Abstract

Background: Women Veterans face elevated risks of pregnancy-related morbidity and mortality compared to their civilian counterparts due to higher rates of medical and mental health comorbidities. High-quality, patient-centered contraceptive care is a critical component of comprehensive women’s health care and can enable Veterans to time and plan pregnancies, including optimizing chronic conditions prior to pregnancy and healthy birth spacing, to reduce adverse outcomes. The Examining Contraceptive Use and Unmet Need in Veterans (ECUUN) survey fielded in 2014-16 demonstrated significant access barriers and a high prevalence of unmet contraceptive need among Veterans using VA. VA has since implemented efforts to improve access to and quality of contraceptive care, including investing in training for primary care providers and implementing a national clinical reminder in 2021 to prompt regular discussions of pregnancy goals and contraceptive needs. To date, no studies examine the impact of these changes on Veterans’ experiences or outcomes. Significance: Given limitations of electronic health record data in capturing contraceptive access barriers or outcomes, Veteran-reported data on experiences and perspectives are urgently needed to evaluate VA’s progress in addressing gaps in contraceptive care as well as its ability to meet Veterans’ current needs. This mixed methods study, which includes a national survey and qualitative interviews, will generate novel insights on changes in contraceptive utilization and outcomes since the ECUUN survey as well as on current access and quality of VA contraceptive care, including community care. This study includes a focus on women Veterans at highest risk of experiencing poor outcomes, including those residing in rural areas and those in minority racial/ethnic groups. Findings from this study will be used by operations leaders to guide VA policy. Innovation & Impact: This proposal is innovative in its timeliness, use of prior VA survey data to draw comparisons over time, and deployment of new state-of-the-art patient-centered measures not yet fielded in VA such as the National Quality Forum (NQF)-endorsed Person-Centered Contraceptive Counseling (PCCC) measure and the Assessment of Perceived Access to Care (APAC) measure. Specific Aims: Aim 1: To use quantitative survey data to examine changes over time since ECUUN in contraceptive access and use, methods used, and pregnancy planning, including differences by Veteran characteristics (e.g., geography, race/ethnicity). Aim 2: To use quantitative survey data to test for current differences in novel person-centered measures of contraceptive access and quality by Veteran characteristics and characteristics of their health care. Aim 3: To contextualize Aim 1 & 2 quantitative findings, including access barriers and/or poor-quality care, by conducting qualitative interviews with Veterans. Methodology: This is a sequential explanatory mixed methods study beginning with a national survey of 3,600 women Veterans of childbearing age who used VA primary care or gynecology care in the past year. Qualitative interviews will then be conducted among Veteran survey respondents, purposively sampling at-risk subgroups (based on geography and race/ethnicity) whose survey responses indicate gaps in contraceptive care access and quality. Quantitative data will inform qualitative sampling and data collection, and quantitative and qualitative data will be integrated using mixed methods analytic techniques such as joint displays. Next Steps/Implementation: Next steps will include conducting a stakeholder engagement meeting with Veterans, women’s health providers, and operational partners including the Offices of Women’s Health and the Office of Rural Health to share key research findings, develop strategic goals, and prioritize interventions to address deficiencies in contraceptive access and quality. Ultimately, this study has the potential to enhance VA’s ability to be a national leader in delivering high-quality, patient-centered contraceptive care and to reduce adverse health outcomes, including pregnancy-related morbidity and mortality, among Veterans nationally.

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DRA: Health Systems Science

DRE: TRL - Applied/Translational, Engagement Science

Keywords: Disparities, Reproductive Care (Gynecological)

MeSH Terms: None at this time.