Reproductive autonomy is defined as the power to control and decide when and if to use contraception, become pregnant, and bear children (39, 40). It can be undermined by limiting reproductive rights, coercion (by partner, provider, researcher), disempowerment, and poor communication with sexual partners (41–43). Historically, marginalized women with SUDs have been unjustly targeted for forced or coerced sterilization as a part of widespread eugenics movements. They were targeted as a means to reduce the growth of families whose mothers were deemed “feebleminded, defective, and criminal” (44). More recently, potentially coercive tactics targeting women with SUD included offering cash incentives for the most effective forms of contraception, contributing to the perception that preventing pregnancy is the primary goal (39, 40). Public health researchers have also largely focused on increasing the initiation of the most effective methods of contraception, such as long-acting contraception (45). However, due to historical injustices, marginalization, fear, and stigma, a more nuanced approach is needed to improve reproductive autonomy and access to a full range of contraceptive or family planning healthcare options. Our previous qualitative study revealed that some people in recovery as well as some people who have issues of chaotic or problematic use who aren't ready to make longer term fertility decisions would appreciate low-barrier access to emergency contraception, as cost and stigma were identified as barriers (46, 47). Moreover, they may benefit from having emergency contraception before they need it. The advance provision of emergency contraception increases the odds that a woman will use it (2.5-fold) and speeds up the time from intercourse to use by 14.6 h as compared to control groups (48).

Little is known about how to effectively engage women with SUD for the promotion of reproductive autonomy, especially among women who want to become pregnant. Improving access to and engagement in preconception and early prenatal care have been identified as maternal/child health priorities (23, 49). Recent literature has emphasized the need for greater engagement in preconception health services and a more proactive approach to address SUD-related health issues before pregnancy (50). Women with SUD who would like to become pregnant could also benefit from an early awareness of a pregnancy, as a positive pregnancy test is associated with behavioral change and reduction in alcohol use, which can be protective against miscarriage in the first trimester and fetal alcohol spectrum disorders (45, 51). Additionally, consuming prenatal vitamins in the preconception period and in early pregnancy confers a protective effect against numerous types of birth defects (52). Pregnancy testing and obtaining prenatal vitamins are part of preconception and early prenatal healthcare, yet women with SUD are more than twice as likely to have only late prenatal care (third trimester only) or no prenatal care (40%) as compared to those without substance use during pregnancy (16%) (53). New community-driven approaches to engage women with SUD who would like to become pregnant or prevent pregnancy are critically needed to promote reproductive autonomy and empowerment to reduce adverse reproductive and maternal/child health outcomes (23, 49).

Peer-based recovery support services are an emerging modality of availing recovery resources delivered in the community or clinical settings by trusted peers (people with lived experience) in formalized and specialized roles (54–56). One such peer-based recovery support service that is rapidly growing is recovery coaching within the Recovery Community Centers (RCC). Recovery coaches (also referred to as “peer support specialists” or “peer mentors”) are peers with lived experience in recovery who help people with SUDs build their recovery capital. Recovery coaches effectively build rapport and collaborative, supportive relationships with people with SUD to facilitate the latter's access to the needed resources (57). Researchers have observed that recovery coaching is associated with reduced substance use (58, 59) reduced odds of drinking to intoxication (60), improved stress management (61), decreased hospitalizations (62), decreased criminal justice involvement (59), and increased treatment adherence (63).

RCCs employ peer recovery coaches and are ideally positioned to offer programs that support reproductive or perinatal health. They are brick-and-mortar facilities serving as a community hub for recovery support services (64). RCCs typically provide a variety of services including drop-in social support, harm reduction services, and facilitated access to recovery capital via recovery coaching (65). These centers are intended for more continuous, ongoing engagement with people with SUD and people who use drugs (PWUDs). They are well positioned to fill important gaps because they are free, highly visible, and inclusive of all pathways of recovery, including harm reduction. While some PWUD may not have felt welcome in recovery communities where abstinence-only was the focus, RCCs prioritize co-location of harm reduction and recovery services to engage individuals across the spectrum of substance use and irrespective of stage of change (66).

RCCs have the potential to fill an important gap in the linkage to reproductive and perinatal healthcare, because current interventions are largely designed for people who are in treatment settings (20), leaving behind 91% of reproductive-age women who need treatment for SUD and who did not receive treatment in the last year (67). Furthermore, there is a need to develop recovery coaching programs designed to promote access to reproductive and perinatal health and healthcare. Though there are specialized programs in recovery, harm reduction, or peer coaching spaces that serve pregnant, parenting, and post-partum people, they are largely understudied and are generally not focused on reproductive health and wellbeing (68–70).

“Future of Health” researchers recently identified four action areas to improve equitable access to healthcare, one of which is to foster cross-sector partnerships (71) to strengthen the capacity of community organizations to shape models of care that disrupt traditional healthcare paradigms. We heeded this call to action specifically by fostering an academic and community partnership to strengthen the capacity of the recovery community to improve access to reproductive and perinatal healthcare following Levesque's conceptual framework of access (72) (Figure 1). The dimensions of this framework encompass the 5 A's of access (approachability, acceptability, availability/accommodation, affordability, and appropriateness) as well as upstream determinants or barriers that impact each dimension. Specifically, by partnering with the recovery community, we aimed to improve the opportunities or abilities to access perinatal and reproductive health resources and healthcare that align with the 5 A's (perceive, seek, reach, pay, and engage) (72).

This academic and recovery community partnership led to a co-created, iterative multi-level intervention model. The RCC implemented and adopted the intervention in iterative phases, with the Pregnancy Empowerment Project first (in 2022–2023) and the addition of a champion coach in the full PeRCHH model (in 2024).

The Pregnancy Empowerment Project was implemented at the organizational level of the RCC where our team trained 58 peer recovery coaches and staff primarily on the concept of how unmet reproductive health needs could impact recovery capital, how to incorporate reproductive health and autonomy into peer recovery coaching, and the rationale and basic health education of three new harm reduction items (pregnancy tests, prenatal vitamins, and emergency contraception). Each item was available from large pharmacies without a prescription in the United States, but we provided them anonymously and free in partnership with a large RCC in Kentucky. These three items served not only as key to health promotion but also as tools with the potential to expand the reach of the RCC to engage more women and participants of reproductive age to build recovery capital (47, 73). The three items were added to public-facing spaces in the RCC, events that they hosted or attended, highlighted on social media, and provided for coaches who worked with interested community partners. As reported elsewhere in greater detail, the co-creation process of development and findings from the Pregnancy Empowerment Project include increased knowledge, attitudes, and skills of the coaches and it was found to be feasible and acceptable for the role of the recovery coach and mission of the RCC (47, 73). Feedback from the focus groups then informed the next iteration we describe in this article, such as being able to make a referral to a coach with lived experience in pregnancy and SUD, more in-depth education about the three items, identifying other resources to serve women of reproductive age, and how to modify the existing recovery coaching tools to include reproductive health.

This article is the first to describe the addition of the specialized role of the peer recovery coach in championing perinatal and reproductive health and pilot data from the full model, the Perinatal, Reproductive Champion of Health and Harm reduction Program (PeRCHH). Specifically, the PeRCHH model included the continuation of the harm reduction items and RCC training from the Pregnancy Empowerment Project and a trained peer recovery coach focused specifically on engaging and reaching people who can get pregnant or are pregnant and reducing existing the barriers to health and healthcare access for this population (See Table 1 for PeRCHH training topic overview). The specialized and trained coach, referred to as the “champion” throughout the article, was first trained by the RCC as a generalist peer recovery coach and then completed an 8-h training followed by reviewing available resources and weekly check-ins by the research team.

The PeRCHH was implemented in partnership with Voices of Hope, a large local RCC, which serves as a community hub for recovery and harm reduction and has a broad reach of services including two mobile units that serve the state's two largest cities and trained coaches working with over 80 organizations or agencies across the state. The staff training was led by two of the authors, a perinatal nurse scientist with a clinical nurse specialty in community and public health and a trained peer research associate with lived experience, extensive experience in training peers, and national certifications in motivational interviewing. The two also led the organizational-level training sessions of the Pregnancy Empowerment Project with all RCC staff. The participant eligibility to work with the champion included being pregnancy-capable or pregnant, aged 18–45 years, who were seeking services, or would like to seek peer coaching services.

Participants seeking recovery services who were pregnant or pregnancy-capable (or had other non-specified reproductive health needs such as sexually transmitted infections) were recruited by the champion, as well as referred to the champion by other RCC staff. Additionally, the research team helped the champion to network and shadow with a local perinatal clinic serving people with SUD and other community organizations serving women. The champion left behind her contact information and a referral form; the organizations agreed to let her know if she had interested participants. All intake information was collected by the champion in person, either at the RCC, or at one of the mobile sites with community partner organizations. Follow-up coaching and check-ins were both in person and over the phone at a mutually agreed-upon time frame. The majority of the interactions took place at the RCC; however, some of them also took place in the healthcare environment (neonatal unit at the hospital) or at other community organizations served by the RCC's mobile team. The champion followed the existing coaching protocols, attempted to reach the participant by phone or text three times, or to discontinue if the participant indicated the desire to terminate earlier. Participants were able to return to generalist coaching at any time beyond the three attempts and were invited to use all the RCC services regardless of enrollment status.

Data collected by the champion included demographics (age range, gender, race/ethnicity, sexual orientation), social needs (food insecurity, unstable housing, transportation, social support), recovery capital scores, and sexual and reproductive health characteristics. These included the number of lifetime pregnancies, miscarriages/abortions, current pregnancy status, reasons for not using birth control (including “I'd such as to get pregnant or wouldn't mind if I became pregnant”).

Aim 1: data was downloaded and de-identified by the RCC, emailed to academic partners via a secure server, and analyzed using Microsoft Excel. The mean score and standard deviation of recovery capital were calculated, while frequencies and percentages were used for categorical data. High- and low-scored items were characterized with examples from the coaching notes.

Aim 2: reach was reported as the number of people served pre- and post-program and the proportion was indicated as a percentage. Uptake was reported as the number of products distributed or provided, and 3 months of data was averaged to account for possible seasonal differences or delays in shipments.

Aim 3: we used Levesque's conceptual framework of access to explore and contextualize the training content, existing coaching roles as they relate to building recovery capital, and champion actions taken from field notes. We identified the key components to access as they relate to the abilities of women with SUD to perceive, seek, reach, pay, or engage in healthcare or health promotion resources.

Informed by our earlier qualitative work (46, 77) and Substance Abuse and Mental Health Services Administration (SAMHSA) Bringing Recovery Supports to Scale (78), we identified relevant roles of coaches and RCCs where their work already promotes the five abilities (perceive, seek, reach, pay, engage) as they relate to building recovery capital and recovery support. Then we aligned these five abilities with the additional components of the PeRCHH training to enhance the role of the peer recovery coach to bring these forms of support specifically to pregnant and pregnancy-capable people (Table 4). We further contextualized this activity with more explicit examples and stories of actions taken with the expansion of the role of the RCC and champion coaching as a part of the PeRCHH implementation as they relate to recovery capital and recovery support.