The Dual Burden of Substance Use Disorder and Unmet Reproductive Health Care Needs
In 1985, HHS Secretary Margaret Heckler released the landmark Report of the Secretary’s Task Force on Black and Minority Health (commonly known as the Heckler Report), which highlighted what she called “a sad and significant fact… the continuing disparity in the burden of death and illness experienced by Blacks and other minority Americans”. Although disparity, as she further notes, “has existed ever since accurate federal record keeping began”, the report marks the first time health inequities were comprehensively described and solutions proposed at the federal level. A rallying cry for change, the overall spirit of the report was hopeful: “It can – it should – mark the beginning of the end of the health disparity that has, for so long, cast a shadow on the otherwise splendid American track record of ever improving health.”
35 years later, many of the metrics identified in the Heckler report have worsened. Maternal mortality has increased, especially for Black women; inequities in infant mortality remain almost unchanged; and the opioid crisis has devastated communities throughout the US.
Reproductive health is often siloed from behavioral health both in clinical care and in the organization of public health. This separation means that inequities in reproductive health for women with substance use disorder are not as visible. The Advancing Equity webinar series and the accompanying materials bring these worlds together and document reproductive health and substance-related disparities in Ohio. Though sobering, these resources highlight opportunities for the realization of the Heckler Report vision.
Why should we care about the reproductive health needs of people who use drugs? Are they really that different from reproductive health needs in general? Today, reproductive health is framed as a human right grounded in autonomy: the right to determine whether and then, when, to have children. Although monumental, this characterization of reproductive health is insufficient. Significant work of primarily Black feminists over the past several decades has demonstrated the importance not only of autonomy, but also of equality in reproductive freedom. This emphasis on social justice is embodied in the reproductive justice framework which adds an essential third principle to reproductive health as a human right: the right to parent children in safe and healthy environments.
Most women with substance use disorder receive no treatment – a massive gap that could be narrowed through the integration of substance use, misuse, and addiction assessment into reproductive health care. Expansion of addiction treatment capacity and quality is needed, especially for women, as less than 23% of facilities provide programs for pregnant or postpartum women and few provide contraception. Treatment is important, but the goal of treatment is not more treatment. The goal of treatment is recovery.
Recovery is more than abstinence. It is about connection, purpose, integrity, and is really defined by people themselves. And sexual and reproductive health are central to recovery.
Moving forward, I hope that the Advancing Equity web series and supplemental resources will help facilitate conversations and support state-wide efforts to realize integrated and holistic services. To be successful, these public health efforts should center on women who use drugs and remain grounded in both autonomy and equality.
Mishka Terplan, MD, MPH, FACOG, DFASAM
Webinar: In 2020, the Center for HOPES, together with the Center for Public Health Practice, presented Advancing Equity, a six-part web series examining the intersection of addiction and reproductive health, and exploring and promoting best practices for advancing health equity and access to care among women with substance use disorders (SUD).
Issue Overview for Providers: Center for HOPES researchers have authored a brief review of the scope of the dual burden issue, the policy context in which it operates, and best practices in providing evidence-based care to affected populations.
 Heckler, M. (1985). Report of the Secretary’s task force on Black & minority health. US Department of Health and Human Services.
 World Health Organization. (2015). Sexual Health, Human Rights, and the Law.
 Roberts, D. E. (1999). Killing the black body: Race, reproduction, and the meaning of liberty. Vintage.
Ross, L., Derkas, E., Peoples, W., Roberts, L., & Bridgewater, P. (Eds.). (2017). Radical reproductive justice: Foundation, theory, practice, critique. Feminist Press at CUNY.
 Ross, L., & Solinger, R. (2017). Reproductive justice: An introduction (Vol. 1). Univ of California Press.
 Martin, C. E., Scialli, A., & Terplan, M. (2020). Unmet substance use disorder treatment need among reproductive age women. Drug and Alcohol Dependence, 206, 107679.
 Terplan, M. (2018, November 22). Reproductive health is grounded in human rights. The Baltimore Sun. https://www.baltimoresun.com/opinion/op-ed/bs-ed-op-1123-gag-rule-20181119-story.html
 Meinhofer, A., Hinde, J. M., & Ali, M. M. (2020). Substance use disorder treatment services for pregnant and postpartum women in residential and outpatient settings. Journal of Substance Abuse Treatment, 110, 9-17.