Women with Suicidal Ideation, Substance Use Disorder, or Intimate Partner Violence in the Emergency Department: Retrospective Analysis of Contraceptive Documentation

TL;DR

Women with suicidal thoughts, substance use, or domestic violence in the emergency department have less contraceptive documentation and worse healthcare outcomes.

Contribution

This study identifies gaps in contraceptive documentation and care access for women with specific risk factors in the ED.

Findings

Women with SI/SUD/IPV had lower contraceptive documentation (39.5% vs 51.7%).

These women had higher rates of uninsurance and longer ED stays compared to controls.

Abstract

Prior research demonstrates that emergency department (ED) patients with suicidal ideation (SI), substance use (SUD), and/or intimate partner violence (IPV) have disproportionate adverse outcomes for both women and infants. The 2013 Hague Protocol suggested that children with caregivers with the above characteristics are also more likely to suffer from child maltreatment. Of all pregnancies in this group, as many as 90% are unintended. We hypothesized that women with SI/SUD/IPV have gaps in care access, high levels of unscheduled care use, and reduced ED contraceptive inquiry, which if addressed could potentially improve outcomes.

We conducted a chart review of 62,284 ED visits from 2018–2021 from a suburban four-hospital system in the Southern United States. We compared women of reproductive age (15–44) with SI/SUD/IPV (4,776) against controls (57,508). The exposures were defined as women with SI, SUD, and/or IPV. We analyzed results using the chi-square test (χ2) with Bonferroni adjustment to test for independence and logistic regression.

Women suffering from SI/SUD/IPV who present to the ED have contraceptive status less frequently documented compared to controls without these factors (39.5 vs 51.7%, RR 0.77, CI, 0.74–0.79, P < .001). They also have reduced access to care, with higher rates of uninsurance (32.7 vs 26.1%, P < .001), more care in the acute care environment, longer ED length of stay (LOS) (mean was 10.38 vs 3.87 hours, P < .001), higher hospitalization rates (61.0 vs 8.7%, P < .001), and higher 30–day ED revisits (11.8 vs 8.8%, P < .001), even after adjusting for the Social Vulnerability Index, acuity, age, and obesity (adjusted odds ratio 1.52 95% CI 1.36–1.70 P < .001).

Despite significant morbidity coupled with reduced access to ambulatory care and disproportionately increased ED use, little ED contraceptive documentation exists. This practice contributes to inequity, given the increased number of unintended pregnancies and greater need of contraceptives in women with suicidal ideation/substance use disorder/intimate partner violence.

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