Original research articleContraceptive care in the VA health care system☆
Introduction
Contraceptive care is a growing priority in the Department of Veterans Affairs (VA) [1], [2]. Women veterans are entering the VA health care system in increasing numbers. Recent estimates indicate that over 40% of women who have served in Iraq and Afghanistan have enrolled in VA health care [3]. Most of these women veterans are of reproductive age and also are disproportionately of a racial/ethnic minority [4]. The current demographic profile of women veterans underscores the importance of ensuring equitable and comprehensive contraceptive care for all women veterans. Yet, little is known about contraceptive use and provision within the VA, and whether racial/ethnic disparities in contraceptive use patterns within the VA are similar to those documented in the larger population where minority women are less likely to use contraception overall and use different types of methods compared to white women.
A variety of women's health care delivery models have been established to provide comprehensive primary care for women [5]. One common model has been the establishment of comprehensive women's health clinics (WHCs) that provide primary as well as gender-specific care, which are present in approximately 54% of VA sites [6]. In general, at VA sites where a comprehensive WHC is present, women will be assigned to this clinic for primary care [7]. WHCs appear to serve as focal points for clinical expertise in women's health including contraceptive care [8], [9], although studies examining whether they actually improve the quality of care for women veterans are lacking. While the availability of on-site hormonal contraception (97%) as well as intrauterine devices (IUDs; 62%) is widespread among VA facilities [6], [10], little is known about the actual use of contraceptive methods and what factors impact the provision of contraception. Lack of familiarity with the most effective, reversible methods of contraception (i.e., IUDs and implants) is commonly reported among primary care clinicians [11], [12], [13], [14] and may be more so for clinicians in traditional VA primary care clinics (PCCs) who are accustomed to providing care only for men. Consequently, women who receive care in PCCs may be less likely to receive counseling and referral for these contraceptive methods and subsequently less likely to use them than women who receive care in WHCs. Furthermore, lack of provider knowledge may shift the knowledge burden to the patient and, as contraceptive knowledge may vary by race/ethnicity [15], [16], [17], accentuate race-based disparities in contraceptive use patterns among women who receive care in non-WHC settings.
We used national VA administrative and pharmacy data to assess the prevalence of contraception by race/ethnicity within the VA and to examine the association between receiving care in WHCs and having a contraceptive method.
Section snippets
Study population
The study cohort included all women veterans between the ages of 18 and 45 years who made at least one visit to a PCC or WHC in fiscal year 2008. This age range is based on the US Centers for Disease Control and Prevention's definition of women of reproductive age (15–45 years) and the fact that all US veterans are at least 18 years of age.
Data sources
This study utilized data from national VA administrative databases including the Pharmacy Benefits Management Database (Version 3) and the Medical SAS
Results
In FY 2008, 119,110 female veterans aged 18–45 years had an outpatient appointment in the VA health care system. Of these, 103,950 (87.3%) women were seen at least once in a PCC or a WHC and composed our study sample. Sample characteristics and facility information are shown by subject race/ethnicity in Table 1. About 6% of the cohort were Hispanic, 40% were white, 25% were AA, 3% were of other race/ethnicity, and 26% had an unknown or missing race classification. Approximately 45% of women had
Discussion
In this study using national VA administrative data, we found that only 22% of female veterans of reproductive age had a documented method of contraception within the VA and that veterans of racial/ethnic minorities were slightly less likely to have a method compared to white women. We also found that receipt of care in VA WHCs was associated with a significantly higher rate of documented contraception compared to care in PCCs.
The National Survey of Family Growth (NSFG) provides nationally
Acknowledgments
This study was supported by the Department of Veterans Affairs, Veteran Health Administration, Office of Research and Development, VISN 4 CHERP Pilot Project Award (PI: Sonya Borrero). Dr. Borrero had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The contents of this manuscript do not represent the views of the Department of Veterans Affairs or the United States Government. The abstract of this manuscript
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Cited by (22)
Reproductive health services: A missed opportunity in VA primary care?
2023, ContraceptionRacial and Ethnic Health Care Disparities Among Women in the Veterans Affairs Healthcare System: A Systematic Review
2016, Women's Health IssuesCitation Excerpt :Interestingly, some of the racial or ethnic differences we found among women at the VA appear on the surface to favor racial or ethnic minority groups. In particular, Black women were found to use contraception belonging in the category of “most effective” methods (intrauterine devices, implants, or surgical sterilization) more often than White women (Borrero et al., 2012). However, this difference is likely driven by higher rates of surgical sterilization among African American women (Borrero et al., 2010; Dehlendorf et al., 2014), who may have higher rates of post-sterilization regret (Borrero et al., 2008).
Reproductive Life Planning in Primary Care: A Qualitative Study of Women Veterans' Perceptions
2015, Women's Health IssuesContraceptive adherence among women Veterans with mental illness and substance use disorder
2015, ContraceptionCitation Excerpt :Inconsistent contraceptive use, including poor adherence with medication regimens as well as method discontinuation [17,18], is therefore an important proxy measure for unintended pregnancy risk among women who rely on user-dependent contraceptive methods (birth control pills/patch/ring/injection). Similar to women in the general population, Veteran women using VA health care most commonly rely on user-dependent methods and less frequently on user-independent long-acting reversible methods [intrauterine devices (IUDs) and subdermal implants] [19,20], making consistent use over time critical. Prior studies, however, have demonstrated low 12-month adherence and continuation with user-dependent hormonal contraceptive methods among Veterans, with risk factors including receipt of 1-month versus 3-month supply, black or Hispanic race, and lower income [21,22].
Associations of mental illness and substance use disorders with prescription contraception use among women veterans
2014, ContraceptionCitation Excerpt :The prevalence of alcohol misuse among women veterans is also high, with 17% screening positive using the Alcohol Use Disorders Identification Test (AUDIT-C) in a national sample of OEF/OIF Veterans [28]. In addition to high rates of mental illness and SUD, women veterans have low rates of prescribed contraception compared to national estimates [29]. Given the rapidly increasing number of young women veterans entering the VA health care system [30], understanding determinants of contraceptive nonuse or use of less effective, nonprescription methods is critical for prevention of unintended pregnancies and improving birth outcomes.
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Conflict of interest: No conflict of interest, financial or other, exists for any of the authors.