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IIR 12-124 – HSR&D Study

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IIR 12-124
Examining Contraceptive Use and Unmet Need Among Women Veterans
Sonya B. Borrero MD MS
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Funding Period: January 2013 - December 2016

BACKGROUND/RATIONALE:
Unintended pregnancy is a prevalent problem in the US that is associated with significant adverse health and social consequences for women and their children. Contraceptive counseling and provision are integral components of primary care for women of reproductive age, as contraception is a highly effective way to prevent unintended pregnancy. The number of female Veterans of reproductive age is rapidly increasing, yet little is known about contraceptive care or outcomes among the growing population of women Veterans who receive health care within the Veterans Administration (VA) Healthcare System.

The Examining Contraceptive Use and Unmet Need (ECUUN) study was conducted to determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy in a national sample of reproductive-aged women Veterans who received health care from the VA. Findings from this study provide critical first evidence on the current state of contraceptive provision and use among women Veterans and how patient, provider, and system factors impact contraceptive provision and use within the VA Healthcare System.

OBJECTIVE(S):
The objectives of this study are to: 1) describe contraceptive use patterns for female Veterans aged 18-45 who use VA for primary care; 2) identify which subpopulations of women Veterans are at particularly high risk for unintended pregnancy; and 3) identify key modifiable barriers and facilitators to contraceptive use and determine how these vary across subpopulations.

METHODS:
To achieve these objectives we used a mixed methods study design. We conducted a cross-sectional, telephone-based survey with a random sample of 2,302 women VA-users between the ages of 18-44 who had at least one VA primary care visit in the prior 12 months. Survey data collected detailed information women's contraceptive use, pregnancy history, and experiences with VA reproductive healthcare and related factors. To provide an even more comprehensive profile of women Veteran's reproductive health, survey data were then linked with VA administrative data, pharmacy data, and the Women's Assessment Tool for Comprehensive Health (WATCH) data on women's health care models at VA facilities. We analyzed survey data to determine the proportion of women using contraception and types of methods used, unmet need for contraception, and the annual rate of unintended pregnancy. We also used quantitative survey data to examine which patient, provider, and system variables are associated with contraceptive and pregnancy outcomes. To deepen our understanding of how multilevel factors influence contraceptive behaviors and pregnancy outcomes, we conducted qualitative interviews with a purposeful sample of 195 survey participants.

FINDINGS/RESULTS:
Results from the 2,302 study participants indicate that 62.3% of women Veterans were using contraception in the month prior to the interview. Specifically, 34.4% were using a highly-effective method (sterilization, implant, or intrauterine device); 17.4% were using a moderately-effective method (contraceptive pill, patch, vaginal ring, or injection); and 10.2% were using less-effective, non-prescription methods (condoms, withdrawal, and natural family planning).

Among the 1,173 of women Veterans at risk for unintended pregnancy (women who had been sexually active with a man in the prior 3 months, had not had a hysterectomy, and were not infertile, pregnant, postpartum or seeking pregnancy), 88.5% were using some form of contraception. Specifically, 48.8% were using highly-effective methods, 23.4% were using moderately-effective methods, 15.9% were using less-effective methods, and 11.4% were using no method. Thus, approximately 27% of women at risk for unintended pregnancy were not using prescription contraception, thereby demonstrating a potential unmet contraceptive need.

The annual pregnancy rate within the entire sample was 67.3 per 1,000 women, and the unintended pregnancy rate was 26.1 per 1,000 women. Thus, 37.1% of pregnancies were reported as unintended.

These rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women Veterans are very similar to those in the general US population, as obtained by the 2011-2013 National Survey of Family Growth. While it is reassuring that contraceptive use rates are not lower and unintended pregnancy rates are not higher among women Veterans compared to the general US population, opportunities for improvement remain. Over a third of pregnancies in both populations are unintended, about 10% of women at risk of unintended pregnancy are not using any method of contraception, and nearly 30% are not using prescription contraception.


IMPACT:
This study provides the first published data on rates of contraceptive use, unmet contraceptive need, and unintended pregnancy in a representative sample of women VA-users. These data provide a global picture of the current state of contraceptive care in VA and suggest that additional efforts are needed to help women Veterans reduce their risk of unintended pregnancy. In addition, this study has yielded a rich and comprehensive dataset that can be used to answer a wide range of research and operations questions about women Veterans' reproductive health and health care. Thus, this study has provided and will continue to provide actionable information to further optimize women Veteran's reproductive healthcare experiences and outcomes within VA.

PUBLICATIONS:

Journal Articles

  1. Koenig AF, Borrero S, Zhao X, Callegari L, Mor MK, Sonalkar S. Factors associated with long-acting reversible contraception use among women Veterans in the ECUUN study. Contraception. 2019 Sep 1; 100(3):234-240.
  2. Wolgemuth T, Judge-Golden C, Callegari L, Zhao X, Mor M, Borrero S. Associations between Pregnancy Intention, Attitudes, and Contraceptive Use among Women Veterans in the ECUUN Study. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2018 Nov 1; 28(6):480-487.
  3. Judge-Golden CP, Borrero S, Zhao X, Mor MK, Callegari LS. The Association between Mental Health Disorders and History of Unintended Pregnancy among Women Veterans. Journal of general internal medicine. 2018 Dec 1; 33(12):2092-2099.
  4. Judge CP, Zhao X, Sileanu FE, Mor MK, Borrero S. Medical contraindications to estrogen and contraceptive use among women veterans. American journal of obstetrics and gynecology. 2018 Feb 1; 218(2):234.e1-234.e9.
  5. Rosenfeld EA, Miller E, Zhao X, Sileanu FE, Mor MK, Borrero S. Male partner reproductive coercion among women veterans. American journal of obstetrics and gynecology. 2018 Feb 1; 218(2):239.e1-239.e8.
  6. Schwarz EB, Sileanu FE, Zhao X, Mor MK, Callegari LS, Borrero S. Induced abortion among women veterans: data from the ECUUN study. Contraception. 2018 Jan 1; 97(1):41-47.
  7. MacDonald S, Hausmann LRM, Sileanu FE, Zhao X, Mor MK, Borrero S. Associations Between Perceived Race-based Discrimination and Contraceptive Use Among Women Veterans in the ECUUN Study. Medical care. 2017 Sep 1; 55 Suppl 9 Suppl 2:S43-S49.
  8. Callegari LS, Zhao X, Schwarz EB, Rosenfeld E, Mor MK, Borrero S. Racial/ethnic differences in contraceptive preferences, beliefs, and self-efficacy among women veterans. American journal of obstetrics and gynecology. 2017 May 1; 216(5):504.e1-504.e10.
  9. Borrero S, Callegari LS, Zhao X, Mor MK, Sileanu FE, Switzer G, Zickmund S, Washington DL, Zephyrin LC, Schwarz EB. Unintended Pregnancy and Contraceptive Use Among Women Veterans: The ECUUN Study. Journal of general internal medicine. 2017 Aug 1; 32(8):900-908.
  10. Rosenfeld E, Callegari LS, Sileanu FE, Zhao X, Schwarz EB, Mor MK, Borrero S. Racial and ethnic disparities in contraceptive knowledge among women veterans in the ECUUN study. Contraception. 2017 Jul 1; 96(1):54-61.
  11. Callegari LS, Zhao X, Nelson KM, Borrero S. Contraceptive adherence among women Veterans with mental illness and substance use disorder. Contraception. 2015 May 1; 91(5):386-92.
  12. Goyal V, Mattocks K, Bimla Schwarz E, Borrero S, Skanderson M, Zephyrin L, Brandt C, Haskell S. Contraceptive provision in the VA healthcare system to women who report military sexual trauma. Journal of women's health (2002). 2014 Sep 1; 23(9):740-5.
Conference Presentations

  1. Callegari LS, Schwarz EB, Zhao X, Mor MK, Rosenfeld EA, Borrero SB. Racial and Ethnic Differences in Contraceptive Preferences: Findings from the Examining Contraceptive Use and Unmet Need among Women Veterans (ECUUN) Study. Paper presented at: VA HSR&D Field-Based Meeting to Engage Diverse Stakeholders and Operational Partners in Advancing Health Equity in the VA Healthcare System; 2016 Sep 21; Philadelphia, PA.
  2. Borrero SB, Callegari L, Zhao X, Sileanu FE, Mor MK, Switzer GE, Zickmund SL, Washington D, Schwarz EB. Rates of Unintended Pregnancy, Contraceptive Use, and Unmet Contraceptive Need Among Women Veterans. Paper presented at: Society of General Internal Medicine Annual Meeting; 2016 May 14; Hollywood, FL.
  3. Callegari LS, Schwarz EB, Zhao X, Mor MK, Zephyrin LS, Borrero S. The Association Between Mental Health Disorders and Unintended Pregnancy Among Women Veterans. Poster session presented at: North American Forum on Family Planning; 2015 Nov 15; Chicago, IL.
  4. Rosenfeld EA, Callegari LS, Schwarz EB, Zhao X, Mor MK, Borrero S. Associations Between Contraceptive Knowledge and Use of Prescription Contraception Among Women Veterans. Poster session presented at: North American Forum on Family Planning; 2015 Nov 15; Chicago, IL.
  5. Borrero SB. Women Veterans: an overview of their unique health profile and healthcare needs. Presented at: University of Pittsburgh School of Nursing The Veteran’s Journey to Achieving Wellness: Successful Reintegration into Civilian Life Conference; 2015 Sep 10; Pittsburgh, PA.
  6. Rosenfeld EA, Callegari LS, Schwarz EB, Zhao X, Mor MK, Borrero SB. Associations between contraceptive knowledge and use of prescription contraception among women Veterans. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  7. Rosenfeld EA, Schwarz EB, Callegari LS, Zhao X, Mor MK, Borrero SB. Racial/ethnic differences in contraceptive knowledge among women Veterans. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  8. Carter A, Borrero S, Wessel C, Bean-Mayberry B, Washington DL, Corbelli J. Racial and ethnic disparities in healthcare among women in the VA: a systematic review. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2015 Apr 24; Toronto, Canada.
  9. Borrero SB. Unintended pregnancy and contraceptive needs among US servicewomen and women Veterans. Presented at: North American Forum on Family Planning; 2014 Oct 12; Miami, FL.
  10. Callegari L, Zhao X, Borrero S. Mental illness and contraceptive adherence among women Veterans. Poster session presented at: North American Forum on Family Planning; 2014 Oct 12; Miami, FL.
  11. Borrero SB, Zhao X, Mor MK, Schwarz EB. Trends in VA contraceptive provision, 2008-2013. Paper presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
  12. Borrero SB, Zhao X, Mor MK, Schwarz EB. Racial variation in receipt of contraception among women Veterans. Poster session presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
  13. Schwarz EB, Zhao X, Mor MK, Borrero SB. Predicted pregnancy rates: a metric to guide contraceptive service delivery improvement. Poster session presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
  14. Goyal V, Borrero SB, Skanderson M, Brandt C, Haskell S. Trends in contraceptive use among women Veterans receiving care within the Department of Veterans Affairs. Poster session presented at: North American Forum on Family Planning; 2013 Oct 6; Seattle, WA.


DRA: Health Systems, Other Conditions
DRE: Prevention
Keywords: Attitudes/Beliefs, Disparities, Outcomes - Patient, Patient Preferences, Reproductive Care (Gynecological), Utilization
MeSH Terms: none