RE: Expanding Contraceptive Access for Women With Substance Use Disorders: Partnerships Between Public Health Departments and County Jails.

Dear Dr Novick, We were troubled by the publication “Expanding Contraceptive Access for Women With Substance Use Disorders: Partnerships Between Public Health Departments and County Jails.” While the title suggests an important goal—improving family planning service availability for a group of people with constrained access—the program’s goal to reduce neonatal abstinence syndrome (NAS) and practice of not offering the full range of reversible birth control methods raises serious concerns for ethical, equitable, and just health care and public health practice. The authors describe a state health department program providing family planning education and limited clinical services, accompanied by information about NAS, to women incarcerated in 15 rural Tennessee jails. The authors not only promote this intervention as increasing access to contraception but also justify it as reducing the financial burden to the state from babies born to people with opioid use disorder (OUD). This premise is deeply problematic. First, the premise devalues the reproduction of people with OUD and sends the message that they should not be having babies, in historical continuity with eugenics campaigns that suppressed the reproduction of “undesirable” social groups. Linking contraception and NAS education sends the message that some people should not reproduce. If people with OUD desire pregnancy, this should not be discouraged, even subtly, and particularly by a state agency from which they may obtain future care. All this in a state that has enacted legislation to criminalize drug use in pregnancy. Second, if a person with OUD wants to avoid pregnancy, ensuring access to noncoercively provided contraception is essential. The authors are clearly aware of the potential for coercion, as they detail a thoughtful approach to avoid coercion. However, the power