Exploring Contraceptive Decisions of Minority Women with Severe Mental Illnesses (SMI) Público

Abstract

Abstract

Background

Women represent two-thirds of the cases of serious mental illness (SMI). Women with SMI are at an increased risk for negative reproductive health outcomes, including unintended pregnancy, negative pregnancy outcomes, STIs, and having coerced or transactional sex. However, they are less likely to receive sexual and reproductive health services.

Objectives

There were two objectives of this study: 1) determine which contraceptive method women with SMI choose to use (if any) and 2) what factors contribute to the consistent and correct use of contraceptives of choice.

Methods

Twelve semi-structured interviews were conducted with women of reproductive age (18-44) with a self-reported SMI at an urban safety net outpatient clinic in Atlanta, GA. Individual interviews were recorded and transcribed verbatim with participant consent. Results were organized using the Gelberg-Andersen Model for Vulnerable Populations and the Intersectionality Framework.

Results

Only eight out of twelve women were sexually active at the time of the interview, although all had a history of sexual activity. Only half of the women in this study met the recommendation for an annual well-woman exam. Women who received preventative health services were more likely to be using a contraceptive option.

Nearly half of the participants reported having at least one unintended pregnancy, two had abortions, and none reported ever having a STI. Reported barriers to contraceptive use is stable relationships (3), contraception beliefs (6), sexual trauma (5), financial costs (4), and transportation (2).

Among those who reported being sexually active, women in this population were more likely to use lesser effective methods of contraception. There were high rates of discontinuance of more effective contraceptive options.

Conclusions

There is a need for increased family planning in this population. Current contraception use in this sample was low, although most participants expressed a desire to delay pregnancy until they felt they were in a stable mental, emotional, and financial state. These finding suggest that there is a need among mental and reproductive health providers to consider the needs of women with SMIs.

Table of Contents

Table of Contents

Abstract.......................................................................................................... 3

Acknowledgements........................................................................................... 4

Introduction..................................................................................................... 5

Purpose Statement and Research Questions................................................. 9

Definition of Terms.................................................................................. 10

Mental Health................................................................................. 10

Mental Illness................................................................................. 10

Serious/ Severe Mental Illness (SMI)................................................. 11

Sexual and Reproductive Health........................................................ 12

Family Planning Services.................................................................. 12

Women of Reproductive Age............................................................. 12

Literature Review............................................................................................ 13

Women with SMI: Unintended Pregnancy, STI Risks, and Contraception Use... 15

Unintended Pregnancy..................................................................... 15

STI Risks....................................................................................... 17

Contraceptive Use........................................................................... 19

Fragmentation of the US Health Care System............................................. 27

Theoretical Frameworks........................................................................... 31

The Behavioral Model of Health Services Use for Vulnerable Populations......... 31

Predisposing Factors for Contraception Among Women with SMI........... 34
Enabling Factors for Contraception Among Women with SMI................ 35
Need Factors for Contraception Among Women with SMI..................... 35
Health Outcome: Contraception Utilization......................................... 38

Intersectionality Framework..................................................................... 38

Methods......................................................................................................... 40

Previous Research: Electronic Medical Record Manual Data Collection..................... 42

Previous Research: Psychiatrist Survey.............................................................. 43

Previous Research: Psychiatrist Interviews......................................................... 43

Current Research Project: Qualitative Interviews with Women with SMI................. 45

Study Sample...................................................................................... 46

Study Sites.......................................................................................... 46

In-Depth Interview Guide...................................................................... 46

Sampling and Recruitment...................................................................... 47

Procedures............................................................................................ 48

Data Management and Data Analysis....................................................... 48

Results.......................................................................................................... 50

Participant Demographics........................................................................ 50

Intersectionality of Identities................................................................... 53

Predisposing Factors for Contraceptive Use................................................ 55

Relationship Status........................................................................ 55

Abuse and Trauma......................................................................... 56

Substance Abuse........................................................................... 59

Unstable Living Conditions.............................................................. 60

Enabling Factors for Contraceptive Use......................................................61

Financial Barriers.......................................................................... 61

Transportation Barriers.................................................................. 62

Social Support.............................................................................. 63

Need Factors for Contraception among Women with SMI............................. 64

Well-women Visits and Prevention Services....................................... 65
Sexual Partners............................................................................. 66
Unintended Pregnancy.................................................................... 67
Abortion....................................................................................... 68
STI History................................................................................... 71

Health Outcome: Contraceptive Use......................................................... 72

Celibacy/ Abstaining from Sex........................................................ 73

Long Acting Reversible Contraception (LARCs).................................. 74

Permanent Contraceptive Methodology............................................ 75

Short Acting Reversible Contraception (SARCs)................................. 76
User-Directed Contraceptive Options................................................ 78

Discussion................................................................................................... 84

Theoretical Frameworks........................................................................ 84

Highly Effective Contraceptive Methods................................................... 86

Less Effective Contraceptive Methods..................................................... 89

Strengths and Limitations..................................................................... 90

Public Health Implications and Recommendations.................................... 91

Conclusions............................................................................................... 94

References................................................................................................ 95

Appendix A: Patient Interview Guide........................................................... 114

Appendix B: Pre-Screening Questionnaire.....................................................118

About this Master's Thesis

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• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Rollins School of Public Health
Department	Behavioral Sciences and Health Education
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Obstetrics and Gynecology Health Sciences, Mental Health Health Sciences, Public Health
Palabra Clave	Contraception Reproductive Health Mental Health
Committee Chair / Thesis Advisor	Lang, Delia L, Emory University
Committee Members	Von Esenwein, Silke, Emory University
Partnering Agencies	Does not apply (no collaborating organization)

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