بارداری و سلامت جنسی در میان معتادان تزریقی جوان بی خانمان

Research on pregnancy and sexual health among homeless youth is limited. In this study, qualitative interviews were conducted with 41 homeless young injection drug users (IDUs) in Los Angeles with a history of pregnancy. The relationship between recent pregnancy outcomes, contraception practices, housing status, substance use, utilization of prenatal care, and histories of sexual victimization are described. A total of 81 lifetime pregnancies and 26 children were reported. Infrequent and ineffective use of contraception was common. While pregnancy motivated some homeless youth to establish housing, miscarriages and terminations were more frequent among youth who reported being housed. Widespread access to prenatal and medical services was reported during pregnancy, but utilization varied. Many women continued to use substances throughout pregnancy. Several youth reported childhood sexual abuse and sexual victimization while homeless. Pregnancy presents a unique opportunity to encourage positive health behaviors in a high-risk population seldom seen in a clinical setting.

An estimated 500,000 to 2 million young people are homeless in the United States (Ringwalt, Greene, Robertson, & McPheeters, 1998). Homeless youth experience substance use, risky sexual practices, victimization, and pregnancy more often than other young people (Clatts and Davis, 1999, Ensign, 1998, Greene and Ringwalt, 1998, Kipke et al., 1995 and Wagner et al., 2001). Pregnant homeless women who use substances are at increased risk for certain negative health outcomes, such as premature birth and delivery of a child with low birth weight (Little et al., 2005). The greater frequency of pregnancy among homeless youth coupled with the likelihood of adverse outcomes makes pregnancy a serious health concern. Little descriptive data about pregnancy and sexual health among homeless youth, however, have been reported. Research indicates that homeless youth infrequently and inconsistently use contraception (Anderson et al., 1994, Anderson et al., 1996, Gelberg et al., 2002, Haley et al., 2004, Kipke et al., 1995 and Wagner et al., 2001). A study of street youth in Los Angeles, for instance, found that only 40% of men and 30% of women reported using condoms at last sexual intercourse, and rates of condom use were inconsistent between casual and regular partners (Anderson et al., 1994). The combination of frequently changing sex partners and a lack of contraceptive use with regular sex partners may increase risk of exposure to HIV and sexually transmitted infections (STIs) (Anderson et al., 1994, Haley et al., 2004, Rew, 2001 and Wagner et al., 2001). Homeless youth are especially vulnerable to sexually transmitted infections, including hepatitis B and HIV. Estimates of the rate of STIs among homeless youth range from 23% to 46% (Rew, 2001). In addition to inconsistent condom use, sexual risk factors among drug users include engaging in survival sex, having multiple sex partners, and involvement in high-risk sexual networks involving other IDUs (Booth, Kwiatkowski, Iguchi, Pinto, & John, 1998). Little is known about what motivates homeless youth to engage in protective health behaviors, and limited research exists concerning effective sexual health intervention strategies for youth living on the street. Substance use during pregnancy is a major public health concern since drugs can negatively impact both a pregnant woman and a developing child. Women who use cocaine during pregnancy, for instance, are more likely to experience spontaneous abortion or miscarriage, premature labor (Chasnoff et al., 1984, Chasnoff et al., 1985 and Chasnoff et al., 1989), and infections, including hepatitis B, herpes simplex, and gonorrhea (Richardson & Day, 1991). For a developing child, potential adverse effects of prenatal drug exposure include low birth weight, preterm delivery, reduced head circumference and developmental deficits, including impairments in verbal and abstract/visual reasoning (Chasnoff et al., 1989, Chasnoff et al., 1984, Chasnoff et al., 1990, Griffith et al., 1994 and Ostrea et al., 1997). Pregnant homeless women are particularly vulnerable since they are likely to encounter situations that encourage continued drug use, such as coping with the difficulties of street life or involvement with a sex partner who uses drugs (Sales & Murphy, 2000). Prenatal care may ameliorate the adverse effects of prenatal drug exposure. While some research shows that prenatal care was associated with improvements in the birth weight of drug exposed infants (Berenson et al., 1996, Chazotte et al., 1995 and Racine et al., 1993), it is unclear whether prenatal care can compensate for other factors related to poor pregnancy outcomes, including diminished maternal health prior to conception (Kogan et al., 1998 and Misra and Guyer, 1998). Research suggests homeless youth who seek prenatal care are more likely to report histories of abuse and exhibit greater frequency of depression and substance use compared to housed youth (Pennbridge et al., 1991 and Yordan and Yordan, 1995). However, research on pregnant homeless youth who do not seek prenatal care is limited. Reports of physical and sexual victimization are generally high among street youth (Bourgois et al., 2004 and Wagner et al., 2001). Additionally, early sexual abuse has been associated with adolescent pregnancy (Fiscella et al., 1998 and Pierre et al., 1998), and pregnancy and drug use further increases a homeless young woman's likelihood of being victimized. In a study of pregnant drug users, Sales and Murphy (2000) found 79% had experienced violence during pregnancy. Furthermore, research suggests women who experience physical abuse are more likely to use alcohol and drugs (Berenson, San Miguel, & Wilkinson, 1992), and this association becomes stronger during pregnancy (Martin, Beaumont, & Kupper, 2003). Moreover, Amaro, Fried, Cabral, and Zuckerman (1990) found that a woman's alcohol use during pregnancy and her partner's drug use were both associated with increased risk of physical abuse. This manuscript explores pregnancy and experiences surrounding pregnancy among a sample of young homeless injection drug users (IDUs) in Los Angeles. Utilizing qualitative data collected from both young men and women, we describe homeless youths' accounts of contraception practices, outcome during most recent pregnancy, impact of housing on pregnancy, utilization of prenatal care, patterns of substance use, and histories of victimization. In particular, we examine the dynamic relationships between pregnancy, housing status, access to care, and drug use among these youth.

Pregnancy presents a unique opportunity to encourage positive health behaviors among high-risk youth who are seldom seen in clinical settings, yet who are need of a variety of health services. Drug treatment, prenatal services, and counseling for victimization and abuse should be incorporated into clinical settings that offer pregnancy tests for high-risk youth. Furthermore, health care providers should be sensitive to the complex and possibly volatile housing situations among high-risk youth since housing status may impact pregnancy outcomes. Pregnancy was an emotional experience for youth in this study – some expressed excitement regarding future parenthood while others offered painful recollections of pregnancy experiences for which they were not prepared physically, emotionally, or economically. Through discussion, education, and connection with local services, health care providers can assist homeless youth who are pregnant or those with histories of pregnancy assert greater personal control over their sexual and reproductive health.