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O'Connor-Terry C, Zhao X, Mor MK, Chang JC, Callegari LS, Borrero S, Quinn DA. Abortion After Pregnancy Occurrence with Contraceptive Use Among Veterans. J Womens Health (Larchmt) 2024. [PMID: 38946661 DOI: 10.1089/jwh.2023.0829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
Objective: Many people report becoming pregnant while using contraception. Understanding more about this phenomenon may provide insight into pregnant people's responses to and healthcare needs for these pregnancies. This study explores the outcome (e.g., birth, miscarriage, abortion) of pregnancies among Veterans in which conception occurred in the month of contraceptive use. Study Design: We used data from the Examining Contraceptive Use and Unmet Need Study, a telephone-based survey conducted in 2014-2016 of women Veterans (n = 2302) ages 18-44 receiving primary care from the Veterans Health Administration. For each pregnancy, we estimated the relationship between occurrence in the month of contraceptive use and the outcome of the pregnancy using multinomial logistic regression, controlling for relevant demographic, clinical, and military factors and clustering of pregnancies from the same Veteran. Results: The study included 4436 pregnancies from 1689 Veterans. Most participants were ≥30 years of age (n = 1445, 85.6%), identified as non-Hispanic white (n = 824, 51.6%), and lived in the Southern United States (n = 994, 55.6%). Nearly 60% (n = 1007) of Veterans who had ever been pregnant reported experiencing a pregnancy in the month of contraceptive use; a majority of those pregnancies (n = 1354, 80.9%) were described as unintended. In adjusted models, pregnancies occurring in the month of contraceptive use were significantly more likely to end in abortion (aOR: 1.76, 95% CI: 1.42-2.18) than live birth. Conclusions: Pregnancy while using contraception is common among Veterans; these pregnancies are more likely to end in abortion than live birth. Given widespread restrictions to reproductive health services across much of the United States, ensuring Veterans' access to comprehensive care, including abortion, is critical to supporting reproductive autonomy and whole health.
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Affiliation(s)
- Carly O'Connor-Terry
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Xinhua Zhao
- Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Maria K Mor
- Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Judy C Chang
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Magee-Women's Research Institute, Pittsburgh, Pennsylvania, USA
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lisa S Callegari
- Departments of Obstetrics & Gynecology and Health Services, University of Washington, Seattle, Washington, USA
- Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Sonya Borrero
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Center for Innovative Research on Gender Health Equity, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Deirdre A Quinn
- Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Center for Innovative Research on Gender Health Equity, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Golden RE, Sanders AM, Frayne SM. RE-AIM applied to a primary care workforce training for rural providers and nurses: the Department of Veterans Affairs' Rural Women's Health Mini-Residency. FRONTIERS IN HEALTH SERVICES 2023; 3:1205521. [PMID: 38028946 PMCID: PMC10656764 DOI: 10.3389/frhs.2023.1205521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 09/04/2023] [Indexed: 12/01/2023]
Abstract
Introduction Application of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate workforce education and training programs targeting clinical health care staff has received relatively little attention. This paper aims to contribute to this area with RE-AIM findings from a women's health-focused workforce training program implemented by the U.S. Department of Veterans Affairs (VA). Over the past two decades, the rapid expansion of the women Veteran population in VA has necessitated a quick response to meet clinical demand. To address this health care need, the VA Offices of Rural Health (ORH) and Women's Health (OWH) partnered to deploy a primary care workforce development initiative for Rural Providers and Nurses-the Rural Women's Health Mini-Residency (Rural WH-MR)-to train VA clinicians in rural locations in skills for the care of women Veterans. Here we assess the applicability of RE-AIM as an evaluation framework in this context. Methods We evaluated the Rural WH-MR, relying on a primarily quantitative approach, rooted in RE-AIM. It included longitudinal and cross-sectional measurements from multiple quantitative and qualitative data sources to develop selected metrics. Data collection instruments consisted of pre-, post-, and follow-up training surveys, course evaluations, existing VA databases, and implementation reports. We developed metrics for and assessed each RE-AIM component by combining data from multiple instruments and then triangulating findings. Results Results from the Rural WH-MR program for fiscal years 2018-2020 indicate that RE-AIM provides an instructive evaluation framework for a rural workforce training program, particularly in eliciting clarity between measures of Reach vs. Adoption and focusing attention on both provider- and patient-level outcomes. Discussion We describe evaluation metric development and barriers to and facilitators of utilizing RE-AIM as an evaluation framework for a provider- and nurse-facing intervention such as this workforce training program. We also reflect upon RE-AIM benefits for highlighting process and outcomes indicators of a training program's success and lessons learned for evaluating rural workforce development innovations. Several of our observations have implications for training and evaluation approaches in rural areas with more limited access to health care services.
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Affiliation(s)
- Rachel E. Golden
- United States Department of Veterans Affairs, HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Veterans Health Administration, Palo Alto, CA, United States
| | - Aimee M. Sanders
- US Department of Veterans Affairs, Office of Women’s Health, Washington, DC, United States
| | - Susan M. Frayne
- United States Department of Veterans Affairs, HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Veterans Health Administration, Palo Alto, CA, United States
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, CA, United States
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Gopisetty DD, Shaw JG, Gray C, Frayne S, Phibbs C, Shankar M. Veteran Postpartum Health: VA Care Team Perspectives on Care Coordination, Health Equity, and Trauma-Informed Care. Mil Med 2023; 188:e1563-e1568. [PMID: 36151892 DOI: 10.1093/milmed/usac275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/21/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION A growing number of veterans are having children, and pregnancy is an opportunity to engage with health care. Within the Veterans Health Administration (VA), the VA maternity care coordination program supports veterans before, during, and after pregnancy, which are periods that inherently involve transitions between clinicians and risk care fragmentation. Postpartum transitions in care are known to be especially tenuous, with low rates of primary care reengagement. The objective of this study is to better understand this transition from the perspectives of the VA care teams. MATERIALS AND METHODS Eight semi-structured qualitative interviews with VA team members who work in maternity care were conducted at a single VA center's regional network. Interviews explored the transition from maternity care to primary care to understand the care team's perspective at three levels: patient, clinician, and systems. Rapid qualitative analysis was used to identify emergent themes. RESULTS Participants identified facilitators and opportunities for improvement in the postpartum transition of care. Patient-clinician trust is a key facilitator in the transition from maternity to primary care for veterans, and the breadth of VA services emerged as a key system-level facilitator to success. Interviewees also highlighted opportunities for improvement, including more trauma-informed practices for nonbinary veterans, increased care coordination between VA and community staff, and the need for training in postpartum health with an emphasis on health equity for primary care clinicians. CONCLUSIONS The Department of Veterans Affairs Healthcare System care team perspectives may inform practice changes to support the transition from maternity to primary care for veterans. To move toward health equity, a system-level approach to policy and programming is necessary to reduce barriers to primary care reengagement. This study was limited in terms of sample size, and future research should explore veteran perspectives on VA postpartum care transitions.
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Affiliation(s)
- Deepti Divya Gopisetty
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025, USA
- Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Jonathan G Shaw
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025, USA
- Division of Primary Care & Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Caroline Gray
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025, USA
| | - Susan Frayne
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025, USA
- Division of Primary Care & Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Ciaran Phibbs
- VA Palo Alto Health Care System, Health Economics Resource Center (HERC), Palo Alto, CA 94304, USA
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA 94304-5660, USA
| | - Megha Shankar
- VA Palo Alto Health Care System, Center for Innovation to Implementation (Ci2i), Menlo Park, CA 94025, USA
- Stanford University School of Medicine, Stanford, CA 94305, USA
- Division of General Internal Medicine, Department of Medicine, UC San Diego, La Jolla, CA 92093, USA
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Quinn DA, Sileanu FE, Borrero S, Callegari LS. Reproductive health services: A missed opportunity in VA primary care? Contraception 2023; 120:109957. [PMID: 36649750 DOI: 10.1016/j.contraception.2023.109957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 01/03/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Integration of reproductive health services into comprehensive primary care is increasingly viewed as a strategy to address service gaps and improve patient-centered care. We assess receipt of contraceptive and prepregnancy health counseling among pregnancy-capable Veterans within Veterans Affairs (VA) primary care. STUDY DESIGN Data are from 1076 participants in a nationally representative, cross-sectional survey of women Veterans ages 18 to 45 with an overall survey response rate of 28%. Descriptive analyses and chi square tests of association were performed. RESULTS Only 44% of pregnancy-capable Veterans reported receiving any contraceptive and/or prepregnancy care from a VA primary care provider in the past year. CONCLUSIONS Although VA guidelines include reproductive services as a core component of primary care, additional efforts may be needed to promote routine provision of this care in practice.
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Affiliation(s)
- Deirdre A Quinn
- Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States; Center for Innovative Research on Gender Health Equity, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Florentina E Sileanu
- Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Sonya Borrero
- Center for Health Equity Research & Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States; Center for Innovative Research on Gender Health Equity, University of Pittsburgh, Pittsburgh, PA, United States; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, United States
| | - Lisa S Callegari
- Departments of Obstetrics & Gynecology and Health Services, University of Washington, Seattle, WA, United States; Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, United States
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Oguntade RT, Ojewole EB, Ogunrombi MO. Unintended pregnancies among HIV-positive women in sub-Saharan Africa: a scoping review protocol. Syst Rev 2023; 12:12. [PMID: 36681857 PMCID: PMC9862844 DOI: 10.1186/s13643-023-02168-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/29/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Unintended pregnancies pose a severe threat to the well-being of HIV-positive women and their unborn children. Factors contributing to the high incidence of unintended pregnancies include contraceptive failure, low uptake of contraceptives, and misuse of contraceptives. Despite various contraceptive options, an increased incidence of unintended pregnancies is rampant among HIV-positive women in the region of sub-Saharan Africa. This study seeks to present evidence of unintended pregnancies among women living with HIV in sub-Saharan Africa, including those using contraceptives. METHOD This study entails a scoping review to survey and interrogate the literature to provide evidence for the incidence of unintended pregnancies among HIV-positive women in sub-Saharan Africa. A proposed framework by Arksey and O'Malley will guide this scoping review. Peer-reviewed articles which address the research questions will constitute the main search. Electronic databases such as EBSCOhost, Cochrane Library, World of Science, World Health Organization (WHO) library databases, Science Direct, Google Scholar PubMed, and gray literature search will be involved. Reference list from studies included will also be searched. The investigation of articles will be done employing keywords from the studies included. The inclusion and exclusion criteria will guide two separate reviewers with the screening of abstracts and full papers. To summarize the findings from this review, thematic content analysis will be done using NVivo version 11. DISCUSSION We expect that this review will add to the current body of knowledge on the incidence of unintended pregnancies among HIV-positive women, identify gaps for further future research, and show evidence that may contribute to strengthening the health system's regulations, guidelines, and policies that may help prevent unintended pregnancies among HIV-positive women. SYSTEMATIC REVIEW REGISTRATION 10.17605/OSF.IO/EY3R5.
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Affiliation(s)
- Racheal Tomilola Oguntade
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of Kwa-Zulu Natal, Durban, South Africa.
| | - Elizabeth Bolanle Ojewole
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of Kwa-Zulu Natal, Durban, South Africa
| | - Modupe Olufunmilayo Ogunrombi
- Department of Clinical Pharmacology, School of Medicine, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
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Gawron LM, He T, Lewis L, Fudin H, Callegari LS, Turok DK, Stevens V. Oral Emergency Contraception Provision in the Veterans Health Administration: a Retrospective Cohort Study. J Gen Intern Med 2022; 37:685-689. [PMID: 36042074 PMCID: PMC9481759 DOI: 10.1007/s11606-022-07596-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 04/01/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND In the USA, oral emergency contraception (EC) use to prevent unintended pregnancy is increasing. Oral EC methods include levonorgestrel (LNG) and ulipristal acetate (UPA), with increased UPA efficacy over LNG in high BMI users and those beyond 3 days post intercourse. The Veterans Health Administration (VHA) provides oral EC at low or no cost, yet prescription-level Veteran data are lacking. OBJECTIVE To describe oral EC provision in VHA, including method type and Veteran user and prescriber characteristics. DESIGN A retrospective cohort study using VHA administrative data. PARTICIPANTS All VHA oral EC prescriptions from January 1, 2016, to December 31, 2020. MAIN MEASURES We linked Veteran-level sociodemographic and military characteristics and provider-level data with each prescription to identify variables associated with oral EC method. KEY RESULTS A total of 4280 EC prescriptions (85% LNG) occurred for 3120 unique Veterans over 5 years. While prescriptions remained low annually, the proportion of UPA prescriptions increased from 12 to 19%. Compared to LNG users, UPA users were older (34% vs 25% over age 35 years, p <0.001); more likely to identify as white (57% vs 46%) and non-Hispanic (84% vs 79%) (p <0.001); and more likely to have a BMI ≥ 25 (76% vs 67%, p <0.001). UPA prescriptions originated most frequently from VA Medical Centers (87%) and women's health clinics (76%) compared to community-based or other clinic types. In multivariable regression models, race, ethnicity, BMI ≥30, and prescriber facility type of a VA Medical Center or a women's clinic location were predictive of UPA prescription. CONCLUSIONS Oral EC provision in VHA remains low, but UPA use is increasing. LNG prescription occurs frequently in high BMI Veterans who would benefit from increased efficacy of UPA. Interventions to expand oral EC access in VHA are essential to ensure Veterans' ability to avert unwanted pregnancies.
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Affiliation(s)
- Lori M Gawron
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30N 1900E Rm 2B-200, Salt Lake City, UT, 84132, USA. .,VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
| | - Tao He
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lacey Lewis
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Hannah Fudin
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Lisa S Callegari
- VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - David K Turok
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, 30N 1900E Rm 2B-200, Salt Lake City, UT, 84132, USA
| | - Vanessa Stevens
- VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
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Callegari LS, Mahorter SS, Benson SK, Zhao X, Schwarz EB, Borrero S. Perceived Contraceptive Counseling Quality Among Veterans Using VA Primary Care: Data from the ECUUN Study. J Gen Intern Med 2022; 37:698-705. [PMID: 36042079 PMCID: PMC9481768 DOI: 10.1007/s11606-022-07586-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND High-quality contraceptive counseling is critical to support Veterans' reproductive autonomy and promote healthy outcomes. OBJECTIVE To describe perceived quality of contraceptive counseling in Veterans Health Administration (VA) primary care and assess factors associated with perceived high- and low-quality contraceptive counseling. DESIGN Cross-sectional study using data from the Examining Contraceptive Use and Unmet Need in women Veterans (ECUUN) national telephone survey. PARTICIPANTS Veterans aged 18-44 who received contraceptive services from a VA primary care clinic in the past year (N=506). MAIN MEASURES Perceived quality of contraceptive counseling was captured by assessing Veterans' agreement with 6 statements regarding provider counseling adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. High-quality counseling was defined as a top score of strongly agreeing on all 6 items; low-quality counseling was defined as not agreeing (neutral, disagreeing, or strongly disagreeing) with >3 items. We constructed two multivariable models to assess associations between patient-, provider-, and system-level factors and perceived high-quality (Model 1) and perceived low-quality counseling (Model 2). KEY RESULTS Most participants strongly agreed that their providers listened carefully (74%), explained things clearly (77%), and spent enough time discussing things (71%). Lower proportions strongly agreed that their provider discussed more than one option (54%), discussed pros/cons of various methods (44%), or asked which choice they thought was best for them (62%). In Model 1, Veterans who received care in a Women's Health Clinic (WHC) had twice the odds of perceiving high-quality counseling (aOR=1.99; 95%CI=1.24-3.22). In Model 2, Veterans who received care in a WHC (aOR=0.49; 95%CI=0.25-0.97) or from clinicians who provide cervical cancer screening (aOR=0.49; 95%CI=0.26-0.95) had half the odds of perceiving low-quality counseling. CONCLUSIONS Opportunities exist to improve the quality of contraceptive counseling within VA primary care settings, including more consistent efforts to seek patients' perspectives with respect to contraceptive decisions.
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Affiliation(s)
- Lisa S Callegari
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way S-152, Seattle, WA, 98108, USA. .,Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, USA. .,Department of Health Services, University of Washington School of Public Health, Seattle, USA.
| | - Siobhan S Mahorter
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way S-152, Seattle, WA, 98108, USA
| | - Sam K Benson
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way S-152, Seattle, WA, 98108, USA
| | - Xinhua Zhao
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, USA
| | | | - Sonya Borrero
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
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Bhatta M, Bian A, Norwood J, Shepherd BE, Ransby I, Nelson J, Turner M, Sterling TR, Castilho JL. Low rates of contraception use in women with HIV. Open Forum Infect Dis 2022; 9:ofac113. [PMID: 35392458 PMCID: PMC8982767 DOI: 10.1093/ofid/ofac113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/07/2022] [Indexed: 11/22/2022] Open
Abstract
Background Women with human immunodeficiency virus (WWH) have low rates of hormonal or long-acting contraceptive use. Few studies have described contraception use among WWH over time. Methods We examined contraception (including all forms of hormonal contraception, intrauterine devices, and bilateral tubal ligations) use among cisgender women aged 18–45 years in care at Vanderbilt’s human immunodeficiency virus (HIV) clinic in Nashville, Tennessee, from 1998 through 2018. Weighted annual prevalence estimates of contraception use were described. Cox proportional hazards models examined factors associated with incident contraception use and pregnancy. Results Of the 737 women included, median age at clinic entry was 31 years; average follow-up was 4.1 years. At clinic entry, 47 (6%) women were on contraception and 164 (22%) were pregnant. The median annual percentage of time on any contraception use among nonpregnant women was 31.7% and remained stable throughout the study period. Younger age was associated with increased risk of pregnancy and contraceptive use. Psychiatric comorbidity decreased likelihood of contraception (adjusted hazard ratio [aHR], 0.52 [95% CI {confidence interval}, .29–.93]) and increased likelihood of pregnancy (aHR, 1.77 [95% CI, .97–3.25]). While not associated with contraceptive use, more recent year of clinic entry was associated with higher pregnancy risk. Race, substance use, CD4 cell count, HIV RNA, smoking, and antiretroviral therapy were not associated with contraception use nor pregnancy. Conclusions Most WWH did not use contraception at baseline nor during follow-up. Likelihood of pregnancy increased with recent clinic entry while contraception use remained stable over time. Continued efforts to ensure access to effective contraception options are needed in HIV clinics.
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Affiliation(s)
- Manasa Bhatta
- School of Medicine, Vanderbilt University, Nashville, TN, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aihua Bian
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jamison Norwood
- Division of Infectious Disease, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bryan E Shepherd
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Imani Ransby
- Division of Infectious Disease, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey Nelson
- Division of Infectious Disease, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Megan Turner
- Division of Infectious Disease, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy R Sterling
- Division of Infectious Disease, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jessica L Castilho
- Division of Infectious Disease, Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
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9
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Quinn DA, Edmonds SW, Zhao X, Borrero S, Ryan GL, Zephyrin LC, Callegari LS. Veteran-Reported Receipt of Prepregnancy Care: Data from the Examining Contraceptive Use and Unmet Need (ECUUN) Study. Matern Child Health J 2021; 25:1254-1264. [PMID: 33929654 PMCID: PMC11220786 DOI: 10.1007/s10995-021-03131-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To identify the prevalence of women Veterans reporting receipt of counseling about health optimization prior to pregnancy, topics most frequently discussed, and factors associated with receipt of this care. METHODS We analyzed data from a nationally representative, cross-sectional telephone survey of women Veterans (n = 2302) ages 18-45 who used VA for primary care in the previous year. Our sample included women who were (1) currently pregnant or trying to become pregnant, (2) not currently trying but planning for pregnancy in the future, or (3) unsure of pregnancy intention. Multivariable logistic regression was used to examine adjusted associations of patient- and provider-level factors with receipt of any counseling about health optimization prior to pregnancy (prepregnancy counseling) and with counseling on specific topics. RESULTS Among 512 women who were considering or unsure about pregnancy, fewer than half (49%) reported receiving any prepregnancy counseling from a VA provider in the past year. For those who did, the most frequently discussed topics included healthy weight (29%), medication safety (27%), smoking (27%), and folic acid use before pregnancy (27%). Factors positively associated with receipt of prepregnancy counseling include history of mental health conditions (aOR = 1.96, 95% CI: 1.28, 3.00) and receipt of primary care within a dedicated women's health clinic (aOR = 2.07, 95% CI: 1.35, 3.18), whereas factors negatively associated include far-future and unsure pregnancy intentions (aOR = 0.35, 95% CI: 0.17, 0.71 and aOR = 0.33, 95% CI: 0.16, 0.70, respectively). CONCLUSIONS FOR PRACTICE Routine assessment of pregnancy preferences in primary care could identify individuals to whom counseling about health optimization prior to pregnancy can be offered to promote patient-centered family planning care.
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Affiliation(s)
- Deirdre A Quinn
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Building #30, Pittsburgh, PA, 15240, USA.
| | - Stephanie W Edmonds
- Office of Nursing Research and Evidence-Based Practice, University of Iowa Health Care, Iowa City, Iowa, USA
- Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Medical Center, Iowa City, IA, USA
- College of Nursing, University of Iowa, Iowa City, Iowa, USA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Building #30, Pittsburgh, PA, 15240, USA
| | - Sonya Borrero
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, University Drive (151C), Building #30, Pittsburgh, PA, 15240, USA
- Center for Research On Health Care, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ginny L Ryan
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Lisa S Callegari
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, WA, USA
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
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10
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Associations Between Sexual Assault and Reproductive and Family Planning Behaviors and Outcomes in Female Veterans. Obstet Gynecol 2021; 137:461-470. [PMID: 33543896 DOI: 10.1097/aog.0000000000004278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the relationship between lifetime sexual assault (defined as someone having experienced sexual assault in their lifetime) and reproductive health care seeking, contraception usage, and family planning outcomes in female veterans. METHODS We conducted a secondary analysis of data collected between 2005 and 2008 from computer-assisted telephone interviews with 1,004 female veterans aged 20-52 years who were enrolled at two Midwestern Department of Veterans Affairs (VA) health care systems. Participants were asked about reproductive, mental, and general health histories, and about lifetime sexual assault. We assessed associations between reproductive histories and contraceptive use among participants who reported lifetime sexual assault, compared with those who had not experienced lifetime sexual assault, by using bivariate and multivariable logistic regression analyses. Lastly, we examined reasons why these participants had not sought Pap test screening. RESULTS More than half (62%) of participants reported experiencing lifetime sexual assault. Because there was an association between older age and history of lifetime sexual assault (P<.001), we stratified the analysis by age. Women with a history of lifetime sexual assault were more likely to have had unprotected intercourse for a year or more (adjusted odds ratio [aOR] 2.31, 95% CI 1.35-3.96) and a teen pregnancy (aOR 2.10, 95% CI 1.07-4.12) than women who did not report lifetime sexual assault. When stratified by age, women aged 40-52 years with a history of lifetime sexual assault were more likely to report more than a year of unprotected sex, teen pregnancy, and not seeking prenatal care with their first pregnancy, than women aged 40-52 who did not report lifetime sexual assault. Women who experienced lifetime sexual assault were more likely to report not seeking Pap tests in the past owing to fear and anxiety when compared with women who had not experienced lifetime sexual assault. CONCLUSION Female veterans who reported lifetime sexual assault had differences in family planning behaviors compared with women who did not report lifetime sexual assault. These findings have implications for clinicians and VA policymakers when determining family planning and reproductive care delivery needs for female veterans of reproductive age.
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Hossain-López S, Ruiz-Berdún D. Being a woman, being a soldier, being a mother: a qualitative analysis of perceptions of pregnancy on working lives of women in the Spanish Armed Forces. BMJ Mil Health 2021; 168:64-69. [PMID: 33688081 DOI: 10.1136/bmjmilitary-2020-001722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/30/2021] [Accepted: 02/09/2021] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Thirty-two years after Spain first allowed women to join the armed forces, 12% of active troops are women, although there are no data on how many of them are mothers. There is a lack of research related to the impact of motherhood on their careers and the challenges they face as well. Previous quantitative research, within North Atlantic Treaty Organization (NATO) forces, has focused on the increased vulnerability and reduced performance of women returning to service after childbirth. However, no study to date has examined the narratives of these women. METHODS A qualitative, cross-sectional study was carried out by means of individual interviews which were subsequently analysed employing the interpretative approach of hermeneutic phenomenology. All the interviews were conducted by videoconference, being recorded for subsequent transcription and analysis with MAXQDA v.2018. RESULTS Servicewoman reported experiencing fear of informing their command chain of their pregnancy. Many women described feelings of constantly having to prove their worth, and thus perceived the physical restrictions associated with pregnancy and/or postpartum as a threat to their previous achievements. This sometimes led to behaviours that posed a risk to the health of mothers and babies, or eventually resulted in both acute and chronic conditions. CONCLUSIONS Some restrictions put in place to protect them during their pregnancies become a source of additional anxiety. Returning to active service, we found that women's desire to fulfil their duties can cause long-term damage to their physical and psychological health. The attitudes servicewomen perceive towards pregnant women and mothers seems to exert a strong influence on the risks they are willing to assume. Understanding and addressing the needs of servicewomen after childbirth, either now, as active members of the Armed Forces, or in the foreseeable future, as veterans, is crucial to both military and civilian healthcare providers.
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Affiliation(s)
- Sheima Hossain-López
- Surgery, Medical and Social Sciences, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá de Henares, Alcala de Henares, Madrid, Spain
| | - D Ruiz-Berdún
- Surgery, Medical and Social Sciences, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá de Henares, Alcala de Henares, Madrid, Spain
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12
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Quinn DA, Sileanu FE, Zhao X, Mor MK, Judge-Golden C, Callegari LS, Borrero S. History of unintended pregnancy and patterns of contraceptive use among racial and ethnic minority women veterans. Am J Obstet Gynecol 2020; 223:564.e1-564.e13. [PMID: 32142832 PMCID: PMC7528209 DOI: 10.1016/j.ajog.2020.02.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/31/2020] [Accepted: 02/21/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nearly half of all pregnancies in the United States each year are unintended, with the highest rates observed among non-Hispanic black and Hispanic women. Little is known about whether variations in unintended pregnancy and contraceptive use across racial and ethnic groups persist among women veteran Veterans Affairs users who have more universal access than other populations to health care and contraceptive services. OBJECTIVES The objectives of this study were to identify a history of unintended pregnancy and describe patterns of contraceptive use across racial and ethnic groups among women veterans accessing Veterans Affairs primary care. STUDY DESIGN Cross-sectional data from a national random sample of women veterans (n = 2302) aged 18-44 years who had accessed Veterans Affairs primary care in the previous 12 month were used to assess a history of unintended pregnancy (pregnancies reported as either unwanted or having occurred too soon). Any contraceptive use at last sex (both prescription and nonprescription methods) and prescription contraceptive use at last sex were assessed in the subset of women (n = 1341) identified as being at risk for unintended pregnancy. Prescription contraceptive methods include long-acting reversible contraceptive methods (intrauterine devices and subdermal implants), hormonal methods (pill, patch, ring, and injection), and female or male sterilization; nonprescription methods include barrier methods (eg, condoms, diaphragm), fertility-awareness methods, and withdrawal. Multivariable logistic regression models were used to examine the relationship between race/ethnicity with unintended pregnancy and contraceptive use at last sex. RESULTS Overall, 94.4% of women veterans at risk of unintended pregnancy used any method of contraception at last sex. Intrauterine devices (18.9%), female surgical sterilization (16.9%), and birth control pills (15.9%) were the 3 most frequently used methods across the sample. Intrauterine devices were the most frequently used method for Hispanic, non-Hispanic white, and other non-Hispanic women, while female surgical sterilization was the most frequently used method among non-Hispanic black women. In adjusted models, Hispanic women (adjusted odds ratio, 1.60, 95% confidence interval, 1.15-2.21) and non-Hispanic black women (adjusted odds ratio, 1.84, 95% confidence interval, 1.44-2.36) were significantly more likely than non-Hispanic white women to report any history of unintended pregnancy. In the subcohort of 1341 women at risk of unintended pregnancy, there were no significant racial/ethnic differences in use of any contraception at last sex. However, significant differences were observed in the use of prescription methods at last sex. Hispanic women (adjusted odds ratio, 0.51, 95% confidence interval, 0.35-0.75) and non-Hispanic black women (adjusted odds ratio, 0.69, 95% confidence interval, 0.51-0.95) were significantly less likely than non-Hispanic white women to have used prescription contraception at last sex. CONCLUSION Significant racial and ethnic differences exist in unintended pregnancy and contraceptive use among women veterans using Veterans Affairs care, suggesting the need for interventions to address potential disparities. Improving access to and delivery of patient-centered reproductive goals assessment and contraceptive counseling that can address knowledge gaps while respectfully considering individual patient preferences is needed to support women veterans' decision making and ensure equitable reproductive health services across Veterans Affairs.
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Affiliation(s)
- Deirdre A Quinn
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA.
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Colleen Judge-Golden
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Lisa S Callegari
- Departments of Obstetrics and Gynecology and Health Services, University of Washington, Seattle, WA; Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Sonya Borrero
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, University of Pittsburgh, Pittsburgh, PA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA; Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, PA
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13
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Gaeddert LA, Schneider AL, Miller CN, Monteith LL, Brenner LA, Katon J, Hoffmire CA. Recruitment of women veterans into suicide prevention research: Improving response rates with enhanced recruitment materials and multiple survey modalities. Res Nurs Health 2020; 43:538-547. [PMID: 32827237 DOI: 10.1002/nur.22065] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/25/2020] [Accepted: 08/06/2020] [Indexed: 11/05/2022]
Abstract
Women veterans (WV) are the fastest growing veteran subpopulation and recognized to be at increased risk for suicide compared with civilians. Improving engagement (e.g., response rates) of WV in survey research is critical to ensuring valid and generalizable findings, which can inform suicide prevention programs tailored for this population. Many factors are known to influence response rates, yet little is known about ways to optimize survey response rates among WV. Three recruitment cohorts (Waves 1 [W1], 2a [W2a], and 2b [W2b]) of WV were invited to participate in an online survey for a national, mixed-methods study examining suicide risk among WV using reproductive health care services paid for or provided by the Veterans Health Administration. To examine the effects of enhanced recruitment efforts, standard recruitment materials were mailed to all three cohorts, with the additions of: a study flyer aiming to build trust between participants and researchers (W2a, W2b) and a paper survey (W2b). Characteristics of responders and non-responders were compared by wave and across survey modalities. Response rates were significantly higher for groups receiving enhanced (W2a = 17.1%; W2b = 24.6%) versus standard (W1 = 12.2%) recruitment materials. WV residing in rural areas were significantly more likely to respond by paper (37.1%) than online (19.8%). Non-respondents were disproportionately racial and ethnic minorities. Disclosure of sensitive information (e.g., military sexual trauma) did not differ by survey modality. Findings suggest that enhanced recruitment materials improve survey response rates among WV, an important consideration for future research with this population.
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Affiliation(s)
- Laurel A Gaeddert
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Alexandra L Schneider
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Christin N Miller
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado
| | - Lindsey L Monteith
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado.,Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lisa A Brenner
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado.,Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado.,Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jodie Katon
- Health Services Research and Development Center of Innovation for Veteran-Centered and Value Driven Care, VA Puget Sound Health Care System, Seattle, Washington.,Department of Health Services, University of Washington, Seattle, Washington
| | - Claire A Hoffmire
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Suicide Prevention, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado.,Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Experiences of Perceived Gender-based Discrimination Among Women Veterans: Data From the ECUUN Study. Med Care 2020; 58:483-490. [PMID: 32000171 DOI: 10.1097/mlr.0000000000001304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Experiences of discrimination are associated with poor health behaviors and outcomes. Understanding discrimination in health care informs interventions to improve health care experiences. OBJECTIVE Describe the prevalence of, and variables associated with, perceived gender-based discrimination in the Veterans Affairs (VA) Healthcare System among women Veterans. DESIGN A cross-sectional, telephone-based survey of a random national sample of young female Veterans. PARTICIPANTS Female VA primary care patients aged 18-45 years. MAIN MEASURES The primary outcome was perceived gender-based discrimination in VA health care. Logistic and linear regression models were used to determine associations between any perceived discrimination and cumulative perceived discrimination with patient and health service characteristics. KEY RESULTS Among 2294 women Veterans, 33.7% perceived gender-based discrimination in VA. Perceiving gender-based discrimination was associated with medical illness [adjusted odds ratio (aOR)=1.67, 95% confidence interval (CI)=1.34, 2.08], mental illness (aOR=2.06, 95% CI=1.57, 2.69), and military sexual trauma (aOR=2.65, 95% CI=2.11, 3.32). Receiving most health care from the same VA provider (aOR=0.73, 95% CI=0.57, 0.94) and receiving care at a VA site with a women's health clinic (aOR=0.76, 95% CI=0.61, 0.95) were associated with reduced odds of any perceived gender-based discrimination. Among those who perceived gender-based discrimination (n=733), perceived discrimination scores were higher among women with increased age, medical illness, or history of military sexual trauma and lower among those who saw the same VA provider for most medical care. CONCLUSIONS One third of women Veterans perceived gender-based discrimination in VA. Obtaining most medical care from the same VA provider and having a women's health clinic at one's VA were associated with less perceived discrimination.
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15
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Judge-Golden CP, Wolgemuth TE, Zhao X, Mor MK, Borrero S. Agreement between Self-Reported "Ideal" and Currently Used Contraceptive Methods among Women Veterans Using the Veterans Affairs Healthcare System. Womens Health Issues 2020; 30:283-291. [PMID: 32321666 DOI: 10.1016/j.whi.2020.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 03/01/2020] [Accepted: 03/11/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Women 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. METHODS This 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. RESULTS Overall, 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." CONCLUSIONS Many 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.
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Affiliation(s)
| | | | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonya Borrero
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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16
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Arora KS, Zhao X, Judge-Golden C, Mor MK, Callegari LS, Borrero S. Factors Associated with Choice of Sterilization Among Women Veterans. J Womens Health (Larchmt) 2020; 29:989-995. [PMID: 32017866 DOI: 10.1089/jwh.2019.8036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: We sought to compare associations of contraceptive preferences, beliefs, self-efficacy, and knowledge with use of sterilization versus other methods of contraception. Materials and Methods: This is a secondary analysis of a telephone-based survey of a nationally representative sample of women Veterans not desiring future pregnancy. Contraceptive method used at last sex was categorized as female sterilization, long-acting reversible contraception (LARC), short-acting methods, or nonprescription methods/no method. Multinomial regression models were performed to compare the association between independent variables (contraceptive preferences, beliefs, self-efficacy, and knowledge) and use of sterilization versus other contraceptive methods. Results: Six hundred twelve women Veterans aged 18-44 years who were sexually active with men, had no history of hysterectomy or infertility, did not desire future pregnancy, and were not using male sterilization as their method of contraception were surveyed. A total of 208 women Veterans reported using female sterilization (34.0%). While method effectiveness was rated as extremely important by the majority of participants, there was no association between perceiving method effectiveness as extremely important and method selected in adjusted multinomial models. Women Veterans were more likely to use sterilization compared to hormonal methods of contraception if they reported that lack of hormones was an extremely important contraceptive method characteristic (aRRR 3.69, 95% CI 1.94-7.03). Women Veterans who strongly agreed with the belief that birth control decisions are mainly a woman's responsibility were less likely to use sterilization compared to LARC (aRRR 0.54, 95% CI 0.29-0.98). Conclusion: Associations between contraceptive preferences, beliefs, self-efficacy, and knowledge and use of sterilization in a population of women Veterans not desiring future pregnancy are complex, and decisions may not solely be driven by desire to select a highly effective method.
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Affiliation(s)
- Kavita Shah Arora
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Colleen Judge-Golden
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lisa S Callegari
- Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington.,Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, Washington
| | - Sonya Borrero
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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17
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Britton LE, Judge-Golden CP, Wolgemuth TE, Zhao X, Mor MK, Callegari LS, Borrero S. Associations Between Perceived Susceptibility to Pregnancy and Contraceptive Use in a National Sample of Women Veterans. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2019; 51:211-218. [PMID: 31749310 PMCID: PMC7147948 DOI: 10.1363/psrh.12122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/26/2019] [Accepted: 06/24/2019] [Indexed: 05/29/2023]
Abstract
CONTEXT Women may be at risk for unintended pregnancy if they forgo contraception or use ineffective methods because they erroneously believe they are unlikely to conceive. However, the relationship between perceived susceptibility to pregnancy and contraceptive use is not fully understood. METHODS Data collected in 2014-2016 for the Examining Contraceptive Use and Unmet Needs study were used to examine perceived susceptibility to pregnancy among 969 women veterans aged 20-45 who were at risk for unintended pregnancy and received primary care through the U.S. Veterans Affairs Healthcare System. Multivariable logistic regression was used to identify associations between perceived susceptibility to pregnancy (perceived likelihood during one year of unprotected intercourse) and use of any contraceptive at last sex. Multinomial regression models were used to examine method effectiveness among women who used a contraceptive at last sex. RESULTS Forty percent of women perceived their susceptibility to pregnancy to be low. Compared with women with high perceived susceptibility to pregnancy, those with low perceived susceptibility were less likely to have used any contraceptive at last sex (86% vs. 96%; adjusted odds ratio, 0.2). Among contraceptive users, women with low perceived susceptibility were less likely than those with high perceived susceptibility to have used a highly effective method (26% vs. 34%; adjusted relative risk ratio, 0.6) or moderately effective method (34% vs. 39%; 0.6) at last sex. CONCLUSIONS Identifying and addressing fertility misperceptions among women with low perceived susceptibility to pregnancy could help promote informed decision making about contraception and reduce the risk of unintended pregnancy.
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Affiliation(s)
- Laura E Britton
- Postdoctoral Fellow, Columbia University School of Nursing, New York
| | | | | | - Xinhua Zhao
- Core Investigator and Statistician, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Maria K Mor
- Director, Biostatistics and Informatics Core, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and adjunct research assistant professor, Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh
| | - Lisa S Callegari
- Core Investigator, Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, Seattle, and associate professor, Departments of Obstetrics & Gynecology and Health Services, University of Washington
| | - Sonya Borrero
- Associate Director, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and professor, Department of Medicine, University of Pittsburgh
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Albright DL, Landor AM, McDaniel JT, Godfrey K, Fletcher KL, Thomas KH, Bertram J. Sexual Behaviors and Health Practices Among Student Service Members and Veterans. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:2595-2604. [PMID: 30874977 DOI: 10.1007/s10508-018-1331-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 09/25/2018] [Accepted: 10/05/2018] [Indexed: 06/09/2023]
Abstract
The purpose of the study was to determine whether veteran students and non-veteran students differed in their sexual behaviors and health practices and, furthermore, whether or not those differences were gender specific. Demographic characteristics of the study sample were explored by calculating frequencies and percentages by military service status. Research questions were explored with maximum likelihood multiple logistic regression. Results showed that student veterans were more likely than non-veteran students to have sex with multiple partners, with males and transgender students more likely than females to report multiple sexual partners. Student veterans were more likely than non-veterans to perform a self-examination for either breast cancer or testicular cancer, with transgender students more likely than females to report having engaged in a self-examination. Student veterans were also more likely than non-veterans to have been vaccinated against HPV or Hepatitis B, with male students more likely than females to have been vaccinated. Furthermore, transgender student veterans were less likely than female veterans to have been vaccinated. Finally, male student veterans were more likely than female veterans to report an STI-related doctor visit, with transgender student veterans more likely than female veterans to report an STI-related doctor visit. College campuses are increasingly implementing student veteran-specific programs and services; however, little if any research specifically has explored ways in which safety and health can be promoted within university settings. We recommend that institutions of higher education make concerted efforts to promote safety and health among its student veteran population.
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Affiliation(s)
- David L Albright
- School of Social Work, University of Alabama, Tuscaloosa, AL, 35486, USA.
| | - Antoinette M Landor
- Human Development and Family Science, University of Missouri, Columbia, MO, USA
| | - Justin T McDaniel
- Department of Public Health and Recreation Professions, Southern Illinois University, Carbondale, IL, USA
| | - Kelli Godfrey
- School of Social Work, University of Alabama, Tuscaloosa, AL, 35486, USA
| | - Kari L Fletcher
- School of Social Work, St. Catherine University-University of St. Thomas, Minneapolis, MN, USA
| | - Kate H Thomas
- Public Health Program, College of Health Sciences, Charleston Southern University, Charleston, SC, USA
| | - Jessica Bertram
- School of Social Work, University of Alabama, Tuscaloosa, AL, 35486, USA
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Perceived Barriers and Facilitators to Contraceptive Use Among Women Veterans Accessing the Veterans Affairs Healthcare System. Womens Health Issues 2019; 30:57-63. [PMID: 31558352 DOI: 10.1016/j.whi.2019.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 08/09/2019] [Accepted: 08/20/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although many studies evaluate factors influencing contraceptive use, little is known about barriers and facilitators that may be specific to or prevalent among women veterans using the Veterans Affairs Healthcare System (VA). DESIGN Semistructured telephone interviews with a national sample of 189 women veterans at risk for unintended pregnancy who receive care in the VA were used to explore barriers and facilitators to contraceptive use as well as elicit suggestions for improving VA contraceptive care. The sample consisted primarily of women with risk factors for adverse reproductive health outcomes, including belonging to ethnic/racial minority groups, having a medical or mental health condition(s), and/or reporting a history of military sexual trauma. Transcript narratives were analyzed using content analysis and the constant comparison method. RESULTS Five distinct themes emerged as barriers or facilitators to contraceptive use depending on participants' VA facility and provider, and women offered concrete suggestions to address each barrier. Most participants (56%) noted poor efficiency as a barrier; others (39%) felt hindered by limited contraceptive counseling and patient education. Approximately one-third (34%) noted that low patient awareness of services impeded care and another one-third (32%) stressed poor interaction with providers as a barrier. Finally, 31% noted feeling ostracized at VA, and emphasized fostering a woman-friendly environment to remove discomfort associated with seeking contraceptive care. CONCLUSIONS These findings suggest that, despite widespread access to low-cost contraception, many women veterans experience barriers to accessing high-quality contraceptive care. These barriers are system and provider specific and warrant further internal evaluation.
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Judge-Golden CP, Smith KJ, Mor MK, Borrero S. Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System. JAMA Intern Med 2019; 179:1201-1208. [PMID: 31282923 PMCID: PMC6618816 DOI: 10.1001/jamainternmed.2019.1678] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings. OBJECTIVE To estimate the financial and reproductive health implications for the VA of implementing a 12-month OCP dispensing option, with the goal of informing policy change. DESIGN, SETTING, AND PARTICIPANTS A decision model from the VA payer perspective was developed to estimate incremental costs to the health care system of allowing the option to receive a 12-month supply of OCPs up front, compared with the standard 3-month maximum, during a 1-year time horizon. A model cohort of 24 309 reproductive-aged, heterosexually active, female VA enrollees who wish to avoid pregnancy for at least 1 year was assumed. Probabilities of continuation of OCP use, coverage gaps, pregnancy, and pregnancy outcomes were drawn from published data. Costs of OCP provision and pregnancy-related care and the number of women using OCPs were drawn from VA administrative data. One-way and probabilistic sensitivity analyses were performed to assess model robustness. MAIN OUTCOMES AND MEASURES Incremental per-woman and total costs to the VA of allowing for 12-month dispensing of OCPs compared with standard 3-month dispensing. RESULTS The 12-month OCP dispensing option, modeled from the VA health system perspective using a cohort of 24 309 women, resulted in anticipated VA annual cost savings of $87.12 per woman compared with the cost of 3-month dispensing, or an estimated total savings of $2 117 800 annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations. CONCLUSIONS AND RELEVANCE Adoption of a 12-month OCP dispensing option is expected to produce substantial cost savings for the VA while better supporting reproductive autonomy and reducing unintended pregnancy among women veterans.
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Affiliation(s)
- Colleen P Judge-Golden
- Medical Scientist Training Program, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kenneth J Smith
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonya Borrero
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania.,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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21
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Ekrami F, Mohammad-Alizadeh Charandabi S, Babapour Kheiroddin J, Mirghafourvand M. The Effect of Counselling on Depression and Anxiety of Women with Unplanned Pregnancy: A Randomized Controlled Trial. Community Ment Health J 2019; 55:1047-1056. [PMID: 31183585 DOI: 10.1007/s10597-019-00428-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/03/2019] [Indexed: 12/13/2022]
Abstract
This randomized controlled trial was conducted on 80 Iranian pregnant women with unplanned pregnancy. The participants were randomly assigned to two groups of intervention and control. The intervention group received one to three sessions of individual counseling and six sessions of group counseling each week in six consecutive weeks, and the control group received routine care. The Edinburgh Postnatal Depression Scale and the Spielberger State-Trait Anxiety Inventory were completed by the participants before and 4 weeks after the intervention. There was no significant difference between groups in terms of socio-demographic characteristics, and the baseline depression and anxiety scores (P > 0.05). The depression and anxiety scales were completed before and 4 weeks after the intervention. The mean scores of depression, state anxiety, and trait anxiety were significantly lower in the counseling group than in the control group 4 weeks after the end of intervention. It is recommended that counseling should be provided for women with unplanned pregnancy.
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Affiliation(s)
- Fatemeh Ekrami
- Students' Research Committee, Nursing and Midwifery Faculty, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Jalil Babapour Kheiroddin
- Department of Psychology, Faculty of Psychology and Educational Sciences, University of Tabriz, Tabriz, Iran
| | - Mojgan Mirghafourvand
- Associate Professor, Social Determinants of Health Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran. .,Midwifery Department, Tabriz University of Medical Sciences, Tabriz, Iran.
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22
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Kroll-Desrosiers AR, Crawford SL, Moore Simas TA, Clark MA, Bastian LA, Mattocks KM. Rates and Correlates of Depression Symptoms in a Sample of Pregnant Veterans Receiving Veterans Health Administration Care. Womens Health Issues 2019; 29:333-340. [PMID: 31105035 DOI: 10.1016/j.whi.2019.04.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Depression is the most commonly diagnosed medical condition among women veterans ages 18 to 44; however, depression symptoms occurring during pregnancy have not been well-studied in this population. METHODS Pregnant veterans were recruited from 15 Veterans Health Administration sites across the United States; our sample included 501 participants. Sociodemographic characteristics, military service, health status, and pregnancy related factors, as well as the Edinburgh Postnatal Depression Scale (EPDS), were collected as part of a telephone survey. Additional data were obtained from electronic health record data. We used multivariable logistic regression models to examine factors associated with an EPDS score suggestive of clinically significant depressive symptoms (≥10). FINDINGS Prenatal EPDS scores of 10 or greater were calculated for 28% of our sample. Our final model indicated that factors associated with decreased odds of an EPDS score of 10 or greater included spousal or partner support during pregnancy (adjusted odds ratio [aOR], 0.35; 95% confidence interval [CI], 0.16-0.77) and employment (aOR, 0.40; 95% CI, 0.24-0.67). A past diagnosis of anxiety (aOR, 2.54; 95% CI, 1.43-4.50), past antidepressant use (aOR, 3.27; 95% CI, 1.71-6.24), and active duty service (aOR, 1.91; 95% CI, 1.08-3.37) were associated with increased odds of having an EPDS score of 10 or greater. CONCLUSIONS This is the first quantitative estimate of depression symptoms in pregnant veterans across multiple Veterans Affairs facilities. The prevalence of depression symptomology was greater than the high end of prevalence estimates in the general pregnant population. Given that the risk of depression increases during the postpartum period, women who can be identified with depressive symptomatology during pregnancy can be offered critical resources and support before giving birth.
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Affiliation(s)
- Aimee R Kroll-Desrosiers
- Department of Population and Quantitative Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.
| | - Sybil L Crawford
- Graduate School of Nursing, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Tiffany A Moore Simas
- Department of Population and Quantitative Sciences, University of Massachusetts Medical School, Worcester, Massachusetts; Department of Obstetrics & Gynecology, University of Massachusetts Medical School/UMass Memorial Health Care, Worcester, Massachusetts; Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts; Department of Psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Melissa A Clark
- Department of Population and Quantitative Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Lori A Bastian
- Division of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Pain Research, Informatics, Multimorbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Kristin M Mattocks
- Department of Population and Quantitative Sciences, University of Massachusetts Medical School, Worcester, Massachusetts; Research and Development, VA Central Western Massachusetts, Leeds, Massachusetts
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23
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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; 100:234-240. [PMID: 31152697 DOI: 10.1016/j.contraception.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 05/19/2019] [Accepted: 05/20/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective of this study is to understand patient-, provider- and system-level factors associated with long-acting reversible contraception (LARC) use among women Veterans and with receipt of LARC methods within the Veterans Affairs (VA) system. STUDY DESIGN We analyzed data from a national telephone-based survey of 2302 women ages 18-44 receiving primary care in VA. Multivariable regression was used to examine adjusted associations of participant-reported patient-, provider- and facility-level factors with LARC use and within-VA receipt of LARC among women Veterans. RESULTS Among 987 women Veterans at risk of unintended pregnancy, 294 (30%) reported using LARC, 65% of whom had received their method within VA. Higher LARC use was observed among women who were multiparous vs. nulliparous [adjusted odds ratio (aOR)=1.52; 95% confidence interval (CI)=1.04-2.22] and did not desire future pregnancies (aOR=1.88; 95% CI=1.31-2.68). Although overall LARC uptake was not associated with any provider- or facility-level factors, receipt of these methods within VA was associated with receiving both general and gender-specific health care by a single provider (aOR=2.81; 95% CI=1.20-6.61) and with receiving care within a women's health clinic (aOR=2.54; 95% CI=1.17-5.50). CONCLUSIONS While patient-level factors were more strongly correlated with use of LARC, provider- and system-level factors influence whether women received these methods within VA. IMPLICATIONS This study of patient-, provider- and system-level correlates of LARC use in VA, the country's largest integrated healthcare system, highlights that women Veterans share similar patient-level factors associated with LARC use as the general population and that continuity with providers and comprehensive women's health services can facilitate LARC access.
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Affiliation(s)
- Angela F Koenig
- Department of Obstetrics and Gynecology, The Hospital of the University of Pennsylvania.
| | - Sonya Borrero
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System; Center for Research on Health Care, University of Pittsburgh School of Medicine
| | - Xinhua Zhao
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Lisa Callegari
- VA Health Services Research and Development Center of Innovation for Veteran-Centered and Value Driven Care, VA Puget Sound Healthcare System; Department of Obstetrics and Gynecology, University of Washington School of Medicine
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, The Hospital of the University of Pennsylvania
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24
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Katon JG, Zephyrin L, Meoli A, Hulugalle A, Bosch J, Callegari L, Galvan IV, Gray KE, Haeger KO, Hoffmire C, Levis S, Ma EW, Mccabe JE, Nillni YI, Pineles SL, Reddy SM, Savitz DA, Shaw JG, Patton EW. Reproductive Health of Women Veterans: A Systematic Review of the Literature from 2008 to 2017. Semin Reprod Med 2019; 36:315-322. [PMID: 31003246 DOI: 10.1055/s-0039-1678750] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The literature on the reproductive health and healthcare of women Veterans has increased dramatically, though there are important gaps. This article aims to synthesize recent literature on reproductive health and healthcare of women Veterans. We updated a literature search to identify manuscripts published between 2008 and July 1, 2017. We excluded studies that were not original research, only included active-duty women, or had few women Veterans in their sample. Manuscripts were reviewed using a standardized abstraction form. We identified 52 manuscripts. Nearly half (48%) of the new manuscripts addressed contraception and preconception care (n = 15) or pregnancy (n = 10). The pregnancy and family planning literature showed that (1) contraceptive use and unintended pregnancy among women Veterans using VA healthcare is similar to that of the general population; (2) demand for VA maternity care is increasing; and (3) women Veterans using VA maternity care are a high-risk population for adverse pregnancy outcomes. A recurrent finding across topics was that history of lifetime sexual assault and mental health conditions were highly prevalent among women Veterans and associated with a wide variety of adverse reproductive health outcomes across the life course. The literature on women Veterans' reproductive health is rapidly expanding, but remains largely observational. Knowledge gaps persist in the areas of sexually transmitted infections, infertility, and menopause.
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Affiliation(s)
- Jodie G Katon
- US Department of Veterans Affairs (VA) Puget Sound Health Care System, Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington.,Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Laurie Zephyrin
- VA Office of Patient Care Services, Women's Health Services, Washington, District of Columbia.,Department of Obstetrics and Gynecology, VA Harbor Medical Center, New York City, New York.,Department of Obstetrics and Gynecology, New York School of Medicine, New York, NY
| | - Anne Meoli
- VHA, SimLEARN National Simulation Center, Orlando, Florida
| | - Avanthi Hulugalle
- New York University College of Global Public Health, New York City, New York
| | - Jeane Bosch
- VA San Diego Healthcare System, San Diego, California
| | - Lisa Callegari
- US Department of Veterans Affairs (VA) Puget Sound Health Care System, Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington.,Department of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Washington
| | - Ileana V Galvan
- VA Office of Patient Care Services, Women's Health Services, Washington, District of Columbia
| | - Kristen E Gray
- US Department of Veterans Affairs (VA) Puget Sound Health Care System, Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington.,Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | - Kristin O Haeger
- VA Office of Patient Care Services, Women's Health Services, Washington, District of Columbia
| | - Claire Hoffmire
- Rocky Mountain MIRECC for Suicide Prevention, VA Eastern Colorado Health Care System, Denver, Colorado.,Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado
| | - Silvina Levis
- Geriatric Research, Education and Clinical Center, Miami Veterans Affairs Medical Center, Miami, Florida
| | - Erica W Ma
- US Department of Veterans Affairs (VA) Puget Sound Health Care System, Health Services Research and Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | | | - Yael I Nillni
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Suzanne L Pineles
- National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Shivani M Reddy
- VA Boston Healthcare System, Boston, Massachusetts.,Center for Advanced Methods Development, RTI International, Waltham, Massachusetts
| | - David A Savitz
- Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Jonathan G Shaw
- Division of Primary Care and Population Health, Stanford University School of Medicine, Palo Alto, California.,Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California
| | - Elizabeth W Patton
- Division of Gynecology, Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts.,Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts
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25
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Yecies E, Judge-Golden C, Callegari L, Borrero S. Contraceptive Care in the Veterans Health Administration. Semin Reprod Med 2019; 37:24-31. [PMID: 31185515 PMCID: PMC7047650 DOI: 10.1055/s-0039-1692201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In recent years, the number of women Veterans obtaining care in the Veterans Affairs (VA) Healthcare System has grown, expanding the need for provision of contraceptive care. Women Veterans are a diverse group of women with complex sociodemographic and medical backgrounds, and meeting their needs presents a unique challenge for VA. Efforts including the establishment of comprehensive women's health clinics and training practitioners in women's health have greatly improved healthcare services for women Veterans over the last few decades. Recent data from a large cross-sectional survey study suggest that contraceptive use in VA is similar to the general population and that rates of unintended pregnancy, while still significant, are not higher than that in the general population. Subgroup analyses of this survey data, however, suggest that ongoing efforts are needed to improve outcomes in vulnerable subpopulations of women Veterans, particularly ethnic/racial minorities and Veterans with complex medical backgrounds. Policy changes such as the elimination of copayments for contraceptive prescriptions and the dispensing of more months of contraceptive supply are evidence-based starting points for improvements, in addition to leveraging VA's integrated system and research infrastructure to improve patient-centered counseling and contraceptive access.
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Affiliation(s)
- Emmanuelle Yecies
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- VA Pittsburgh Healthcare System, Pittsburgh, PA
| | | | - Lisa Callegari
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Drive Care, VA Health Services Research and Development, Seattle, WA
- Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, WA
- Department of Health Services, University of Washington School of Public Health, Seattle, WA
| | - Sonya Borrero
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- VA Pittsburgh Healthcare System, Pittsburgh, PA
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA
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26
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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. J Gen Intern Med 2018; 33:2092-2099. [PMID: 30187377 PMCID: PMC6258629 DOI: 10.1007/s11606-018-4647-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 07/18/2018] [Accepted: 08/21/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Women Veterans have high rates of mental health disorders and other psychosocial factors which may render this population particularly vulnerable to negative health outcomes associated with unintended pregnancy. OBJECTIVE The objective of our study was to assess the relationship between self-reported mental illness and history of unintended pregnancy among women Veterans. DESIGN AND PARTICIPANTS Data are from a nationally representative, cross-sectional telephone survey of women Veterans, ages 18-45, who used VA for primary care within 12 months prior to interview (survey completion rate 83%). MAIN MEASURES Predictors were self-report of any and number of mental health disorders (depression, anxiety, post-traumatic stress disorder, bipolar disorder, or schizophrenia). Outcomes were any and number of unintended pregnancies. Multivariable logistic and negative binomial regression were used to assess relationships between mental illness and unintended pregnancy. To assess women's current risk of unintended pregnancy, we examined associations between any mental health disorder and contraceptive use at last sex among heterosexually active women not desiring pregnancy. KEY RESULTS Among 2297 women Veterans, 1580 (68.8%) reported a history of at least one mental health disorder, with 20.1, 21.6, and 27.0% reporting one, two, or three or more conditions, respectively. Any history of unintended pregnancy was reported by 1315 women (57.3%); 28.3% reported one, 15.6% reported two, and 13.4% reported three or more. Compared to women with no mental illness, women with any mental health disorder were more likely to report any unintended pregnancy (60.3 vs. 50.5%; adjusted OR 1.40; 95% CI 1.15, 1.71) and to have experienced greater numbers of unintended pregnancies (adjusted incidence rate ratio 1.29; 95% CI 1.15, 1.44). Increasing numbers of mental health disorders were associated with greater numbers of unintended pregnancies. Contraceptive use and method efficacy at last sex did not differ by mental health status. CONCLUSIONS Women Veterans with mental health disorders are more likely to have experienced any and greater numbers of unintended pregnancies than Veterans without mental health disorders.
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Affiliation(s)
| | - Sonya Borrero
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA.,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA
| | - Xinhua Zhao
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA
| | - Maria K Mor
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lisa S Callegari
- Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, WA, USA.,Health Services Research and Development, VA Puget Sound Health Care System, Seattle, WA, USA
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27
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Katon JG, Ma EW, Sayre G, Zephyrin LC, Cordasco KM, Yano EM, Fortney JC. Women Veterans’ Experiences with Department of Veterans Affairs Maternity Care: Current Successes and Targets for Improvement. Womens Health Issues 2018; 28:546-552. [DOI: 10.1016/j.whi.2018.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/16/2018] [Accepted: 08/21/2018] [Indexed: 12/22/2022]
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28
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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. Womens Health Issues 2018; 28:480-487. [PMID: 30241794 PMCID: PMC6215491 DOI: 10.1016/j.whi.2018.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 07/26/2018] [Accepted: 07/31/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Although pregnancy intention is strongly associated with contraceptive use, little is known about the interaction between pregnancy intention and attitude, or how they jointly affect contraceptive use. METHODS Cross-sectional data from a national survey of women veterans who receive care within the Veterans Affairs Healthcare System were used to examine relationships among pregnancy intention (in next year, in >1 year, never, not sure), attitude toward hypothetical pregnancy (worst thing, neutral, best thing), and contraceptive use among women at risk for unintended pregnancy. Bivariate and multivariable analyses assessed associations between pregnancy intention and attitude, both separately and jointly, with contraceptive use. Multinomial regression assessed the relationship of intention and attitude with contraceptive method effectiveness. RESULTS Among 858 women at risk of unintended pregnancy, bivariate analysis demonstrated that pregnancy intention and attitude were associated, but not perfectly aligned. In logistic regression models including both variables, intention of never versus in next year (adjusted odds ratio [aOR], 2.78; 95% confidence interval [CI], 1.34-5.75) and attitude of worst thing versus best thing (aOR, 2.86; 95% CI, 1.42-5.74) were each positively associated with contraception use. Among women using contraception, intention of never (aOR, 3.17; 95% CI, 1.33-7.59) and attitude of worst thing (OR, 2.09; 95% CI, 1.05-4.17) were associated with use of highly effective (e.g., intrauterine devices and implants) versus least effective (e.g., barrier) methods. CONCLUSIONS These findings support prior research suggesting that pregnancy intention alone does not fully explain contraceptive behaviors and imply that attitude toward pregnancy plays an important role in shaping contraceptive use independent of pregnancy intentions.
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Affiliation(s)
- Tierney Wolgemuth
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Colleen Judge-Golden
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lisa Callegari
- Departments of Obstetrics and Gynecology and Health Services, University of Washington, Seattle, Washington; Center for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Sonya Borrero
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Center for Women's Health Research and Innovation, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
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29
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Haeger KO, Lamme J, Cleland K. State of emergency contraception in the U.S., 2018. Contracept Reprod Med 2018; 3:20. [PMID: 30202545 PMCID: PMC6123910 DOI: 10.1186/s40834-018-0067-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/20/2018] [Indexed: 12/30/2022] Open
Abstract
Emergency contraception is indicated in instances of unprotected sexual intercourse, including reproductive coercion, sexual assault, and contraceptive failure. It plays a role in averting unintended pregnancies due to inconsistent use or non-use of contraception. Options for emergency contraception vary by efficacy as well as accessibility within the U.S. This paper provides an overview of levonorgestrel (Plan B One-Step and generic counterparts), ulipristal acetate (sold as ella), and the copper intrauterine device (IUD, sold as ParaGard), including the mechanisms of action, administration, efficacy, drug interactions, safety, side effects, advantages, and drawbacks. It will also review current misconceptions about emergency contraception and access for subpopulations, including adolescents, immigrants, survivors of sexual assault, rural populations, and military/veteran women. This paper will address barriers such as gaps in knowledge, and financial, health systems, and practice barriers. Continuing areas of research, including the impact of body weight on the efficacy of emergency contraceptive pills and potential interactions between ulipristal acetate and ongoing hormonal contraceptives, are also addressed.
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Affiliation(s)
- Kristin O. Haeger
- Department of Veterans Affairs, Veterans Health Administration, Office of Patient Care Services, Women’s Health Services, 810 Vermont Ave., NW, Washington, DC, 20420 USA
| | - Jacqueline Lamme
- Department of Obstetrics & Gynecology, U.S. Naval Hospital Okinawa, Okinawa, Japan
| | - Kelly Cleland
- Office of Population Research, Princeton University, 218 Wallace Hall, Princeton, NJ 08544 USA
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30
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Judge CP, Zhao X, Sileanu FE, Mor MK, Borrero S. Medical contraindications to estrogen and contraceptive use among women veterans. Am J Obstet Gynecol 2018; 218:234.e1-234.e9. [PMID: 29111146 PMCID: PMC5807130 DOI: 10.1016/j.ajog.2017.10.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/08/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Women veterans have high rates of medical comorbidities and may be particularly vulnerable to adverse health outcomes associated with unintended pregnancy. OBJECTIVES The objective of the study was to estimate the prevalence of medical contraindications to estrogen-containing combined hormonal contraception among women veterans of reproductive age and to evaluate the relationship between contraindications and contraceptive use. STUDY DESIGN This was a secondary analysis of data from a cross-sectional, telephone-based survey with a national sample of 2302 female veterans, aged 18-45 years, who use the Veterans Administration Healthcare System for primary care. This analysis included women at risk of unintended pregnancy, defined as heterosexually active and not pregnant or trying to conceive and with no history of hysterectomy or infertility. Seven contraindications to combined hormonal contraception were identified using survey data or medical diagnosis codes: hypertension; coronary artery disease; active migraine in women older than 35 years or migraine with aura; smoking in women older than 35 years; and a history of thromboembolism, stroke, or breast cancer. Outcomes were current use of combined hormonal contraception and contraceptive method type (combined hormonal contraception, and other prescription methods, nonprescription methods or no method). Multivariable logistic and multinomial regression were used to assess the relationship between contraindications and combined hormonal contraception use and method type, respectively. RESULTS Among 1169 women veterans at risk of unintended pregnancy, 339 (29%) had at least 1 contraindication to combined hormonal contraception. The most prevalent conditions were hypertension (14.9%) and migraine (8.7%). In adjusted analyses, women with contraindications were less likely than women without contraindications to report use of combined hormonal contraception (adjusted odds ratio, 0.54, 95% confidence interval, 0.37-0.79). Relative to use of combined hormonal contraception, women with contraindications were more likely than women without contraindications to use other prescription methods (adjusted odds ratio, 1.74, 95% confidence interval, 1.17-2.60), nonprescription methods (adjusted odds ratio, 1.96, 95% confidence interval, 1.19-3.22), and no method (adjusted odds ratio, 2.29, 95% confidence interval, 1.35-3.89). CONCLUSION Women veterans at risk of unintended pregnancy have a high burden of medical contraindications to estrogen. Women with contraindications were less likely to use combined hormonal contraceptive methods but were more likely to use no method, suggesting an unmet need for contraception in this medically vulnerable population.
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Affiliation(s)
- Colleen P Judge
- University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Xinhua Zhao
- Center for Health Equity, Research, and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, PA
| | - Florentina E Sileanu
- Center for Health Equity, Research, and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity, Research, and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, PA
| | - Sonya Borrero
- Center for Health Equity, Research, and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, PA; Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA
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Rosenfeld EA, Miller E, Zhao X, Sileanu FE, Mor MK, Borrero S. Male partner reproductive coercion among women veterans. Am J Obstet Gynecol 2018; 218:239.e1-239.e8. [PMID: 29056537 DOI: 10.1016/j.ajog.2017.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/29/2017] [Accepted: 10/12/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Male partner reproductive coercion is defined as male partners' attempts to promote pregnancy through interference with women's contraceptive behaviors and reproductive decision-making. Male partners may try to promote pregnancy through birth control sabotage such as taking away or destroying their partners' contraceptives, refusing to wear condoms, and/or verbally pressuring their partners to abstain from contraceptive use. Reproductive coercion is associated with an elevated risk for unintended pregnancy. Women who experience intimate partner violence, who are in racial/ethnic minorities, and who are of lower socioeconomic status are more likely to experience reproductive coercion. Women veterans who use Veterans Affairs for health care may be particularly vulnerable to reproductive coercion because they are disproportionally from racial/ethnic minority groups and experience high rates of intimate partner violence. OBJECTIVES We sought to examine the prevalence, correlates, and impact of reproductive coercion among women veterans who are served by the Veterans Affairs healthcare system. STUDY DESIGN We analyzed data from a national telephone survey of women veterans aged 18-44 years, with no history of sterilization or hysterectomy, who had received care within the Veterans Affairs system in the previous 12 months. Participants who had sex with men in the last year were asked if they experienced male partner reproductive coercion. Adjusted logistic regression was used to examine the relationship between participant characteristics and male partner reproductive coercion and the relationship between reproductive coercion and the outcomes of contraceptive method used at last sex and pregnancy and unintended pregnancy in the last year. RESULTS Among the 1241 women veterans in our study cohort, 11% reported experiencing male partner reproductive coercion in the past year. Black women, younger women, and single women were more likely to report reproductive coercion than their white, older, and married counterparts. Women who experienced military sexual trauma were also more likely to report reproductive coercion compared with women who did not report military sexual trauma. In adjusted analyses, compared with women who did not experience reproductive coercion, those who did were less likely at last sex to have used any method of contraception (76% vs 80%; adjusted odds ratio, 0.61; 95% confidence interval, 0.38-0.96), prescription contraception (43% vs 55%; adjusted odds ratio, 0.62; 95% confidence interval, 0.43-0.91), and their ideal method of contraception (35% vs 45%; adjusted odds ratio, 0.63; 95% confidence interval, 0.43-0.93). Those who reported coercion were more likely to have had a pregnancy in the last year (14% vs 10%; adjusted odds ratio, 2.07; 95% confidence interval, 1.17-3.64); there were no significant differences in unintended pregnancy by coercion status (6% vs 4%; adjusted odds ratio, 1.63; 95% confidence interval, 0.71-3.76). CONCLUSION Eleven percent of women veterans in our sample experienced male partner reproductive coercion, which may impact their use of contraception and ability to prevent pregnancy.
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Affiliation(s)
- Elian A Rosenfeld
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System.
| | - Elizabeth Miller
- Division of Adolescent Medicine, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh
| | - Sonya Borrero
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System; Center for Research on Health Care, University of Pittsburgh School of Medicine
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Schwarz EB, Sileanu FE, Zhao X, Mor MK, Callegari LS, Borrero S. Induced abortion among women veterans: data from the ECUUN study. Contraception 2018; 97:41-47. [PMID: 29055781 PMCID: PMC5732058 DOI: 10.1016/j.contraception.2017.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 09/14/2017] [Accepted: 09/21/2017] [Indexed: 10/18/2022]
Abstract
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. METHODS We analyzed data from 2298 women veterans younger than 45 years who completed a telephone-based, cross-sectional survey of randomly sampled English-speaking women from across the United States who had received VA healthcare. We compared lifetime, last-5-year and last-year rates of unintended pregnancy and abortion among participants to age-matched data from the National Survey of Family Growth. As few abortions were reported in the last year, we used multivariable logistic regression to examine associations between abortion in the last 5 years and age, race/ethnicity, income, education, religion, marital status, parity, geography, deployment history, housing instability, and past medical and mental health among VA patients. RESULTS Women veterans were more likely than matched US women to report ever having an abortion [17.7%, 95% confidence interval (CI): 16.1%-19.3% vs. 15.2% of US women]. In the last 5 years, unintended pregnancy and abortion were reported by veterans at rates similar to US women. In multivariable models, VA patients were more likely to report abortion in the last 5 years if their annual income was less than $40,000 (adjusted odds ratio (OR) 2.95, 95% CI 1.30-6.70), they had experienced homelessness or housing instability (adjusted OR 1.91, 95% CI 1.01-3.62), they were single (adj. OR 2.46, 95% CI 1.23-4.91) and/or they had given birth (adjusted OR 2.29, 95% CI 1.19-4.40). CONCLUSION Women veterans face unintended pregnancy and seek abortion as often as the larger US population. IMPLICATIONS The Veterans Health Care Act, which prohibits provision of abortion services, increases vulnerable veterans' out-of-pocket healthcare costs and limits veterans' reproductive freedom.
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Affiliation(s)
- Eleanor Bimla Schwarz
- Division of General Internal Medicine, University of California, Davis School of Medicine.
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System; Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh
| | - Lisa S Callegari
- Health Services Research and Development, VA Puget Sound Health Care System; Department of Obstetrics & Gynecology, University of Washington School of Medicine
| | - Sonya Borrero
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System; Center for Research on Health Care, University of Pittsburgh School of Medicine
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McCall JD, Tsai J. Characteristics and Health Needs of Veterans in Jails and Prisons: What We Know and Do Not Know about Incarcerated Women Veterans. Womens Health Issues 2017; 28:172-180. [PMID: 29217313 DOI: 10.1016/j.whi.2017.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 09/28/2017] [Accepted: 10/13/2017] [Indexed: 12/19/2022]
Abstract
PURPOSE The majority of U.S. veterans in prisons and local jails are men, but incarcerated women veterans remain an important and understudied group. METHODS This study reported differences in sociodemographic, health, and criminal justice characteristics using Veterans Affairs (VA) administrative data on a national sample of 30,964 incarcerated veterans (30,440 men and 524 women) who received outreach from the VA Health Care for Reentry Veterans program between 2007 and 2011. Descriptive statistics and multivariable logistic regressions determined gender and racial differences in this population. RESULTS Compared with incarcerated veterans who were men, incarcerated women veterans were younger (d = 0.68), had significantly lower lifetime arrests (AOR, 0.65; p < .001; 99% CI, 0.49-0.87), and were less likely to have been incarcerated for a violent offense (AOR, 0.47; p < .001; 99% CI, 0.35-0.63). Notably, 58% of women were of reproductive age. Women were more likely to have reported eye problems, hypertension, chronic obstructive pulmonary disease, and seizure disorder, and were more likely to receive a preliminary diagnosis of mood disorder than men. Women were more likely to have received VA benefits, used VA health care before, and be willing to use VA services after release. A few important differences emerged when stratified by race. CONCLUSIONS These findings suggest that incarcerated women veterans are interested in VA health care services, but there is lack of information about women's health needs through the Health Care for Reentry Veterans program. The inclusion of Health Care for Reentry Veterans screening questions about women's health issues may support the VA's interests to better engage women veterans in care.
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Affiliation(s)
- Janice D McCall
- Carlow University, Department of Social Work, Pittsburgh, Pennsylvania; Veterans Affairs Healthcare System, Center for Health Equity Research and Promotion (CHERP), Pittsburgh, Pennsylvania
| | - Jack Tsai
- Veterans Affairs New England Mental Illness Research, Education, and Clinical Center (MIRECC), West Haven, Connecticut; Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut; Veterans Affairs National Center on Homelessness Among Veterans, West Haven, Connecticut.
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Jackson JL. Capsule Commentary on Borrero et al., Unintended Pregnancy and Contraceptive Use among Women Veterans: The ECUUN Study. J Gen Intern Med 2017. [PMID: 28634903 PMCID: PMC5515801 DOI: 10.1007/s11606-017-4097-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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