EXECUTIVE SUMMARY
Homelessness adds multiple barriers to contraception counseling and care. These patients often cannot access OB/GYNs or family planning clinics because of transportation and insurance obstacles.
- It is important for all clinicians to ask patients experiencing homelessness about their contraceptive needs and to counsel them on all methods.
- Because funding is a challenge if patients are marginally housed, they need help applying for state and federal insurance and aid.
- According to recent research, homeless women show more interest in long-acting reversible contraception when they receive comprehensive contraceptive counseling.
Women living in emergency shelters and other transitional settings face many barriers to obtaining their contraceptive of choice. They also would prefer if their physician told them about their options, the authors of a recent study noted.1
“We wanted to explore what barriers and facilitators exist across the system for people experiencing homelessness to access and use contraception,” says Erika Thompson, PhD, MPH, CPH, lead study author and an associate professor at the University of North Texas Health Science Center School of Public Health. “We conducted interviews with women experiencing homelessness, healthcare providers, and social service providers to get a comprehensive perspective. We found that providers may perceive women having other priorities than contraception; as a result, they may not bring it up with women.”
People may not be aware of all contraceptive methods, so counseling is important to dispel myths and raise awareness of the various options. “I think the most important thing is to inquire about contraceptive needs for all patients, regardless of housing stability, and to provide comprehensive contraception counseling to this population,” Thompson says.
Many of the people served by organizations that target those experiencing homelessness do not meet the federal definition of someone who is homeless, says Carol Klocek, MSW, MBA, chief executive officer of the Center for Transforming Lives in Fort Worth, TX.
“We as a service provider offer housing services and emergency shelter, transitional housing, and rapid re-housing. We also provide early childhood educational services,” Klocek explains. “Those are where contraception and the need for contraception comes up.”
But many of the women served by the organization are not eligible for federally funded services targeting the homeless because they may live in a hotel or on a friend’s couch, Klocek says. Clients who are marginally housed may have to navigate the county’s healthcare system with more barriers than those who are eligible for additional services.
An increase in family size among people experiencing homelessness is another factor related to contraceptive care barriers. “Homeless families have increased maybe as much as by three individuals in the last five to six years,” Klocek says. “When we first looked at this, the average family size was 2.4 people. Now, it’s five people per family.”
The women may give birth every year. By age 27, they may have as many as eight children. “We’re seeing really large families, and that’s all about not having access to contraception,” Klocek explains. “I’ve been providing care for the homeless population for almost 20 years. Before, we’d occasionally see a family with six to eight children — now, it’s much more common.”
In Klocek’s experience, it is not that more families are becoming homeless — it is that people who are precariously housed are having more children.
Counseling Is Inconsistent
The anecdotal evidence and study evidence point to a lack of consistent contraceptive care and counseling as a potential reason for homeless women with larger families. Thompson and colleagues found that participants were interested in long-acting reversible contraception (LARC) when they learned more about it.
“In the study, we showed women the contraceptive effectiveness chart that lists all the different methods,” Thompson explains.
Interviews of women suggested that many were interested in LARC once they knew something about it, but they faced transportation, housing, and other barriers to obtaining LARC.
People who are homeless face so many challenges that obtaining their desired form of contraception may not be a top priority, especially if it involves multiple clinic visits.
“The clinics we talked to are not able to provide same-day LARC,” Thompson says. “There are broader system-level barriers, such as transportation to clinics, insurance, and lack of same-day LARC insertion.” Ideally, the women would receive comprehensive contraceptive counseling and same-day LARC, if they prefer that method.
Working with a population that experiences homelessness is incredibly challenging. “Women have to go from program to program and figure out if they’re eligible, and that’s one layer,” Thompson explains. “The system may not prioritize things like reproductive health because they’re trying to meet immediate reproductive needs.”
Conflicting needs and goals create a chasm between social service providers and the medical system, which may not recognize that reproductive health is a priority among this population. “For this extremely vulnerable population that has all these barriers of employment, child care, housing, acute medical issues, violence, and substance use, reproductive health may not emerge to the forefront,” Thompson says. “But we shouldn’t ignore that.”
There also are barriers related to social service providers’ ability to link women to services. “We think there can be opportunities to have better linkages from social service providers, who are trusted by women experiencing homelessness, to inquire and refer to reproductive health services and connect with healthcare providers,” Thompson notes.
Some social service organizations that help people who are homeless may have religious views that prevent them from addressing their clients’ sexual and reproductive health needs. “Women are interacting with social service providers who are amazing and may not be prioritizing their reproductive health because it’s not in the scope of their work,” Thompson says. “How can we have better linkages for social service care and reproductive healthcare?”
In an ideal world, social service providers could send women in the community a list of referrals and ask them at intake if this is how they can connect them. “Not all social service providers may prioritize reproductive healthcare, and some may be religious-oriented, and that’s in their scope; they need to be accountable to boards as well,” Thompson explains.
Insurance Is a Barrier
Another barrier is insurance. Two-thirds of the women included in the study received Medicaid. For those who did not, insurance coverage was problematic, particularly because they lived in Texas, which is one of the states that did not expand Medicaid coverage.
“They mentioned insurance, and so did providers,” Thompson says. “One woman said, ‘One minute I might have insurance, and the next minute I can’t pay for it with my insurance.’”
The Healthy Texas Women program is designed to fill in the gap left by the lack of expanded Medicaid, but there are multiple layers and qualification/application barriers.
“If you’re experiencing homelessness, how do you apply for healthcare, child care, etc.?” Thompson asks. “There are so many layers to finding out what you qualify for in terms of coverage.”
Although LARC was a top choice among participants, obtaining affordable LARC was another issue. The women mainly saw healthcare providers and public health professionals who did not specialize in reproductive and sexual health. They often were not counseled on their contraceptive options. Plus, none of the study’s participants could obtain same-day LARC.
The adults experiencing homelessness often had additional medical priorities, such as lacerations and acute illness. When they saw healthcare providers, clinicians addressed those needs first. Some providers did not ask women about contraception or whether they wanted to become pregnant because they assumed their patients would mention it first, Thompson says.
“In some ways, we as healthcare providers or public health professionals have a responsibility to assess needs,” she adds. “It may not always be comfortable for patients to bring up reproductive health, especially if they’re in more precarious situations.”
It is important for providers to ask women about sexual reproductive health without judgment and stigma. “A woman experiencing homelessness may have a fear of judgment — ‘She’s homeless and she shouldn’t be having sex,’” Thompson explains. “Or, she may not have reproductive control in the situation she’s in.”
Texas is not a friendly state in terms of reproductive health, Thompson notes. Abortion is not an option for a homeless person who becomes pregnant and does not want a child, so it is especially important to help each person obtain the contraception they want.
“As healthcare providers, how do we level the playing field and reduce that stigma and provide reproductive healthcare?” Thompson asks. One step would be for Texas and all states to expand Medicaid. They also can initiate programs that are easier for people to access and meet eligibility, she adds.
The onus is not entirely on providers, who often are doing the best they can in such a difficult time for reproductive health. “In our state, reproductive health providers are under constant threat and are constantly having to adjust to any legal or policy changes from the state legislature,” Thompson laments. “That makes it challenging for them to provide evidence-based care that we know women need.”
The study’s findings emerged in the same time period as Texas’ Senate Bill 8 prohibited abortion after six weeks, and when the U.S. Supreme Court overturned Roe v. Wade.
“It emphasized we need to act now because women’s options about what to do when they become pregnant are becoming more restricted,” Thompson says. “We need patient-centered solutions to assess social service needs and to ask about basic needs and patients’ reproductive health. This is especially important in states like Texas, where if a woman is wanting to prevent a pregnancy, contraception has to come to the forefront because women don’t have another option.”
REFERENCE
- Thompson EL, Galvin AM, Garg MA, et al. A socioecological perspective to contraceptive access for women experiencing homelessness in the United States. Contraception 2023 Feb 24;109991. doi: 10.1016/j.contraception.2023.109991. [Online ahead of print].
Homelessness adds multiple barriers to contraception counseling and care. These patients often cannot access OB/GYNs or family planning clinics because of transportation and insurance obstacles. It is important for all clinicians to ask patients experiencing homelessness about their contraceptive needs and to counsel them on all methods.
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