Background: One in ten people in the U.S. are affected by a substance use disorder (SUD), roughly one third of whom are women. Rates of unintended pregnancy are higher in this population than in the general public. Little is understood about how women with SUD use prescription contraception and think about pregnancy.

Methods: By analyzing Medicaid claims data and conducting qualitative interviews with women with SUD, this doctoral thesis seeks to: 1) compare any use of and consistent, continued coverage by prescription contraceptives between women with and without SUD; 2) determine the extent to which SUD is associated with pregnancy, abortion, and adverse feto-maternal outcomes in women who use prescription contraception; and 3) explore facilitators of and barriers to contraceptive utilization by women with SUD, using qualitative interviews.

Results: Compared to women without SUD, women with SUD are less likely to use any prescription contraceptive, particularly long-acting reversible methods. Among women who do use long-acting methods, SUD is associated with less continued, consistent coverage by a prescription contraceptive. Among women who use contraception, SUD is also associated with increased odds of abortion. When interviewed, women with SUD report fatalistic attitudes towards pregnancy planning, and have difficulty conceptualizing how susceptibility to pregnancy may change over time. Women with SUD also report that pregnancy has substantial impact on their drug treatment prospects.

Conclusions: This study is the first to examine contraceptive utilization by women with SUD who are enrolled in Medicaid or state-subsidized insurance. Our study may help to inform clinical practice and policy development to improve the reproductive health and wellbeing of women with SUD.