Elsevier

Contraception

Volume 85, Issue 6, June 2012, Pages 580-588
Contraception

Original research article
Contraceptive care in the VA health care system

https://doi.org/10.1016/j.contraception.2011.10.010Get rights and content

Abstract

Background

Little is known about contraceptive care within the Veterans Affairs (VA) health care system. This study was conducted to assess the prevalence of documented contraception by race/ethnicity within the VA and to examine the association between receiving primary care in women's health clinics (WHCs) and having a documented contraceptive method.

Study Design

We examined national VA administrative and pharmacy data for 103,950 female veterans aged 18–45 years who made at least one primary care clinic visit in 2008. Multivariable regression models were used to examine the associations between race/ethnicity and receipt of care in a WHC with having a method of contraception while controlling for confounders.

Results

Only 22% of women veterans had a documented method of contraception during 2008. After adjusting for potential confounders, Hispanic and African–American women were significantly less likely to have a method compared to whites [odds ratio (OR): 0.82; 95% confidence interval (CI): 0.76–0.88 and OR: 0.85; 95% CI: 0.81–0.89, respectively]. Women who went to WHCs were significantly more likely to have a method of contraception compared to women who went to traditional primary care clinics (OR: 2.05; 95% CI: 1.97–2.14).

Conclusions

Overall contraceptive prevalence in the VA is low, but receiving care in a WHC is associated with a significantly higher likelihood of having a contraceptive method.

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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  • Racial and Ethnic Health Care Disparities Among Women in the Veterans Affairs Healthcare System: A Systematic Review

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    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).

  • Contraceptive adherence among women Veterans with mental illness and substance use disorder

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    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

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Conflict of interest: No conflict of interest, financial or other, exists for any of the authors.

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