Predictors of Veterans Affairs Health Service Utilization by Women Veterans during Pregnancy

BackgroundResearchers have examined predictors of Veterans Affairs (VA) service use by women veterans in general, but less is known about predictors of VA service use by pregnant veterans. This study examined characteristics associated with planned and actual VA service use by pregnant veterans.MethodsThis study includes data from 510 pregnant veterans enrolled in the Center for Maternal and Infant Outcomes Research in Translation Study. Women veterans completed phone interviews during their first trimester and at 3 months postpartum. The Center for Maternal and Infant Outcomes Research in Translation surveys assessed medical and mental health conditions, VA health care use, trauma history, and pregnancy complications. We conducted bivariate and multivariable logistic regression models assessing planned and actual use of VA services during pregnancy.ResultsLifetime post-traumatic stress disorder (odds ratio [OR], 1.73; 95% confidence interval [CI], 1.11–2.69) and history of military sexual trauma (OR, 1.85; 95% CI, 1.19–2.87) were significantly associated with planned VA service use in multivariable models. Lifetime diagnoses of anxiety (OR, 1.78; C.I., 1.15–2.75) were associated with an increased likelihood of actual VA use during pregnancy, whereas Hispanic ethnicity (OR, 0.59; 95% CI, 0.36–0.96), younger age (OR, 0.95; 95% CI, 0.91–0.99), and access to private health insurance (OR, 0.55; 95% CI, 0.37–0.84) were associated with a decreased likelihood of actual VA service use during pregnancy.ConclusionsResults emphasize the association between high-risk mental health characteristics and specific demographic characteristics with VA service use among pregnant veterans. Study findings highlight a continued need for women's health care at the VA, as well as the availability of VA providers knowledgeable about perinatal health issues, and informed community providers regarding women veterans' health.     

Use of nonpreferred contraceptive methods among women in Ohio

ObjectivesWe describe the prevalence and correlates of nonuse of preferred contraceptive method among women 18-44 years of age in Ohio using contraception.Study DesignThe population-representative Ohio Survey of Women had 2529 participants in 2018–2019, with a response rate of 33.5%. We examined prevalence of preferred method nonuse, reasons for nonuse, and satisfaction with current method among current contraception users (n = 1390). We evaluated associations between demographic and healthcare factors and preferred method nonuse.ResultsAbout 25% of women reported not using their preferred contraceptive method. The most common barrier to obtaining preferred method was affordability (13%). Those not using their preferred method identified long-acting methods (49%), oral contraception (33%), or condoms (21%) as their preferred methods. The proportion using their preferred method was highest among intrauterine device (IUD) users (86%) and lowest among emergency contraception users (64%). About 16% of women using permanent contraception reported it was not their preferred method. Having the lowest socioeconomic status (versus highest) (prevalence ratio [PR]: 1.47, 95% CI: 1.11–1.96), Hispanic ethnicity (versus non-Hispanic white) (PR: 1.83, 95% CI: 1.15–2.90), reporting poor provider satisfaction related to contraceptive care (PR: 2.33, 95% CI: 1.02–5.29), and not having a yearly women's checkup (PR: 1.31, 95% CI: 1.01–1.68) were significantly associated with nonuse of preferred method. Compared to preferred-method nonusers, higher proportions of preferred-method users reported consistent contraceptive use (89% vs. 73%, p < 0.001) and intent to continue use (79% vs. 58%, p < 0.001).ConclusionsAffordability and poor provider satisfaction related to contraceptive care were associated with nonuse of preferred contraceptive method. Those using their preferred method reported more consistent use.ImplicationsCost is an important barrier for women in obtaining their preferred contraceptive methods. Low quality birth control care may also be a barrier to preferred-method use. Removal of cost barriers and improvement in contraceptive counseling strategies may increase access to preferred contraceptive methods.     

Characteristics and Health Care Preferences Associated with Cardiovascular Disease Risk among Women Veterans

BackgroundWomen veterans are at increased risk for cardiovascular disease (CVD), but little is known about comorbidities and healthcare preferences associated with CVD risk in this population.MethodsWe describe the prevalence of CVD-relevant health behaviors, mental health symptoms, and health care use characteristics and preferences among participants of the National Survey of Women Veterans (conducted 2008–2009).FindingsFifty-four percent of respondents were at risk for CVD (defined as a diagnosis of hypertension, diabetes, current tobacco use, or obesity without CVD). In unadjusted analysis, ORs for being at risk for CVD were greater among those interested in gender-specific clinical settings (OR, 2.0; 95% CI, 1.2–3.4) and gender-specific weight loss programs (OR, 1.8; 95% CI, 1.1–2.9). ORs were also greater for women who were physically inactive (OR, 1.9; 95% CI, 1.1–3.3), with current symptoms of depression (OR, 2.5; 95% CI, 1.1–6.1), anxiety (OR, 2.1; 95% CI, 1.2–3.6), and posttraumatic stress disorder (OR, 2.4; 95% CI, 1.2–4.8). Adjusting for age, race/ethnicity, marital status, education level, employment, and source of health care use, the ORs for CVD risk were higher for women with current posttraumatic stress disorder symptoms (2.5; 95% CI, 1.1–5.3) and gender-specific health care preferences (2.0; 95% CI, 1.1–3.4), and gender-specific weight loss programs (1.9; 95% CI, 1.1–3.2).ConclusionsRisk for CVD was common and preferences for gender-specific care and posttraumatic stress disorder were associated with being at risk for CVD. Women's health clinics may be a good location for targeted CVD prevention interventions for women veterans both in and outside the Veterans Health Administration.     

Contraceptive choices of overweight and obese women in a publically funded hospital: possible clinical implications

BackgroundDespite the growing obesity epidemic in the United States, family planning for overweight and obese women has been understudied. The aim of this study was to describe the contraception methods selected by normal weight, overweight and obese women.Study DesignWe retrospectively reviewed 7262 charts of women who underwent first trimester surgical termination of pregnancy at the John H. Stroger, Jr. Hospital of Cook County between January 1, 2008, and January 1, 2010. We analyzed the relationship between body mass index (BMI) and choice of contraceptive method, after adjusting for age, race, smoking and level of education.ResultsWhen compared to patients with BMI <25 kg/m², overweight (BMI 25–29.9 kg/m²) and obese patients (BMI ≥30 kg/m²) were more likely to select the intrauterine device (OR 1.3, 95% CI 1.28–1.32 for overweight; OR 1.6, 95% CI 1.59–1.61 for obese), contraceptive ring (OR 1.4, 95% CI 1.28–1.52 for overweight; OR 1.6, 95% CI 1.57–1.63 for obese) and tubal ligation (OR 1.5 95% CI 1.44–1.62 for overweight; OR 2.9, 95% CI 2.79–3.01 for obese). They were less likely to choose injectable contraception (OR 0.7, 95% CI 0.59–0.81 for overweight; OR 0.52, 95% CI 0.48–0.56 for obese). There was no relationship between BMI and choice of condoms, oral contraceptive pills and implantable methods.ConclusionIn our population, the contraceptive choices of overweight and obese women differed from those of normal weight women. These differences in contraceptive selection are important to recognize in light of the potential effect of BMI on the safety and efficacy of different contraceptive methods. Further research is needed to evaluate the contraceptive preferences, risks and benefits for overweight and obese women.     

Agreement between Self-Reported “Ideal” and Currently Used Contraceptive Methods among Women Veterans Using the Veterans Affairs Healthcare System

BackgroundWomen veterans who use the Veterans Affairs Healthcare System theoretically have access to the full range of contraceptive methods. This study explores match between currently used and self-reported “ideal” methods as a potential marker of contraceptive access and preference matching.MethodsThis mixed methods study uses data from a nationally representative survey of reproductive-aged women veterans who use the Veterans Affairs Healthcare System for primary care, including 979 participants at risk of unintended pregnancy. Women reported all contraceptive methods used in the past month and were asked, “If you could choose any method of contraception or birth control to prevent pregnancy, what would be your ideal choice?” and selected a single “ideal” method. If applicable, participants were additionally asked, “Why aren't you currently using this method of contraception?” We used adjusted logistic regression to identify patient-, provider-, and system-level factors associated with ideal–current method match. We qualitatively analyzed open-ended responses about reasons for ideal method nonuse.ResultsOverall, 58% were currently using their ideal method; match was greatest among women selecting an IUD as ideal (73%). Non-White race/ethnicity (adjusted odds ratio, 0.68; 95% confidence interval, 0.52–0.89) and mental illness (adjusted odds ratio, 0.69; 95% confidence interval, 0.52–0.92) were negatively associated with ideal–current match in adjusted analyses; the presence of a gynecologist at the primary care site was associated with an increased odds of match (adjusted odds ratio, 1.35; 95% confidence interval, 1.03–1.75). Modifiable barriers to ideal method use were cited by 23% of women, including access issues, cost concerns, and provider-level barriers; 79% of responses included nonmodifiable reasons for mismatch including relationship factors and pregnancy plans incongruent with ideal method use, suggesting limitations of our measure based on differential interpretation of the word “ideal.”ConclusionsMany women veterans are not currently using the contraceptive method they consider ideal. Results emphasize the complexity of contraceptive method selection and of measuring contraceptive preference matching.     

Prevalence and correlates of ambivalence towards pregnancy among nonpregnant women

BACKGROUND: Ambivalence towards pregnancy is rarely acknowledged in policy discussions. METHODS: We surveyed 441 nonpregnant women who consecutively presented to two urgent care clinics in California about their current intentions to conceive using a five-point scale. We examined the association between ambivalence towards pregnancy, sociodemographic characteristics and use of contraception. RESULTS: Almost one third of women (29.0%; 95% CI=25-33%) expressed ambivalence about their intentions to become pregnant. In multivariable modeling, being older than 30, being nonwhite and having a personal or religious objection to abortion were significantly associated with ambivalence towards pregnancy. Compared with women who stated they were trying to avoid pregnancy, women who expressed ambivalence were significantly less likely to have used a barrier or hormonal form of contraception at last intercourse (OR=0.36, 95% CI=0.23-0.57) and more likely to use the natural family planning (NFP) method (OR=3.31, 95% CI=1.39-7.90) or withdrawal (OR=1.61, 95% CI=0.98-2.65). CONCLUSION: Ambivalence towards pregnancy is common and is associated with use of less effective contraceptive methods.     

Induced abortion among women veterans: data from the ECUUN study

Objective

We compared rates of induced abortion among women veterans receiving Veterans Affairs (VA) healthcare to rates in the general US population, as current policy prohibits VA provision of abortion counseling or services even when pregnancy endangers a veteran's life.

Reproductive Life Plan Counseling and Effective Contraceptive Use among Urban Women Utilizing Title X Services

BackgroundAlthough the Centers for Disease Control and Prevention and the U.S. Office of Population Affairs recommend inclusion of reproductive life plan counseling (RLPC) in all well-woman health care visits, no studies have examined the effect of RLPC sessions on the decision to use effective contraception at publicly funded family planning sites. RLPC could be a particularly impactful intervention for disadvantaged social groups who are less likely to use the most effective contraceptive methods.MethodsUsing data from 771 nonpregnant, non–pregnancy-seeking women receiving gynecological services in the Cincinnati—Hamilton County Reproductive Health and Wellness Program, multinomial logistic regression models compared users of nonmedical/no method with users of 1) the pill, patch, or ring, 2) depot medroxyprogesterone acetate, and 3) long-acting reversible contraception (LARC). The effect of RLPC on the use of each form of contraception, and whether it mediated the effect of race/ethnicity and education on contraceptive use, was examined while controlling for age, insurance status, and birth history. The interaction between RLPC and race/ethnicity and the interaction between RLPC and educational attainment was also assessed.FindingsRLPC was not associated with contraceptive use. The data suggested that RLPC may increase LARC use over nonmedical/no method use. RLPC did not mediate or moderate the effect of race/ethnicity or educational attainment on contraceptive use in any comparison.ConclusionsIn this system of publicly funded family planning clinics, RLPC seems not to encourage effective method use, providing no support for the efficacy of the RLPC intervention. The results suggest that this intervention requires further development and evaluation.     

Organizational factors associated with screening for military sexual trauma

PurposeThis exploratory study investigated organizational factors associated with receipt of military sexual trauma (MST) screening during an early timeframe of the Veterans Health Administration’s (VHA) implementation of the universal MST screening policy.MethodsThe sample consisted of all VHA patients eligible for MST screening in fiscal year 2005 at 119 VHA facilities. Analyses were conducted separately by gender and by user status (i.e., new patients to the VHA health care system in FY 2005 and continuing users who had previously used the VHA health care system in the past year). Multivariate generalized estimating equations were used to assess the effects of facility-level characteristics and adjusted for person-level covariates.ResultsFacility-level mandatory universal MST screening policies were associated with increased odds of receiving MST screening among new female patients and both continuing and new male patients: Odds ratio (OR), 2.87 (95% confidence interval [CI], 1.39–5.89) for new female patients; OR, 8.15 (95% CI, 2.93–22.69) for continuing male patients; and OR, 4.48 (95% CI, 1.79–11.20) for new male patients. Facility-level audit and feedback practices was associated with increased odds of receiving MST screening among new patients: OR, 1.91 (95% CI, 1.26–2.91) for females and OR, 1.86 (95% CI, 1.22–2.84) for males. Although the facility-level effect for women’s health clinic (WHC) did not emerge as significant, patient-level effects indicated that among these facilities, women who used a WHC had greater odds of being screened for MST compared with women who had not used a WHC: OR, 1.79 (95% CI, 1.18–2.71) for continuing patients and OR, 2.20 (95% CI, 1.59–3.04) for new patients.ConclusionThis study showed that facility policies that promote universal MST screening, as well as audit and feedback practices at the facility, significantly improved the odds of patients receiving MST screening. Women veterans’ utilization of a WHC was associated with higher odds of receiving MST screening. This study provides empirical support for the use of policies and audit and feedback practices which the VHA has used since the implementation of the MST screening directive to encourage compliance with VHA’s MST screening policy and is likely associated with the present-day success in MST screening across all VHA facilities.     

Disparities in Sexually Transmitted Infection/HIV Testing,Contraception, and Emergency Contraception Care Among Adolescent Sexual Minority Women Who Are Racial/Ethnic Minorities

PurposeSexual minority women and racial/ethnic minority women in the United States are at increased risk for sexually transmitted infections (STIs) and unintended pregnancy. Yet, we know little about STI/HIV testing and contraceptive care among women who have sex with women only and women who have sex with both women and men, and who are racial/ethnic minorities. This study examined receipt of STI/HIV testing and contraceptive care among sexually active adolescent women by sex of sexual contact(s) and race/ethnicity.MethodsOur sample included 2,149 sexually active adolescent women from the National Survey of Family Growth (2011–2019). We examined receipt of sexual and reproductive health (SRH) services by sex of sexual contact(s) and race/ethnicity: STI and HIV testing, contraceptive counseling, contraceptive method, emergency contraception (EC) counseling, and EC method.ResultsService receipt was low for all adolescent women, with disparities by sex of sexual contact(s) and by race/ethnicity. Women who have sex with women only had the lowest rates across all services; women who have sex with both women and men had higher rates of STI and HIV testing and EC counseling than women who have sex with men only. Non-Hispanic Black women had higher rates of STI and HIV testing than non-Hispanic White peers, and non-Hispanic Black and Hispanic women had lower rates of contraception method receipt than their non-Hispanic White peers. Racial/ethnic disparities persisted when results were stratified by sex of sexual contact(s).DiscussionThere is an unmet need for improved SRH service delivery for all adolescent women and for services that are not biased by sex of sexual contact(s) and race/ethnicity.     

Factors associated with the provision of antenatal contraceptive counseling

BACKGROUND: A chart review was conducted to evaluate patient and provider characteristics associated with having a documented antenatal plan regarding future contraception. STUDY DESIGN: A retrospective chart review of 528 parturients delivering between January and August 2002 was performed. Data obtained from chart review included demographics, antecedent pregnancy outcome, number of prenatal visits, provider type and documentation of an antenatal plan for postpartum contraception. RESULTS: Non-Hispanic white women, as compared to other racial/ethnic groups, were more likely to have documented counseling plans (OR 1.5, 95% CI 0.9-2.3), while non-English-speaking women were significantly less likely to have contraceptive plans recorded (OR 0.5, 95% CI 0.3-0.8). Women with recorded antenatal plans attended more prenatal visits (median 10 vs. 8, p < .001). Nurse practitioners were significantly more likely to document antenatal contraceptive counseling than were residents (OR 3.7, 95% CI 2.4-5.5). In the adjusted analysis, the factors most strongly being positively correlated with antenatal documentation included attending > 10 prenatal visits (adjusted OR 6.2, 95% CI 2.9-13.2), being seen by a nurse practitioner (adjusted OR 4.5, 95% CI 2.9-7.0) and being non-English speaking (adjusted OR 0.6, 95% CI 0.3-1.0). CONCLUSION: The provision of antenatal contraceptive counseling is associated with certain characteristics, including the patient's primary language, the number of prenatal visits and type of provider seen.     

Context of care and contraceptive method use.

OBJECTIVES: We assessed the relationship between context of care (incorporates insurance status with clinical setting) on contraceptive use among a national sample of reproductive-aged women. Our hypothesis is that compared to privately insured women who receive their health care in private doctors' offices, women who are publicly insured or self-pay and/or receive their health care in a clinic are more likely to use permanent or long-acting contraceptive methods. METHODS: The study population, consisting of 4,358 women surveyed as part of the 1995 National Survey of Family Growth (NSFG) who were both at risk of unintended pregnancy and currently sexually active, was analyzed using polytomous logistic regression. RESULTS: Following adjustment for age, race/ethnicity, marital status, education, income, parity and smoking, there was a trend toward long-acting contraceptive use among women with public insurance or who were self-pay, regardless of clinical setting compared to privately insured women seen in private clinics. Self-pay and publicly insured women of low parity tended to use long-acting contraception, as did privately insured women seen in clinics. CONCLUSIONS: Insurance information, as well as clinical setting, may guide clinicians' contraceptive decision-making.     

Postpartum Transition of Care: Racial/Ethnic Gaps in Veterans’ Re-Engagement in VA Primary Care after Pregnancy

IntroductionPregnancy presents an opportunity to engage veterans in health care. Guidelines recommend primary care follow-up in the year postpartum, but loss to follow-up is common, poorly quantified, and especially important for those with gestational diabetes (GDM) and hypertension. Racial maternal inequities are well-documented and might be exacerbated by differential postpartum care. This study explores variation in postpartum re-engagement in U.S. Department of Veteran Affairs health care system (VA) primary care to identify potential racial/ethnic inequities in this care transition.MethodsWe conducted a complete case analysis of the 2005–2014 national VA birth cohort (n = 18,414), and subcohorts of veterans with GDM (n = 1,253) and hypertensive disorders of pregnancy (HDP; n = 2,052) using VA-reimbursed discharge claims and outpatient data. Outcomes included incidence of any VA primary care visit in the postpartum year; in age-adjusted logistic regression, we explored race/ethnicity as a primary predictor.ResultsIn the year after a VA-covered birth, the proportion of veterans with one or more primary care visit was 53.8% overall, and slightly higher in the GDM (56.0%) and HDP (57.4%) subcohorts. In adjusted models, the odds of VA primary care follow-up were significantly lower for Black/African American (odds ratio, 0.87; 95% confidence interval, 0.81–0.93), Asian (odds ratio, 0.76; 95% confidence interval, 0.61–0.95), and Hawaiian/other Pacific Islander (odds ratio, 0.73; 95% confidence interval, 0.55–0.96) veterans, compared with White veterans. Among the subcohorts with GDM or HDP, there were no significant associations between primary care and race/ethnicity.ConclusionsOne-half of veterans re-engage in VA primary care after childbirth, with significant racial differences in this care transition. Re-engagement for those with the common pregnancy complications of HDP and GDM is only slightly higher, and less than 60%. The potential for innovations such as VA maternity care coordinators to address such gaps merits attention.     

Diffusion of innovation in women's health care delivery: the Department of Veterans Affairs' adoption of women's health clinics.

BACKGROUND: In response to concerns about the availability and quality of women's health services in Department of Veterans Affairs (VA) medical centers in the early 1990s, Congress approved landmark legislation earmarking funds to enhance women's health services. A portion of the appropriation was used to launch Comprehensive Women's Health Centers as exemplars for the development of VA women's health care throughout the system. We report on the diffusion and characteristics of VA women's health clinics (WHCs) 10 years later. METHODS: In 2001, we surveyed the senior women's health clinician at each VA medical center serving > or =400 women veterans (83% response rate) regarding their internal organizational characteristics in relation to factors associated with organizational innovation (centralization, complexity, formalization, interconnectedness, organizational slack, size). We evaluated the comparability of WHCs (n = 66) with characteristics of the original comprehensive women's health centers (CWHCs; n = 8). RESULTS: Gender-specific service availability in WHCs was comparable to that of CWHCs with important exceptions in mental health, mammography and osteoporosis management. WHCs were less likely to have same-gender providers (p < .05), women's health training programs (p < .01), separate women's mental health clinics (p < .001), separate space (p < .05), or adequate privacy (p < .05); however, they were less likely to have experienced educational program closures (p < .001) and staffing losses (p < .05) compared to CWHCs. CONCLUSIONS: Diffusion of comprehensive women's health care is as yet incomplete. More research is needed to examine the quality of care associated with these models and to establish the business case for managers faced with small female patient caseloads.     

The Rise of Female Sterilization: A Closer Look at Colombia

Objective In the 1970s, OCPs and IUDs were the most popular contraceptive methods in Colombia. According to data from the most recent Demographic and Health Survey (DHS), sterilization has become the most common form of birth control in Colombia. This study aims to examine the characteristics of Colombian women desiring long-acting contraception. Methods This study uses the 2005 and 2010 Colombian DHS dataset. Women who choose long-acting contraception were divided into those using female sterilization and those using long-acting reversible contraception (LARC). A multivariate logistic regression model was used to compare demographic and social determinants of contraceptive choice among reproductive age women seeking long-acting contraception between the years 2005 and 2010. Results Among women using a long-acting contraceptive method in 2010, compared to 2005, women were significantly more likely to be sterilized (1.14 OR, 95% CI 1.09–1.18) and less likely to use LARC (0.88 OR, 95% CI 0.85–0.92). Of women seeking long-acting contraception, those exposed to a family planning provider were less likely to undergo sterilization (0.54 OR, 95% CI 0.51–0.58) and more likely to use LARC (1.84 OR, 95% CI 1.73–1.96). When compared to all contraceptive users, younger women and women with less than two children were more likely to use LARC than sterilization. Conclusion Between 2005 and 2010, an increase in the proportion of contracepting women being sterilized in Colombia occurred. Our findings suggest that exposure to a family planning provider and appropriate contraceptive counseling appears to be key determinants of long-acting contraceptive choice. To improve use of long-acting, effective contraception, efforts should be made to increase access to family planning providers.     

Associations between recent contraceptive use and quality of life among women

BackgroundWhether contraception affects health-related quality of life (HRQoL) is unclear.Study DesignWe conducted a cross-sectional analysis of routine intake data collected from women aged 18–50 years, including the RAND-36 (Research and Development Corporation) measure of HRQoL, pregnancy intentions and recent contraceptive use. We used multivariable logistic regression to test the relationship between HRQoL and use of any and specific contraceptives. Physical and mental HRQoLs were dichotomized based on US population averages. Models were adjusted for age, race, marital status, education and pregnancy intentions.ResultsAmong the 726 women, those using any form of contraception were more likely to have average or better mental HRQoL than women using no contraception [adjusted odds ratio (aOR)=1.60, 95% confidence interval (CI) 1.01–2.53]. Women using injectable contraception were less likely than those using combined hormonal methods to have average or better physical HRQoL (aOR=0.26, 95% CI 0.09–0.80) and mental HRQoL (aOR=0.24, 95% CI 0.06–0.86).ConclusionsMeasures of women's HRQoL differ with contraceptive use.