Unintended Pregnancy among Active Duty Service Women and Women

Veterans and Access to Contraception in DoD and VHA

Alicia Y. Christy M.D., MHSCR, Colonel (retired) U.S. Army

Deputy Director Reproductive Health Women’s Health Services (WHS)

Veterans Health Administration (VHA)

Professor Obstetrics & Gynecology Uniformed Services University of the Health Sciences

Adjunct Professor Obstetrics & Gynecology Howard University School of Medicine

4 December 2019

Disclosures

• Presenters have no relevant financial or non-financial interest or interests to disclose.

• This continuing education activity is managed and accredited by AffinityCE in collaboration with AMSUS.

• Disclosure will be made when a product is discussed for an unapproved use

• AffinityCE and AMSUS staff as well as Planners and Reviewers, have no relevant financial or non-financial interests to disclose.

• Commercial Support was not received for this activity

Learning Objectives

At the conclusion of this activity, the participant will be able to:

1. Estimate rates of unintended pregnancy among active duty and Veteran women receiving care in VA

2. Relate to the limitations of studies of unintended pregnancy and contraceptive use

3. Utilize Strategies to decrease unintended pregnancy and contraceptive access

Psychologist Specific Learning Objectives

Estimate rates of unintended pregnancy among active duty and Veteran women receiving care in the VA

Relate to the limitations of studies of unintended pregnancy and contraceptive use

Utilize Patient education and Pre deployment counseling to decrease unintended pregnancy and contraceptive access

Unintended Pregnancy Rates Active Duty Women

• Active-duty women aged 18–44 years (n=3,745) in 2005 DoD Survey of Health Related Behaviors Among Active Duty Military Personnel

• Approximately 54% of pregnancies were unintended, based on self-reports

• After accounting for likely underreporting for abortion, adjusted unintended pregnancy rate was 117/ 1,000 (civilian rate 51/1,000)

• Higher rates among– Younger– Less educated – Non Caucasian– Cohabitating– Enlisted women when compared to officers (110 vs 28 per 1,000)

Lindberg, L. D. (2011). Unintended pregnancy among women in the US military. Contraception, 84(3), 249-251. doi:10.1016/j.contraception.2011.01.017

ANNUAL RATE OF UNINTENDED PREGNANCY

Variable Total sample(n =2,302)

U.S. populationage-adjusted to VA population

Rate of pregnancy Per 1,000 women

67.3 96.2

Rate of unintended pregnancyPer 1,000 women

26.1 34.4

Proportion of pregnancies that are unintended

37.1 35.2

6

Borrero S et al The ECUUN study. Journal of General Internal Medicine. 2017; 32(8): 900-908. Schwarz EB et al Contraception. 2018; 97(1):41-47.

Unintended Pregnancy Rates Women VeteransUnintended pregnancy was defined as a pregnancy that was reported as having been either “unwanted” at the time of conception or as having occurred “sooner than desired” Borrero: JGIM, 2017

Limitations of Studies of Unintended Pregnancy

• Yablonsky et al. identified a research gap in the area of unintended pregnancies among active duty/Veteran women– There were only seven identified articles– 0% considered high quality – 29% rated as low quality1

• Some DoD studies include non-active duty women• Many of VHA’s studies examine only women Veterans receiving

care in VA• Non-representative study population• Decision models may under- or overestimate pregnancies based

on model assumptions• Underreporting of abortion and unwanted pregnancies in both

DoD and VA2

1 Yablonsky A, Martin R, Highfill-McRoy R, McAnany J, Fitzmaurice S, Lee I, et al. Military women's health: A scoping review and gap analysis, 2000-2015 (Report No. N15-015). Silver Spring: Naval Medical Research Center. 20172 Jones RK, Kost K. Fam Plann 2007;38:187–97.

Strategies to Decrease Unintended Pregnancy

5%

52%

43%

Causes of Unintended Pregnancy

Contraceptive Failure

Non-Use of Contraception

Inconsistent/Incorrect Use of Contraception

Adapted from Gold RB Guttmacher Institute 2009

• Only 5% of unintended pregnancies are due to contraceptive failure

• User independent methods (LARCs) are associated with very low failure rates

• LARCs also decrease the likelihood of incorrect or inconsistent use

Method Choice U.S.

Pill, 25.3%

Injectable,3.9%

IUD, 11.8%

Tubal, 21.8%

2.6%Implant

Vasectomy, 6.5%

Vaginal Ring, 2.4%

Withdrawal, 8.1%

Male Condom, 14.6%

Fertility awareness, 2.2% Other, 1.0%

Adapted from www.guttmacher.org

LARC Usage Among Active Duty Women

• In a 2013 survey, only 3.6% of respondents reported using LARC methods during deployment 1

• More recent studies have reported a LARC usage rate of 12–14% 2,3

1 Grindlay K et al Contraception. 2013;87(2):162-9

2 Erickson AK et al Obstet Gynecol. 2017;129(5):800-9.

3 Witkop CT et al. Contraception. 2017;96(1):47-53. (developer of Decide + Be Ready)

Factors Associated with Higher LARC Use VHA Study

Variable Adjusted odds ratio

95% C.I.

Multiparous vs. nulliparous 1.52 1.04–2.22

Did not desire future pregnancies

1.88 1.31–2.68

General and gender specific care by single provider

2.81 1.20-6.61

Receiving care within a women's health clinic

2.54 1.17-5.50

Koenig AF et al Contraception. [In press; published online May 29, 2019].

VHA Use of Long Acting Reversible Contraception

• National telephone-based survey study

• 2,302 women ages 18–44 receiving primary care in VA

• 987 women Veterans at risk of unintended pregnancy

• 294 (30%) reported using LARC

• 65% received their method within VAKoenig AF et al Contraception. [In press; published online May 29, 2019].

Increasing Use of LARCs

• Higher rates of LARC use among women VA-users than the general US population.

• These higher LARC rates suggest that VA has been able to mitigate some of the barriers to LARC access that occur in other settings.

• To help facilitate patient-centered approaches to contraceptive counseling, VA has developed a web-based tool (MyPath) that is currently being tested.

MacDonald S et al Medical Care. 2017; 55(9 Suppl 2):S43-S49.

Wolgemuth T et al Women’s Health Issues. 2018; 28(6): 480-487.

Addressing Barriers to Care

• DoD same-day contraception clinics

• Postpartum LARC

• Education (USU app Decide + Be Ready)

• VHA Care model (Women’s Health Care Providers)

• VHA Mini residencies and other training in gender specific care

Callegari LS et al. Women’s Health Issues. 2019; 29(3):283-28.

Closing Comments

• Unintended pregnancy rates among active duty women and women Veterans exceed the Healthy People 2010 goal of 30%

• Research gaps in the topic area remain

• Some of the strategies to decrease unintended pregnancy include

– Increased Access

– Increased use of highly efficacious contraception

– Patient education

– Pre deployment counseling (i.e. levonorgestrel containing IUDs for control of menses)

THANK YOU

12/11/2019 WHS 16

VHA Caring for Women Veterans Across the Life Span

Original artwork Alicia Y. Christy M.D.

CE/CME Credit

If you would like to receive continuing education credit for this activity, please visit:

http://amsus.cds.pesgce.com

Hurry,

CE Certificates will only be

available for 30 DAYS

after this event!