Access to and Utilization of Reproductive Healthcare Among Appalachian Women Who Use Drugs

Background and Purpose:
Substance use during pregnancy is a growing concern in the U.S., particularly in the Appalachian region where rates of prenatal drug use exceed national averages and access to healthcare is limited (Umer et al., 2023; ARC, 2023). Illicit drug use among pregnant women is linked to increased risks of stillbirth, preterm birth, and maternal mortality (Baer et al., 2019; Forray & Foster, 2015). Appalachian women face unique barriers to reproductive healthcare due to geographic isolation, stigma, provider shortages, and criminalization of substance use during pregnancy (Wilson & Brown, 2024). Guided by Stigma Theory and the Social Determinants of Health Framework, this study examined associations between past-year illicit drug use and access to and utilization of reproductive healthcare among reproductive-age Appalachian women.

Methods:
We conducted a secondary analysis of a survey on unmet family planning needs among 357 sexually active women aged 18–49 and residing in Appalachia (Swan et al., 2021). Measures included past-year illicit drug use, reproductive history, healthcare access, contraceptive access and use, and history of unintended pregnancies. Bivariate tests and logistic regression models were used to assess associations between substance use and reproductive healthcare indicators.

Results:
More than a quarter (27.2%) of participants reported past-year illicit drug use. Compared to those who did not, women who used drugs were younger (p = .011), more likely to receive public assistance (p = .037), and more likely to have Medicaid (p < .001). Results showed that Appalachian women who use drugs experience more barriers to care. They were more likely to indicate that it was hard to get an appointment (p = .001) and less likely to perceive that their healthcare provider valued their thoughts and decisions (p = .005). They also experienced more barriers to contraceptives. They were less likely to report access to contraceptives in their area (p = .044) and less likely to report being comfortable calling to get an appointment for contraceptives (p = .002). They were less likely to perceive contraceptives as affordable (p = .012), more likely to worry about where to get contraceptives (p < .001), and more likely to have a hard time getting contraceptives (p < .001). When controlling for other factors, women who used drugs were 2.21 times less likely to have had a checkup in the past year (p = .015), 2.89 times more likely to report difficulty accessing contraceptives (p < .001), and 2.84 times more likely to have had unintended pregnancies (p < .001)

Conclusions and Implications:
Findings highlight systemic disparities in reproductive healthcare access for Appalachian women who use drugs. Stigma and structural barriers contribute to underutilization of reproductive healthcare and higher rates of unintended pregnancies. Public health interventions must integrate substance use treatment with reproductive healthcare, expand Medicaid coverage, and increase contraceptive access. Provider training in stigma reduction and trauma-informed care is also critical. Future research should examine legal barriers, educational interventions, and culturally appropriate outreach strategies to promote healthcare engagement among this underserved population.