexel University Institutional Review Board; for secondary analysis of de-identified data, NYU Grossman School of Medicine does not require review.

Participants reported if they had ever been pregnant, and if so, whether they had ever had a miscarriage, an abortion, both, or neither. The study outcomes are miscarriage only, abortion only, and both, while the referent group for all was never experiencing miscarriage and abortion. We sought to examine miscarriage and abortion as separate outcomes considering that the factors driving their risk likely differ, and even potentially shared correlates such as socioeconomic factors may have different mechanisms of effect (Alves & Rapp, 2021; Steinauer & Patil, 2021).

Individual-Level factors were: age categorized into quartiles; race/ethnicity; employment; sexual orientation; education level; marital status; self-reported lifetime diagnoses (e.g., PTSD, bipolar, hypertension); past 12-month methadone and buprenorphine; attendance at a syringe exchange program (SEP); lifetime injection drug and opioid use; past 30-day use of opioids (e.g., heroin, fentanyl, prescription misuse), benzodiazepine, stimulants, and hallucinogens; and number of lifetime overdoses.

Interpersonal-level factors included partner violence in the past 12 months (e.g., stalking, control, physical, or emotional abuse).

Structural-level factors included: housing instability, engagement in survival sex categorized as never, lifetime, past 12 months, and past 30 days, and history of criminal justice involvement.

Of the 220 women in the sample, one was missing response data for history of pregnancy; among the 199 women who had ever been pregnant, 6% were missing response data for pregnancy outcomes and were not included in analyses. Most covariates were not missing data, with exceptions of age (0.5%), employment (1.5%), marital status (1%), and sexual orientation (7.5%); the larger percentage for sexual orientation was due to coding those who reported “prefer not to say” (1.5%) along with actual non-response (6.0%) as missing. Respondents with missing data were excluded from analyses of that covariate.

Analyses were conducted in Stata 15. We estimated the frequency and prevalence of lifetime pregnancy in the total sample of women (N=220), and of reproductive outcomes among those who had been pregnant with non-missing data (N=187). Among those who had been pregnant, we estimated bivariate associations between each of the factors and the outcomes of miscarriage, abortion, and both using Chi-square tests. We used modified Poisson regression with robust variance estimation to calculate prevalence ratios (PR) and 95% confidence intervals (CI) for associations between each factor and the outcomes (Barros & Hirakata, 2003; Zou, 2004). Because our analyses aimed to explore correlations between the factors and outcomes, we did not estimate adjusted associations.

Results

Prevalence of Reproductive Outcomes.

Of the 220 women in the sample, the average age was 36 years, the majority were white (64%), and 90% had ever been pregnant. Of those who had been pregnant (N=187), almost half (47.1%) reported a miscarriage and 42% had ever had an abortion; 18% had experienced both.

Correlates of Miscarriage.

Women who were married reported a higher prevalence of miscarriage compared to single women (Table 1). Women who reported using any opioids in the past 30 days had a higher prevalence of miscarriage, and apart from Valium misuse, no other substances were correlated. Women who had 4 or more overdoses had a higher prevalence of miscarriage compared to those who never had an overdose. None of the interpersonal factors were correlated with miscarriage (Table 2). Structural-level correlates included housing instability, survival sex in the past 30 days, and history of arrest.

Table 1.

Bivariate Associations between Individual-Level Correlates and Miscarriage and Abortion among Women with a History of Pregnancy Accessing Harm Reduction Services in Philadelphia, Pennsylvania 2016–2017 (n=187)

Factors N (%)a with History of Miscarriageb PR (95% CI) for Association with Miscarriage N (%)a with History of Abortionc PR (95% CI) for Association with Abortion N (%)a with History of Bothc PR (95% CI) for Association with Bothd
Individual-Level Factors
Demographics
Age
    20–30 Years 16 (37.2) Ref 15 (34.9) Ref 5 (22.7) Ref
    31–36 Years 22 (48.9) 1.31 (0.80, 2.15) 17 (37.8) 1.08 (0.62, 1.89) 7 (35.0) 1.54 (0.58, 4.10)
    37–45 Years 28 (54.9) 1.48 (0.93, 2.34) 30 (58.8) 1.69 (1.05, 2.70) 18 (62.1) 2.73 (1.20, 6.24)
    46 Years or Older 21 (44.7) 1.20 (0.72, 1.99) 15 (31.9) 0.91 (0.51, 1.64) 6 (26.1) 1.15 (0.41, 3.24)
Race
    White 51 (44.7) Ref 55 (48.2) Ref 23 (42.6) Ref
    Black 19 (47.5) 1.06 (0.72, 1.56) 13 (32.5) 0.67 (0.41, 1.10) 10 (35.7) 0.84 (0.46, 1.51)
    Hispanic 10 (55.6) 1.24 (0.78, 1.97) 5 (27.8) 0.58 (0.27, 1.24) 2 (28.6) 0.67 (0.20, 2.27)
    Other 8 (53.3) 1.19 (0.71, 2.00) 5 (33.3) 0.69 (0.33, 1.45) 2 (33.3) 0.78 (0.24, 2.54)
Employment Status N/A
    Unemployed 84 (46.7) Ref 74 (41.1) Ref 36 (38.3)
    Employed 3 (50.0) 1.07 (0.47, 2.43) 3 (50.0) 1.22 (0.53, 2.76) 0 (0.0)
Sexual Orientation
    Straight 61 (45.9) Ref 60 (45.1) Ref 24 (40.0) Ref
    Gay/Bisexual 25 (50.0) 1.09 (0.78, 1.52) 17 (34.0) 0.75 (0.49, 1.16) 12 (37.5) 0.94 (0.54, 1.62)
Highest Education Level
    Less than High School 25 (45.4) Ref 18 (32.7) Ref 8 (28.6) Ref
    High School/GED 37 (46.8) 1.03 (0.71, 1.50) 37 (46.8) 1.43 (0.92, 2.24) 19 (44.2) 1.55 (0.78, 3.05)
    Beyond High School 26 (49.1) 1.08 (0.72, 1.61) 23 (43.4) 1.32 (0.81, 2.16) 10 (41.7) 1.46 (0.68, 3.11)
Marital Status
    Single (Never Married) 53 (41.7) Ref 52 (40.9) Ref 23 (33.8) Ref
    Married 9 (69.2) 1.66 (1.09, 2.52) 7 (53.8) 1.32 (0.76, 2.27) 5 (71.4) 2.11 (1.18, 3.76)
    Divorced/Separated/Widowed 26 (55.3) 1.32 (0.95, 1.84) 19 (40.4) 0.99 (0.66, 1.48) 9 (45.0) 1.33 (0.74, 2.40)
Health Conditions
Ever Diagnosed with PTSD
    No 49 (43.8) Ref 41 (36.6) Ref 18 (31.0) Ref
    Yes 39 (52.0) 1.19 (0.88, 1.61) 37 (49.3) 1.35 (0.96, 1.88) 19 (51.4) 1.65 (1.00, 2.72)
Ever Diagnosed with Bipolar
    No 42 (46.2) Ref 37 (40.7) Ref 19 (38.0) Ref
    Yes 46 (47.9) 1.04 (0.76, 1.41) 41 (42.7) 1.05 (0.75, 1.48) 18 (40.0) 1.05 (0.53, 1.75)
Ever Diagnosed with Depression
    No 19 (43.2) Ref 10 (22.7) Ref 6 (22.2) Ref
    Yes 69 (48.2) 1.12 (0.76, 1.63) 68 (47.6) 2.09 (1.18, 3.71) 31 (45.6) 2.05 (0.96, 4.37)
Ever Diagnosed with Anxiety
    No 29 (50.0) Ref 17 (29.3) Ref 12 (33.3) Ref
    Yes 59 (45.7) 0.91 (0.66, 1.26) 61 (47.3) 1.61 (1.04, 2.51) 25 (42.4) 1.27 (0.73, 2.21)
Ever Diagnosed with Asthma
    No 59 (44.7) Ref 56 (42.4) Ref 27 (38.0) Ref
    Yes 29 (52.7) 1.18 (0.86, 1.62) 22 (40.0) 0.94 (0.64, 1.38) 10 (41.7) 1.10 (0.62, 1.92)
Ever Diagnosed with Chronic Bronchitis
    No 79 (46.2) Ref 73 (42.7) Ref 33 (38.8) Ref
    Yes 9 (56.2) 1.22 (0.77, 1.93) 5 (31.2) 0.73 (0.35, 1.55) 4 (40.0) 1.03 (0.46, 2.31)
Ever Diagnosed with Diabetes
    No 77 (45.6) Ref 72 (42.6) Ref 32 (38.1) Ref
    Yes 11 (61.1) 1.34 (0.89, 2.01) 6 (33.3) 0.78 (0.39, 1.54) 5 (45.4) 1.19 (0.59, 2.42)
Ever Diagnosed with Hypertension
    No 65 (46.8) Ref 59 (42.4) Ref 26 (38.8) Ref
    Yes 23 (47.9) 1.02 (0.72, 1.45) 19 (39.6) 0.93 (0.62, 1.39) 11 (39.3) 1.01 (0.58, 1.76)
Ever Diagnosed with HCV
    No 47 (49.0) Ref 34 (35.4) Ref 18 (35.3) Ref
    Yes 41 (45.0) 0.92 (0.68, 1.25) 44 (48.4) 1.36 (0.97, 1.93) 19 (43.2) 1.22 (0.74, 2.03)
Substance Use and Treatment
Methadone Treatment in Past 12 Months
    No 65 (48.2) Ref 52 (38.5) Ref 28 (37.8) Ref
    Yes 23 (44.3) 0.92 (0.64, 1.31) 26 (50.0) 1.30 (0.92, 1.84) 9 (42.9) 1.13 (0.64, 2.02)
Suboxone Treatment in Past 12 Months
    No 68 (46.0) Ref 63 (42.6) Ref 31 (39.2) Ref
    Yes 20 (51.3) 1.12 (0.78, 1.59) 15 (38.5) 0.90 (0.58, 1.40) 6 (37.5) 0.96 (0.48, 1.91)
Attended SEP in Past 12 Months
    No 31 (46.3) Ref 20 (29.8) Ref 12 (30.0) Ref
    Yes 57 (47.5) 1.03 (0.74, 1.41) 58 (48.3) 1.62 (1.07, 2.44) 25 (45.4) 1.52 (0.87, 2.64)
Ever Injected Drugs
    No 20 (47.6) Ref 11 (26.2) Ref 7 (28.0) Ref
    Yes 68 (46.9) 0.98 (0.68, 1.41) 67 (46.2) 1.76 (1.03, 3.02) 30 (42.9) 1.53 (0.77, 3.04)
Ever Used Opioids
    No 9 (40.9) Ref 5 (22.7) Ref 2 (16.7) Ref
    Yes 79 (47.8) 1.17 (0.69, 1.98) 73 (44.2) 1.95 (0.88, 4.30) 35 (42.2) 2.53 (0.69, 9.25)
Opioid Use in Past 30 Days
    No 17 (36.2) Ref 12 (25.5) Ref 3 (12.5) Ref
    Yes 71 (50.7) 1.40 (0.93, 2.12) 66 (47.1) 1.85 (1.10, 3.11) 34 (47.9) 3.83 (1.28, 11.41)
Heroin Used in Past 30 Days
    No 24 (43.6) Ref 17 (30.9) Ref 7 (25.0) Ref
    Yes 64 (48.5) 1.11 (0.78, 1.58) 61 (46.2) 1.50 (0.96, 2.31) 30 (44.8) 1.79 (0.89, 3.60)
Hydrocodone Used in Past 30 Days
    No 84 (46.2) Ref 76 (41.8) Ref 36 (38.3) Ref
    Yes 4 (80.0) 1.73 (1.09, 2.76) 2 (40.0) 0.96 (0.32, 2.85) 1 (100.0) 2.61 (2.02, 3.38)
Fentanyl Used in Past 30 Days
    No 71 (44.6) Ref 56 (35.2) Ref 25 (30.5) Ref
    Yes 17 (60.7) 1.36 (0.96, 1.92) 22 (78.6) 2.23 (1.67, 2.97) 12 (92.3) 3.03 (2.10, 4.36)
OxyContin Used in Past 30 Days
    No 83 (45.9) Ref 74 (40.9) Ref 34 (37.0) Ref
    Yes 5 (83.3) 1.82 (1.23, 2.69) 4 (66.7) 1.63 (0.90, 2.95) 3 (100.0) 2.70 (2.07, 3.54)
Percocet Used in Past 30 Days
    No 76 (44.7) Ref 68 (40.0) Ref 29 (34.5) Ref
    Yes 12 (70.6) 1.58 (1.11, 2.24) 10 (58.8) 1.47 (0.95, 2.28) 8 (72.7) 2.11 (1.32, 3.37)
Cocaine Used in Past 30 Days
    No 44 (41.2) Ref 42 (39.2) Ref 17 (30.9) Ref
    Yes 44 (55.0) 1.34 (0.99, 1.81) 36 (45.0) 1.15 (0.82, 1.61) 20 (50.0) 1.62 (0.98, 2.68)
Crack Used in Past 30 Days
    No 38 (44.7) Ref 36 (42.4) Ref 14 (35.9) Ref
    Yes 50 (49.0) 1.10 (0.80, 1.49) 42 (41.2) 0.97 (0.69, 1.37) 23 (41.1) 1.14 (0.68, 1.94)
Meth Used in Past 30 Days
    No 83 (47.2) Ref 70 (39.8) Ref 33 (37.1) Ref
    Yes 5 (45.4) 0.96 (0.49, 1.88) 8 (72.7) 1.83 (1.22, 2.74) 4 (66.7) 1.80 (0.96, 3.38)
PCP Used in Past 30 Days
    No 79 (48.2) Ref 62 (37.8) Ref 30 (36.1) Ref
    Yes 9 (39.1) 0.81 (0.48, 1.39) 16 (69.6) 1.84 (1.32, 2.57) 7 (58.3) 1.61 (0.92, 2.82)
Marijuana Used in Past 30 Days
    No 59 (47.6) Ref 50 (40.3) Ref 24 (38.1) Ref
    Yes 29 (46.0) 0.97 (0.70, 1.34) 28 (44.4) 1.10 (0.78, 1.56) 14 (40.6) 1.07 (0.63, 1.80)
Xanax Used in Past 30 Days
    No 53 (45.3) Ref 42 (35.9) Ref 18 (31.0) Ref
    Yes 35 (50.0) 1.10 (0.81, 1.50) 36 (51.4) 1.43 (1.03, 2.00) 19 (51.4) 1.65 (1.00, 2.72)
Klonopin Used in Past 30 Days
    No 71 (46.1) Ref 58 (37.7) Ref 26 (33.8) Ref
    Yes 17 (51.5) 1.12 (0.77, 1.62) 20 (60.6) 1.61 (1.14, 2.27) 11 (61.1) 1.81 (1.11, 2.94)
Valium Used in Past 30 Days
    No 80 (45.2) Ref 71 (40.1) Ref 32 (35.6) Ref
    Yes 8 (80.0) 1.77 (1.25, 2.51) 7 (70.0) 1.74 (1.12, 2.72) 5 (100.0) 2.81 (2.13 3.72)
Number of Lifetime Overdoses Experienced
    0 23 (39.0) Ref 13 (22.0) Ref 5 (15.2) Ref
    1 – 3 33 (45.8) 1.18 (0.78, 1.77) 41 (56.9) 2.58 (1.53, 4.35) 21 (52.5) 3.46 (1.46, 8.22)
    4 or More 32 (57.1) 1.46 (0.99, 2.17) 24 (42.9) 1.94 (1.10, 3.44) 11 (50.0) 3.30 (1.32, 8.23)
Open in a new tab
a

Percentages reported the prevalence of the reproductive outcome within each stratum of the covariate

b

N=88 women reported ever experiencing a miscarriage

c

N=78 women reported ever experiencing an abortion

d

N=37 women reported every experiencing both a miscarriage and an abortion

Table 2.

Bivariate Associations between Interpersonal- and Structural-Level Correlates and Miscarriage and Abortion among Women with a History of Pregnancy Accessing Harm Reduction Services in Philadelphia, Pennsylvania 2016–2017 (n=187)

Factors N (%)a with History of Miscarriageb PR (95% CI) for Association with Miscarriage N (%)a with History of Abortionc PR (95% CI) for Association with Abortion N (%)a with History of Bothc PR (95% CI) for Association with Bothd
Interpersonal-Level Factors
Intimate Partner Violence
Stalked by Partner Past 12 Months
    No 80 (48.2) Ref 67 (40.4) Ref 33 (38.8) Ref
    Yes 8 (38.1) 0.79 (0.45, 1.40) 11 (52.4) 1.30 (0.83, 2.03) 4 (40.0) 1.03 (0.46, 2.31)
Partner Controlled Contact with Others Past 12 Months
    No 72 (48.0) Ref 55 (36.7) Ref 26 (34.7) Ref
    Yes 16 (43.2) 0.90 (0.60, 1.35) 23 (62.2) 1.70 (1.22, 2.35) 11 (55.0) 1.59 (0.96, 2.63)
Partner Controlled Access to Possessions Past 12 Months
    No 78 (49.1) Ref 63 (39.6) Ref 30 (38.5) Ref
    Yes 10 (35.7) 0.73 (0.43, 1.23) 15 (53.6) 1.35 (0.91, 2.01) 7 (41.2) 1.07 (0.57, 2.02)
Partner Controlled Access to Phone Past 12 Months
    No 77 (49.4) Ref 60 (38.5) Ref 30 (38.0) Ref
    Yes 11 (35.5) 0.72 (0.44, 1.19) 18 (58.1) 1.51 (1.05, 2.16) 7 (43.8) 1.15 (0.62, 2.16)
Partner Physical Abuse Past 12 Months
    No 65 (47.0) Ref 53 (38.4) Ref 25 (35.7) Ref
    Yes 23 (46.9) 1.00 (0.70, 1.41) 25 (51.0) 1.33 (0.94, 1.88) 12 (48.0) 1.34 (0.80, 2.25)
Partner Threatened Physical Abuse Past 12 Months
    No 72 (47.1) Ref 62 (40.5) Ref 30 (38.0) Ref
    Yes 16 (47.1) 1.00 (0.67, 1.48) 16 (47.1) 1.16 (0.77, 1.74) 7 (43.8) 1.15 (0.62, 2.16)
Partner Emotional Abuse Past 12 Months
    No 68 (51.1) Ref 50 (37.6) Ref 27 (39.1) Ref
    Yes 20 (37.0) 0.72 (0.49, 1.07) 28 (51.8) 1.38 (0.98, 1.93) 10 (38.5) 0.98 (0.56, 1.74)
Partner Attempted to Force Sex Past 12 Months
    No 80 (47.3) Ref 69 (40.8) Ref 32 (38.1) Ref
    Yes 8 (44.4) 0.94 (0.55, 1.61) 9 (50.0) 1.22 (0.74, 2.01) 5 (45.4) 1.19 (0.59, 2.42)
Partner Coerced/Forced Sex Past 12 Months
    No 80 (47.6) Ref 70 (41.7) Ref 33 (39.3) Ref
    Yes 8 (42.1) 0.88 (0.51, 1.54) 8 (42.1) 1.01 (0.58, 1.77) 4 (36.4) 0.92 (0.40, 2.12)
Structural-Level Factors
Housing Instability
Living in the Streets Past 30 Days
    No 52 (41.6) Ref 50 (40.0) Ref 20 (31.8) Ref
    Yes 36 (58.1) 1.40 (1.04, 1.88) 28 (45.2) 1.13 (0.80, 1.60) 17 (53.1) 1.67 (1.02, 2.73)
Living in Abandoned Building Past 30 Days
    No 64 (43.5) Ref 62 (42.2) Ref 26 (35.6) Ref
    Yes 24 (60.0) 1.38 (1.01, 1.89) 16 (40.0) 0.95 (0.62, 1.45) 11 (50.0) 1.40 (0.83, 2.37)
Living Temporarily with Family/Friends Past 30 Days
    No 56 (40.9) Ref 56 (40.9) Ref 21 (31.3) Ref
    Yes 32 (64.0) 1.56 (1.17, 2.09) 22 (44.0) 1.08 (0.74, 1.56) 16 (57.1) 1.82 (1.13, 2.95)
Living in Shelter Past 30 Days
    No 81 (47.4) Ref 70 (40.9) Ref 35 (38.9) Ref
    Yes 4 (43.8) 0.92 (0.52, 1.65) 8 (50.0) 1.22 (0.72, 2.06) 2 (40.0) 1.03 (0.34, 3.12)
Living in Motel Past 30 Days
    No 82 (46.6) Ref 74 (42.0) Ref 35 (38.9) Ref
    Yes 6 (54.6) 1.17 (0.67, 2.06) 4 (36.4) 0.86 (0.39, 1.93) 2 (40.0) 1.03 (0.34 3.12)
Trauma
Engaged in Survival Sex
    Never 17 (37.0) Ref 11 (23.9) Ref 4 (15.4) Ref
    In Lifetime 12 (38.7) 1.05 (0.58, 1.88) 11 (35.5) 1.48 (0.73, 3.00) 5 (27.8) 1.80 (0.56, 5.85)
    In the Past 12 Months 14 (48.3) 1.31 (0.76, 2.23) 15 (51.7) 2.16 (1.16, 4.04) 6 (50.0) 3.25 (1.11, 9.47)
    In the Past 30 Days 45 (55.6) 1.50 (0.98, 2.30) 41 (50.6) 2.12 (1.21, 3.70) 22 (56.4) 3.67 (1.42, 9.46)
Criminal Justice Involvement
Ever Arrested
    No 11 (29.0) Ref 9 (23.7) Ref 3 (12.5) Ref
    Yes 77 (51.7) 1.78 (1.06, 3.01) 69 (46.3) 1.96 (1.08, 3.56) 34 (47.9) 3.83 (1.28, 11.41)
Ever Incarcerated
    No 19 (38.0) Ref 15 (30.0) Ref 4 (16.7) Ref
    Yes 69 (50.4) 1.32 (0.90, 1.96) 63 (46.0) 1.53 (0.96, 2.43) 33 (46.5) 2.79 (1.10, 7.09)
Open in a new tab
a

Percentages reported the prevalence of the reproductive outcome within each stratum of the covariate

b

N=88 women reported ever experiencing a miscarriage

c

N=78 women reported ever experiencing an abortion

d

N=37 women reported every experiencing both a miscarriage and an abortion

Correlates of Abortion

Except for being 37–45 years old, none of the demographics were correlated with abortion (Table 1). Abortion was correlated with PTSD, depression, anxiety, and HCV. Attending an SEP was also correlated. Women who reported lifetime injection and opioid use had a higher prevalence of abortion. Past 30-day use of any opioid and fentanyl were correlated with approximately twice the prevalence of abortion. Reporting methamphetamine and PCP use, and misuse of benzodiazepines was also correlated. Women who had an overdose had a higher prevalence of abortion. Interpersonal correlates of abortion included reporting a partner had controlled contact with others and access to a phone (Table 2). Structural factors correlated with abortion included engaging in survival sex in the past 12 months and 30 days, and history of arrest and incarceration (Table 2).

Correlates of Experiencing Both Miscarriage and Abortion

Women aged 37–45 years had an elevated prevalence of experiencing both outcomes (Table 1). Married women had a higher prevalence of both outcomes compared to those who were single. PTSD and depression were correlated with both outcomes. Past 30-day use of any opioids was associated with almost four times the prevalence of experiencing both outcomes, and misuse of hydrocodone, fentanyl, OxyContin, and Percocet were associated with between two to three times the prevalence. Methamphetamine, PCP, and misuse of benzodiazepines were correlated. Women who had experienced overdose had over three times the prevalence of both outcomes. Except for reporting that a partner controlled contact with others, none of the interpersonal factors were associated (Table 2.) Housing instability was correlated with reporting miscarriage and abortion, and survival sex and criminal justice involvement were associated with approximately three times the prevalence of reporting both reproductive outcomes.

Discussion

Among women receiving harm reduction services, most had been pregnant, and miscarriage and abortion were prevalent. There were overlapping and unique individual-, interpersonal-, and structural-level factors correlated with experiencing miscarriage, abortion, and both. Our findings highlight the need to reach women who use drugs with not only substance use services, but also reproductive health and social support services.

Our observed prevalence of reproductive outcomes corresponds to the few prior studies (Dasgupta et al., 2018; Edelman et al., 2014; MacAfee et al., 2020). We found that women who reported miscarriage also reported cocaine use and housing instability, whereas women who reported abortion also reported other health conditions, injection drug use, use of methamphetamine and hallucinogens, misuse of benzodiazepines, and partner violence. Shared correlates included opioid use, including misuse of prescription opioids, overdose, survival sex, and criminal justice involvement. Similar factors were associated with. experiencing both outcomes, though effect estimates were often stronger, underscoring the potential vulnerability of this group.

Our results support correlates identified in the few extant studies. For example, in a sample of women in methamphetamine treatment, use of other stimulants and mental health problems were associated with pregnancy loss, including abortion (Brecht & Herbeck, 2014), and in a sample of women under community supervision, partner violence was associated with miscarriage and abortion (Dasgupta et al., 2018). While we and others have highlighted that substance use is an important correlate of reproductive health, a range of factors are also associated with miscarriage and abortion, often times more strongly.

Our results are unadjusted cross-sectional correlations in which temporality and direction of associations cannot be ascertained. For example, the correlation between a partner controlling access to others and abortion could suggest that women also may lack control in preventing unintended pregnancy (Chibber et al., 2014). Yet it is possible that women may be at risk for abuse following abortion (Silverman et al., 2010). Moreover, drug use and overdose, mental disorders, and trauma co-occur, and may be exacerbated by other sociodemographic factors like race and poverty. There is the potential for intersecting and cyclical relationships among these factors and reproductive health among women who use drugs that are our bivariate analyses were not able to examine, and larger, longitudinal studies that can accommodate more complex analyses of these dynamics as drivers of reproductive health are needed. Other limitations include self-reported data subject to recall and social desirability bias, non-generalizability due to the small and geographically-restricted sample, exclusion of women who were missing pregnancy outcome data from analyses, and lack of details on the outcomes (e.g., gestational age at miscarriage, type of abortion, number of miscarriages and abortions experienced).

Our exploratory results suggest that offering additional services to women accessing harm reduction may be needed to improve health across domains, including reproductive health. Women who use drugs report a desire for integrated reproductive health services (Robinowitz et al., 2016; Terplan et al., 2016), and recent pilot studies, including one at the same harm reduction agency in our study, found it was feasible and acceptable to provide sexual and reproductive health services at harm reduction sites (Owens et al., 2020; Roth et al., 2021). Integrated substance use and sexual and reproductive health services may increase utilization in both domains among women who use drugs due to improved accessibility and non-stigmatizing care (Muncan et al., 2020).

In conclusion, our exploratory study identified a range of factors correlated with miscarriage and abortion, which are prevalent but understudied outcomes among women who use drugs. Future longitudinal research is needed to inform intervention and integrated service development as well as to determine how screening for these factors may identify women in particular need for reproductive health services.

Acknowledgements

This work was supported by the Behavioral Sciences Training in Drug Abuse Research (T32 DA7233).

Footnotes

Declaration of Interest

The authors report no conflict of interest.

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