Search

To determine the contribution of specific contraceptive side effects to method switch and modern-method discontinuation among Kenyan women.A prospective cohort study.Five counties in Western Kenya.Women aged ≥18 years old and emancipated female minors ≥14 years old using modern, reversible contraception were recruited while attending 10 public health facilities.Patient-reported adverse effect symptoms, method switch and discontinuation were reported through weekly text message-based surveys for 24 weeks.Prevalence, hazards ratio (HR).Among 825 women, 44% were using implants, 43% injectables, 7% an intrauterine device and 6% oral contraceptive pills at enrolment. Most (61%) women were continuing a method used in the previous month. During the 24-week follow up, incidence of contraceptive switch was 61.3 per 100 person-years (95% confidence interval [CI] 52.4-71.8) and incidence of discontinuation was 38.5 per 100 person-years (95% CI 31.6-47.0). On average, one-quarter (prevalence [Pr] 0.24, 95% CI 0.22-0.26) of participants reported side effects or method problems weekly, with sexual side effects the most prevalent symptom (Pr 0.15, 95% CI 0.13-0.16). Lack of expected bleeding was associated with higher risk of method switch (adjusted hazard ratio [aHR] 2.36, 95% CI 1.22-4.57). Risk of all-modern method discontinuation was higher among women experiencing irregular bleeding (aHR 2.39, 95% CI 1.20-4.77), weight changes (aHR 2.72, 95% CI 1.47-4.68) and sexual side effects (aHR 2.42, 95% CI 1.40-4.20).Addressing irregular bleeding, weight changes and sexual side effects through development of new products that minimise these specific side effects and anticipatory counseling may reduce method-related discontinuation.Bleeding, weight changes, sexual problems associated with discontinuation of #contraception, but many continue despite side effects.

The Department of Veterans Affairs (VA) relies on facilities outside of VA to provide mammograms for most VA patients. Prior work suggests challenges to coordinating some sex-specific services between VA and other health care systems (e.g., gynecologic malignancies, maternity care), but little is known about barriers and facilitators to mammogram care coordination. We sought to describe processes for coordinating mammograms referred outside of VA and to characterize VA staff perspectives on care coordination barriers and facilitators.We conducted semistructured interviews with 44 VA staff at 10 VA Medical Centers that refer all mammograms outside of the VA. Respondents included staff across multiple VA departments involved in coordinating mammograms. We used a rapid templated approach to analyze audio-recorded interviews to characterize the coordination processes and identify barriers and facilitators to care coordination.Interviews elucidated a common mammogram care coordination process, with variability in how process steps were achieved. We identified six themes: 1) the process is generally perceived as inefficient, 2) clarity in VA staff roles and responsibilities is essential, 3) internal VA communication facilitates coordination, 4) challenges arise from variability in community provider processes and their limited understanding of VA processes, 5) coordination challenges can negatively impact veterans, and 6) technology holds promise but remains a barrier.Coordination of mammograms that are referred outside of VA is challenging for staff in multiple VA departments and roles. VA programs should focus on improving communication and role clarity within the VA and better harnessing technology to support coordination efforts.

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. 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. 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). 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.

People with chronic medical illnesses are at particularly high risk for adverse pregnancy outcomes, yet current clinical approaches largely fail to identify and support their individualized reproductive and pregnancy goals. Instead, the predominant approach to pregnancy in subspecialty medicine is disease centered rather than patient centered. To better meet the individual needs and preferences of people with childbearing potential who have chronic medical conditions, we advocate in this article for a paradigm shift in subspecialty care that honors individuals' reproductive autonomy and human right of reproduction.

Background: Hysterectomy can be performed with concomitant bilateral salpingo-oophorectomy (BSO) to treat symptomatic pathology of the ovary (e.g., endometriosis) or to prevent ovarian cancer. Our objective was to examine the relationship between race and concomitant BSO by menopausal status in the Veterans Affairs (VA) health care system. Methods: This is a longitudinal study utilizing VA administrative data to identify hysterectomies provided or paid for by VA (i.e., source of care) between 2007 and 2014. We defined BSO as removal of both ovaries and fallopian tubes at the time of hysterectomy, identified by International Classification of Diseases-Ninth Revision codes. Covariates included demographic (e.g., ethnicity) and gynecological diagnoses (e.g., endometriosis). We used generalized linear models with a log-link and binomial distribution to estimate associations of race with BSO by menopausal status and source of care. Results: We identified 6,785 Veterans with hysterectomies, including 2,320 with concomitant BSO. Overall, Black Veterans were more likely to be single, obese, and undergo abdominal hysterectomy. After adjustment, premenopausal Black Veterans had a 41% lower odds of BSO than their White counterparts (odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.51-0.68). Stratifying on source of care, these results remained unchanged (provided: OR: 0.61, 95% CI: 0.52-0.72; paid: OR: 0.58, 95% CI: 0.48-0.71). There was insufficient evidence of an association among postmenopausal Veterans. Conclusions: Premenopausal Black Veterans are less likely to undergo BSO even after adjustment for salient characteristics. Our findings may have implications for equitable gynecological care for Veterans. Additional research is needed to better understand the role of differential preferences or cancer risk in these racial differences.

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.

ImportanceEarly pregnancy loss (EPL), or miscarriage, is the most common complication of early pregnancy, and many patients experiencing EPL present to the emergency department (ED). Little is known about how patients who present to the ED with EPL differ from those who present to outpatient clinics and how their management and outcomes differ.ObjectiveTo compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics.Design, Setting, and ParticipantsThis retrospective cohort study used the IBM MarketScan Research Database, a national insurance claims database. Participants were pregnant people aged 15 to 49 years in the US who presented to either an ED or outpatient clinic for initial diagnosis of EPL from October 2015 through December 2019. Data analysis was performed from May 2021 to March 2022.ExposuresThe primary exposure was location of service (ED vs outpatient clinic). Other exposures of interest included demographic characteristics, current pregnancy history, and comorbidities.Main Outcomes and MeasuresThe primary outcome was EPL management type (surgical, medication, or expectant management). Complications, including blood transfusion and hospitalization, and characteristics associated with location of service were also evaluated. Bivariable analyses and multivariable logistic regression were used for data analysis.ResultsA total of 117 749 patients with EPL diagnoses were identified, with a mean (SD) age of 31.8 (6.1) years. Of these patients, 20 826 (17.7%) initially presented to the ED, and 96 923 (82.3%) presented to outpatient clinics. Compared with the outpatient setting, patients in the ED were less likely to receive surgical (2925 patients [14.0%] vs 23 588 patients [24.3%]) or medication (1116 patients [5.4%] vs 10 878 patients [11.2%]) management. In the adjusted analysis, characteristics associated with decreased odds of active (surgical or medication) vs expectant management included ED (vs outpatient) presentation (adjusted odds ratio [aOR], 0.46; 95% CI, 0.44-0.47), urban location (aOR, 0.87; 95% CI, 0.82-0.91), and being a dependent on an insurance policy (vs primary policy holder) (aOR, 0.71; 95% CI, 0.67-0.74); whereas older age (aOR per 1-year increase 1.01; 95% CI, 1.01-1.01), established prenatal care (aOR, 2.35; 95% CI, 2.29-2.42), and medical comorbidities (aOR, 1.05; 95% CI, 1.02-1.09) were associated with increased odds of receiving active management. Patients in the ED were more likely than those in outpatient clinics to need a blood transfusion (287 patients [1.4%] vs 202 patients [0.2%]) or hospitalization (463 patients [2.2%] vs 472 patients [0.5%]), but complications were low regardless of location of service.Conclusions and RelevanceIn this cohort study of privately insured patients with EPL, differences in management between the ED vs outpatient setting may reflect barriers to accessing comprehensive EPL management options. More research is needed to understand these significant differences in management approaches by practice setting, and to what extent EPL management reflects patient preferences in both outpatient and ED settings.

UNSTRUCTURED The United States has abysmal reproductive health indices that, in part, reflect stark inequities experienced by people of color and those with preexisting medical conditions. The growth of “femtech,” or technology-based solutions to women’s health issues, in the public and private sectors is promising, yet these solutions are often geared toward health-literate, socioeconomically privileged, and/or relatively healthy white cis-women. In this viewpoint, we propose a set of guiding principles for building technologies that proactively identify and address these critical gaps in health care for people from socially and economically marginalized populations that are capable of pregnancy, as well as people with serious chronic medical conditions. These guiding principles require that such technologies: (1) include community stakeholders in the design, development, and deployment of the technology; (2) are grounded in person-centered frameworks; and (3) address health disparities as a strategy to advance health equity and improve health outcomes.

Objectives Women experiencing early pregnancy loss (EPL) frequently present to the emergency department (ED), but little is known about who receives EPL care in these settings. We aimed to estimate the proportion of ED visits for EPL‐related care and determine characteristics associated with seeking care for EPL in the ED in a national sample. Methods We conducted a secondary analysis of the 2006–2016 National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationally representative survey of US ED visits. We identified women ages 15–44 years who presented to the ED for threatened or confirmed EPL based on diagnosis code or chief complaint. We estimated the proportion of ED visits attributable to EPL‐related care among all ED visits and among women 15–44 years old. Using multivariable logistic regression, we evaluated patient and visit characteristics associated with receiving EPL‐related care versus all other care. Results The 2006–2016 NHAMCS dataset included 325,037 visits (weighted n = 1,447,144,423), including 82,871 visits among women ages 15–44 years (weighted n = 371,016,125). Of all ED visits for women ages 15–44 years, 2.7% (95% confidence interval, 2.5–2.9) were for EPL‐related care. This equates to ≈900,000 visits annually. Compared with women ages 15–44 years presenting to the ED for other reasons, those presenting for EPL‐related care were younger and more likely to be Black or Hispanic. Conclusions EPL‐related care accounts for over 900,000 ED visits in the United States each year. These findings highlight the current burden of EPL visits upon EDs nationally.

Postpartum depression (PPD) is common and disproportionately affects people of color. Experiences of emotional upset due to racism (EUR) may be an important predictor of PPD outcomes. Therefore, we aimed to determine if EUR during the 12 months before delivery was associated with PPD symptomology, asking for help for depression, and depression diagnosis among postpartum people of color (PPOC). We conducted a cross-sectional secondary data analysis among PPOC from 11 states and New York City using PRAMS data, 1/1/2015-12/31/2017. We assessed symptomology using an unvalidated PHQ-2. Logistic regression was performed without and with stratification by ethnicity (non-Hispanic PPOC vs Hispanic PPOC) to estimate whether EUR during 12 months before delivery was associated with (1) PPD symptoms, (2) asking for help for depression, and (3) depression diagnosis. Models adjusted for age, educational attainment, timely prenatal care, payment method, stress during pregnancy, and pre-pregnancy depression. Seventy-four thousand nine hundred nine (11.8%) PPOC reported EUR in the 12 months before delivery. After adjustment, EUR was associated with a 10.3 percentage point (%pt; 95% CI: 6.8, 13.8), 13.6%pt (95% CI: 8.8, 18.5), and 4.1%pt (95% CI: 1.4, 8.0) higher probability of positive PPD screening among all PPOC, non-Hispanic PPOC, and Hispanic PPOC, respectively. EUR was not associated with asking for help for depression but was associated with a higher prevalence of depression diagnosis among all PPOC (4.6%pt; 95% CI: 1.0, 8.4) and non-Hispanic PPOC (6.0%pt; 95% CI: 0.8, 11.2).Experiences of EUR are associated with an increased prevalence of PPD symptoms. Additional prospective research spanning the pre-pregnancy through postpartum periods is needed to examine the dynamic relationship between racism, symptomology, help-seeking, and diagnosis of depression.

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 Administration 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.

Minimally invasive hysterectomy for fibroids decreases recovery time and risk of postoperative complications compared with abdominal hysterectomy. Within Veterans Affair (VA), black women with uterine fibroids are less likely to receive a minimally invasive hysterectomy than white women.To quantify the contributions of patient, facility, temporal and geographic factors to VA black-white disparity in minimally invasive hysterectomy.A cross-sectional study.Veterans with fibroids and hysterectomy performed in VA between October 1, 2012 and September 30, 2015.Hysterectomy mode was defined using ICD-9 codes as minimally invasive (laparoscopic, vaginal, or robotic-assisted) versus abdominal. The authors estimated a logistic regression model with minimally invasive hysterectomy modeled as a function of 4 sets of factors: sociodemographic characteristics other than race, health risk factors, facility, and temporal and geographic factors. Using decomposition techniques, systematically substituting each white woman's characteristics for each black woman's characteristics, then recalculating the predicted probability of minimally invasive hysterectomy for black women for each possible combination of factors, we quantified the contribution of each set of factors to observed disparities in minimally invasive hysterectomy.Among 1255 veterans with fibroids who had a hysterectomy at a VA, 61% of black women and 39% of white women had an abdominal hysterectomy. Our models indicated there were 99 excess abdominal hysterectomies among black women. The majority (n=77) of excess abdominal hysterectomies were unexplained by measured sociodemographic factors beyond race, health risk factors, facility, and temporal or geographic trends.Closer examination of the equity of VA gynecology care and ways in which the VA can work to ensure equitable care for all women veterans is necessary.

Counseling to identify and support individuals' desires for family formation is a key component of preventive health care that is often absent in primary care visits. This study evaluates a novel, web-based, person-centered intervention to increase the frequency and quality of communication about reproductive goals and healthcare needs in Veterans Health Administration (VA) primary care.We describe a hybrid type 1 effectiveness-implementation cluster randomized controlled trial in seven VA healthcare systems testing a web-based reproductive health decision support tool (MyPath). VA primary care providers are enrolled and randomized to intervention or usual care arms. Veterans scheduled to see intervention-arm providers receive a text message inviting them to use MyPath ahead of their appointment; Veterans scheduled to see control-arm providers receive usual care. Target enrollment is 36 providers and 456 Veterans. Outcomes are assessed by Veteran self-report after the visit and at 3- and 6-months follow-up. The primary outcome is occurrence of reproductive health discussions involving shared decision making; secondary outcomes include measures of communication, knowledge, decision conflict, contraceptive utilization, and receipt of services related to prepregnancy health. Data on implementation barriers, facilitators and cost are collected.The trial is ongoing with no results to report. We have enrolled 36 primary care providers across 7 VA healthcare systems and recruitment of Veterans is ongoing.Results will inform efforts to increase the quality and person-centeredness of reproductive healthcare delivery in primary care and to operationalize and scale up use of digital decision support tools in clinical settings.http://ClinicalTrials.gov Identifier: NCT04584294 Trial Status: Recruiting.

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.

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.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.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).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.

Over the past decade, increasing attention has been paid to intervening in individuals' health in the "preconception" period as an approach to optimizing pregnancy outcomes. Increasing attention to the structural and social determinants of health and to the need to prioritize reproductive autonomy has underscored the need to evolve the preconception health framework to center race equity and to engage with the historical and social context in which reproduction and reproductive health care occur. In this commentary, we describe the results of a meeting with a multidisciplinary group of maternal and child health experts, reproductive health researchers and practitioners, and Reproductive Justice leaders to define a new approach for clinical and public health systems to engage with the health of nonpregnant people. We describe a novel "Reproductive and Sexual Health Equity" framework, defined as an approach to comprehensively meet people's reproductive and sexual health needs, with explicit attention to structural influences on health and health care and grounded in a desire to achieve the highest level of health for all people and address inequities in health outcomes. Principles of the framework include centering the needs of and redistributing power to communities, having clinical and public health systems acknowledge historical and ongoing harms related to reproductive and sexual health, and addressing root causes of inequities. We conclude with a call to action for a multisectoral effort centered in equity to advance reproductive and sexual health across the reproductive life course.

Objective To estimate the feasibility of using measures developed by the Clinical Workgroup of the National Preconception Health and Health Care Initiative to assess women's prepregnancy wellness in a large health care system. Methods We examined Department of Veterans Affairs' (VA) national administrative data, including inpatient, outpatient, fee-basis, laboratory, pharmacy, and screening data for female veterans aged 18-45 who had at least one pregnancy outcome (ectopic pregnancy, spontaneous abortion, stillbirth, and live birth) during fiscal years 2010-2015 and a VA primary care visit within 1 year before last menstrual period (LMP). LMP was estimated from gestational age at the time of pregnancy outcome, then used as a reference point to assess eight prepregnancy indicators from the Workgroup consensus measures (eg, 3 or 12 months before LMP). Results We identified 19,839 pregnancy outcomes from 16,034 female veterans. Most (74.9%) pregnancies ended in live birth; 22.6% resulted in spontaneous abortion or ectopic pregnancy, and 0.5% in stillbirth. More than one third (39.2%) of pregnancies had no documentation of prenatal care within 14 weeks of LMP. Nearly one third (31.2%) of pregnancies occurred in women with obesity. Among pregnancies with a recent relevant screening, 29.2% were positive for smoking and 28.4% for depression. More than half (57.4%) of pregnancies in women with preexisting diabetes did not have documentation of optimal glycemic control. Absence of sexually transmitted infection screening in the year before or within 3 months of LMP was high. Documentation of prenatal folic acid use was also high. Exposure in the same timeframe to six classes of teratogenic medications was low. Conclusion Despite limitations of administrative data, monitoring measures of prepregnancy wellness can provide benchmarks for improving women's health across health care systems and communities. Areas for intervention to improve female veterans' prepregnancy wellness include healthy weight, optimizing control of diabetes before pregnancy, and improved use and documentation of key prepregnancy health screenings.

In the general population, Black and Latina women are less likely to undergo minimally invasive hysterectomy than White women, which may be related to racial/ethnic variation in fibroid prevalence and characteristics. Whether similar differences exist in the Department of Veterans Affairs Healthcare System (VA) is unknown.Using VA clinical and administrative data, we identified all women veterans undergoing hysterectomy for benign indications in fiscal years 2012-2014. We identified hysterectomy route (laparoscopic with/without robot-assist, vaginal, abdominal) by International Classification of Diseases, 9th edition, codes. We used multinomial logistic regression to estimate associations of race/ethnicity with hysterectomy route and tested whether associations varied by fibroid diagnosis using an interaction term. Models adjusted for age, income, body mass index, gynecologic diagnoses, medical comorbidities, whether procedure was performed or paid for by VA, geographic region, and fiscal year.Among 2,744 identified hysterectomies, 53% were abdominal, 29% laparoscopic, and 18% vaginal. In multinomial models, racial/ethnic differences were present among veterans with but not without fibroid diagnoses (p value for interaction .001). Among veterans with fibroids, Black veterans were less likely than White veterans to have minimally invasive hysterectomy (laparoscopic vs. abdominal relative risk ratio [RRR], 0.52; 95% CI, 0.38-0.72; vaginal vs. abdominal RRR, 0.58; 95% CI, 0.43-0.73). Latina veterans were as likely as White veterans to have laparoscopic as abdominal hysterectomy (RRR, 1.34; 95% CI, 0.87-2.07) and less likely to have vaginal than abdominal hysterectomy (RRR, 0.32; 95% CI, 0.15-0.69).Receipt of minimally invasive hysterectomy among women veterans with fibroids varied by race/ethnicity. Further investigation of the underlying mechanisms and potential interventions to increase minimally invasive hysterectomy among minority women veterans is needed.

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.

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.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.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.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.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.

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.

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.

Background Little is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system.

BACKGROUND: Women with chronic health conditions benefit from reproductive planning and access to highly effective contraception. OBJECTIVE: To determine the prevalence of and relationship between chronic health conditions and use of highly effective contraception among reproductive-age women. DESIGN: Retrospective cohort study using electronic health records. PARTICIPANTS: We identified all women 16–49 years who accessed care in the two largest health systems in the US Intermountain West between January 2010 and December 2014. MAIN MEASURES: We employed administrative codes to identify highly effective contraception and flag chronic health conditions listed in the US Medical Eligibility Criteria for Contraceptive Use (US MEC) and known to increase risk of adverse pregnancy outcomes. We described use of highly effective contraception by demographics and chronic conditions. We used multinomial logistic regression to relate demographic and disease status to contraceptive use. KEY RESULTS: Of 741,612 women assessed, 32.4% had at least one chronic health condition and 7.3% had two or more chronic conditions. Overall, 7.6% of women with a chronic health condition used highly effective contraception vs. 5.1% of women without a chronic condition. Women with chronic conditions were more likely to rely on public health insurance. The proportion of women using long-acting reversible contraception did not increase with chronic condition number (5.8% with 1 condition vs. 3.2% with 5 or more). In regression models adjusted for age, race, ethnicity, and payer, women with chronic conditions were more likely than those without chronic conditions to use highly effective contraception (aRR 1.4; 95% CI 1.4–1.5). Public insurance coverage was associated with both use of long-acting reversible contraception (aRR 2.2; 95% CI 2.1–2.3) and permanent contraception (aRR 2.9; 95% CI 2.7–3.1). CONCLUSIONS: Nearly a third of reproductive-age women in a regional health system have one or more chronic health condition. Public insurance increases the likelihood that women with a chronic health condition use highly effective contraception.

Background When hysterectomy is used to treat uterine fibroids, a minimally invasive versus open abdominal approach is preferred. Depression and post-traumatic stress disorder (PTSD) may be associated with surgical mode. We sought to examine whether depression and PTSD are associated with minimally invasive hysterectomy (MIH). Methods This was a cross-sectional study of veterans with uterine fibroids undergoing hysterectomy in the Department of Veterans Affairs between 2012 and 2014. Diagnoses and procedures were identified by International Classification of Disease, Ninth Revision, codes. MIH was defined as laparoscopic, vaginal, or robotic-assisted versus open abdominal. A dichotomous variable indicated presence of depression or PTSD. Clinical variables, including uterine size, were abstracted from the medical record. We employed generalized linear models to estimate adjusted percentages and 95% confidence intervals (CIs) of MIH by presence of depression or PTSD and sequentially adjusted for sociodemographic variables and health indicators (model 1), and then gynecologic and reproductive history variables, including uterine size (model 2). Results We included 770 veterans in our analytic sample. Veterans with depression or PTSD were more likely than those without such diagnoses to have a MIH (49% vs. 42%). Differences were attenuated in model 1 (47% [95% CI, 37%–57%] vs. 43% [95% CI, 34%–52%]) and no longer detectable in model 2 (45% [95% CI, 36%–54%] vs. 44% [95% CI, 36%–52%]). Conclusions Veterans with depression or PTSD were more likely that those without to have an MIH, possibly owing to smaller uterine size, suggesting that they may be undergoing hysterectomy earlier in the disease process. Further research is needed to understand whether this reflects high-quality, patient-centered care.

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.

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.

Preconception care (PCC), defined as a set of interventions to help women optimize their health and well-being prior to pregnancy, can improve pregnancy outcomes and is recommended by national organizations including the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists. Women Veterans who use the Department of Veterans Affairs (VA) health care system may face elevated risks of adverse pregnancy and birth outcomes due to a high prevalence of chronic medical and mental health conditions as well as psychosocial stressors including sexual trauma history and intimate partner violence. Many women Veterans of childbearing age experience poverty and homelessness, which are key social determinants of poor reproductive health outcomes. Furthermore, racial/ethnic disparities in maternal and neonatal outcomes are well documented, and nearly half of women Veterans of reproductive age are minority race/ethnicity. High-quality, equitable, patient-centered PCC services to address modifiable risks in this population are therefore a priority for VA. In this article, we provide a brief background of PCC, discuss the health risks of Veterans associated with adverse pregnancy outcomes, and highlight VA initiatives related to PCC. Lastly, we discuss implications and future directions for PCC research and policy within VA and across other health systems.

Background Approximately one-half of women undergoing hysterectomy in the Department of Veterans Affairs health care system receive minimally invasive hysterectomies (MIH), with Black women less likely than White women to receive MIH. We sought to characterize gynecologists’ perspectives on factors contributing to the availability and provision of MIH and on the role of race/ethnicity in decision making. Methods Between October 2017 and January 2018, we conducted 16 in-depth semistructured telephone interviews with Department of Veterans Affairs gynecologists exploring practice characteristics and barriers and facilitators to providing MIH, including clinical and nonclinical characteristics of patients impacting surgical decision making. We identified key themes using simultaneous deductive and inductive thematic analysis. Results Gynecologists identified provider-, facility-, and patient-level barriers and facilitators to MIH. Provider-level factors included gynecologists' skills and training in MIH, and facility factors included access to qualified surgical assistants, availability of surgical equipment, and operating room resources, particularly time. On the patient level, clinical characteristics, including uterine size, were the most common determinants of surgical approach, but nonclinical factors such as patients’ attitudes toward surgery also contributed. Race/ethnicity was identified by a minority of respondents as influencing hysterectomy route through clinical presentation and surgical attitudes. Conclusions Given the range of factors identified, efforts to promote MIH in the Department of Veterans Affairs will likely require a multipronged approach that includes support for MIH training, increased access to surgical assistants with MIH skills, and reduced barriers to obtaining equipment. Patient perspectives are needed to more fully capture nonclinical patient-level contributors to MIH and differences in MIH between Black and White Veterans.

Background Women veterans' unique experiences in the military and burden of health comorbidities increase their risk of adverse pregnancy outcomes and may influence their counseling needs related to planning or preventing pregnancy. We investigated women veterans’ experiences of family planning counseling in the military and Veterans Affairs (VA) health care systems as well as their counseling preferences. Methods We conducted 32 qualitative interviews among women veterans ages 18–44 years receiving primary care at the VA Puget Sound or VA Pittsburgh health care systems between March and June 2016 to explore their experiences and preferences related to counseling about pregnancy goals and planning and contraception. Transcripts were analyzed using inductive and deductive content analysis, and key themes were identified. Results Nearly all participants described negative experiences in family planning counseling encounters in the military and/or VA, including perceptions of gender-based discrimination and pressure to choose certain contraceptive methods, perceived judgment of their reproductive choices, and a lack of continuity with providers. Some women also reported positive experiences in family planning encounters in the VA, including feeling respected, receiving comprehensive information about options, and having their perspectives and concerns elicited. Counseling preferences that emerged included that providers initiate and validate family planning discussions, establish trust and avoid judgment, elicit women's individual preferences, and engage them as equal partners in decision making. Conclusions Women veterans reported a spectrum of negative and positive experiences in family planning encounters in the military and VA that, in conjunction with their preferences, provide key insights for patient-centered reproductive health care in VA.

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. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s11606-018-4647-8) contains supplementary material, which is available to authorized users.

Objective Emerging data suggest that mental illness and substance use disorder (SUD) are important risk factors for inconsistent contraceptive use. We investigated whether mental illness without or with SUD is associated with contraceptive adherence and continuation of hormonal methods among women Veterans. Study design We conducted a retrospective analysis of national Veteran’s Administration data among women aged 18–45 with a hormonal contraceptive prescription (pill/patch/ring/injectable) during the first week of fiscal year 2013. We tested associations between mental illness diagnoses (depression, posttraumatic stress disorder, anxiety, bipolar disorder, schizophrenia, adjustment disorder) without or with SUD diagnoses (drug/alcohol abuse) and 12-month contraceptive adherence (number and length of gaps ≥ 7 days between refills and months of contraceptive coverage) using multivariable regression models. Results Among 9780 Veterans, 43.6% had mental illness alone, 9.4% comorbid mental illness and SUD, and 47.0% neither diagnosis. In adjusted analyses, compared to women with neither diagnosis, women with mental illness alone had a similar rate of gaps but increased odds of having gaps longer than 30 days [odds ratio (OR): 1.35, 95% confidence interval (CI): 1.10–1.52] and fewer months of contraceptive coverage ( β _coefficient: − 0.39, 95% CI: − 0.56 to − 0.23). Women with mental illness and SUD experienced more gaps (incidence rate ratio: 1.12, 95% CI: 1.03–1.21), increased odds of gaps longer than 30 days (OR: 1.46, 95% CI: 1.10–1.79), fewer months of contraceptive coverage ( β _coefficient: − 0.90, 95% CI: − 1.20 to − 0.62) and reduced odds of continuous 12-month coverage (adjusted OR: 0.76, 95% CI: 0.63–0.93). Conclusions Mental illness, particularly with comorbid SUD, is associated with reduced contraceptive adherence and continuation among women Veterans. Women with these risk factors could potentially benefit from use of long-acting reversible methods. Implications Women Veterans have a high burden of mental illness and SUD, which we found are associated with inconsistent contraceptive use. Efforts to improve adherence to hormonal contraceptives and to increase availability of long-acting reversible methods in this vulnerable population are warranted.

The extent of the increased risk of pregnancy hypertensive disorders following assisted reproductive technology (ART) was investigated. PubMed and the Cochrane Collaboration Library were used as data sources to identify and select longitudinal cohorts comparing pregnancies following ART with spontaneously conceived pregnancies, between 1978 and June 2016. Risk ratios and 95% confidence intervals (CIs) of three outcomes, ie, gestational hypertension (GH), preeclampsia (PE), and their sum (PHD), were calculated. Stratification of results by gestation order (singletons and nonsingletons) was pursued, but a separate “all orders” mixed stratification was considered. Sixty‐six longitudinal studies (7 038 029 pregnancies; 203 375 following any ART) were eligible. All outcomes independent of gestation order (“all orders”) were increased following any invasive ART: GH (+79% [95% CI, 24%–157%]) and PE (+75% [95% CI, 50%–103%]) to a greater extent, with smaller increases in PHD (+54% [95% CI, 39%–70%]). The risk of PHD following ART steadily increased independent of gestation order.

BackgroundThe levonorgestrel intrauterine system (LNG-IUS) is a contraceptive method that can cause irregular bleeding and cramping during the first 6 months of use. Expected side effects are common reasons given for LNG-IUS device discontinuation within 12 months of use. Anticipatory counselling regarding expected LNG-IUS side effects may reduce method discontinuation and improve patient satisfaction. Educational videos could improve anticipatory counselling for LNG-IUS users; however, none have been developed. This article describes the process of developing an anticipatory counselling video with input from women in the first 6 months of LNG-IUS use and from family planning (FP) experts.MethodsWe used a participatory, iterative process to develop an anticipatory counselling video about the first 6 months of LNG-IUS use. We developed a preliminary draft using evidence from the published literature. We sought feedback from 11 FP experts and 49 LNG-IUS users to revise the script before creating the final video.ResultsFP experts suggested balancing negative with positive information and using colloquial language. LNG-IUS users requested more detailed information on the LNG-IUS mechanism of action and expected side effects in the form of statistics, infographic animations, testimonials from LNG-IUS users, and technical as opposed to colloquial language. The final video is 6 min in length and features seven LNG-IUS users, three physicians, and infographic animations.ConclusionIncluding input from FP experts and LNG-IUS users in the development process resulted in a 6-min anticipatory counselling video that will be piloted among patients on the day of their LNG-IUS insertion.

Given the increasing number of women service members and veterans of childbearing age, it is important to understand the preconception risks in this potentially vulnerable population. This study compared the prevalence of modifiable preconception risk factors among women with and without a history of service.Analyses included data from the 2013 and 2014 Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System. Preconception risk factors included health behaviors, chronic conditions, and mental health among women of childbearing age. Multivariate logistic regressions were used to compare the adjusted prevalence of each outcome among women with and without a history of service. Interaction terms assessed variation by age and history of service.Compared with women without a history of service, women with a history of service reported higher prevalence of insufficient sleep (49.6% vs. 36.3%; p .001) and diagnosed depression (26.5% vs. 21.6%; p .01). Women with a history of service were overall less likely to have obesity (19.8% vs. 26.5%; p .001). Age-stratified results suggested that, compared with women without a history of service, women with a history of service were more likely to smoke in the 25 to 34 age group and reported comparable levels of obesity in the 35 to 44 age group.Women with a history of service demonstrated a preconception health profile that differs from women without a history of service. It is critical that providers are aware of their patients' military status and potential associated risks.

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.

Objective To assess whether racial/ethnic disparities in contraceptive knowledge observed in the general US population are also seen among women Veterans served by the Veterans Affairs (VA) healthcare system. Study design We analyzed data from a national telephone survey of 2302 women Veterans aged 18–44 who had received care within VA in the prior 12 months. Twenty survey items assessed women's knowledge about various contraceptive methods. Multivariable logistic regression was used to examine racial/ethnic variation in contraceptive knowledge items, adjusting for age, marital status, education, income, parity, and branch of military service. Results Contraceptive knowledge was low among all participants, but black and Hispanic women had lower knowledge scores than whites in almost all knowledge domains. Compared to white women, black women were significantly less likely to answer correctly 15 of the 20 knowledge items, with the greatest adjusted difference observed in the item assessing knowledge about the reversibility of tubal sterilization (adjusted percentage point difference (PPD): −23.0; 95% CI: −27.8, −18.3). Compared to white women, Hispanic women were significantly less likely to answer correctly 11 of the 20 knowledge items, with the greatest adjusted difference also in the item assessing tubal sterilization reversibility (PPD: −13.1; 95% CI: −19.5, −6.6). Conclusion Contraceptive knowledge among women Veterans served by VA is suboptimal, especially among racial/ethnic minority women. Improving women's knowledge about important aspects of available contraceptive methods may help women better select and effectively use contraception. Implications Providers in the VA healthcare system should assess and address contraceptive knowledge gaps as part of high-quality, patient-centered reproductive health care.

Objective To identify factors associated with contraceptive nonuse and use of less effective methods among obese women in the US. Study Design We analyzed data from sexually active obese women (body mass index >30 kg/m 2 ) age 20–44 using the 2006–2010 National Survey of Family Growth. We conducted multinomial logistic regression to assess associations between current contraceptive use and demographic, reproductive and health services factors. Specifically, we compared contraceptive nonusers, behavioral method users (withdrawal and fertility awareness) and barrier method users (condoms) to prescription method users (pill, patch, ring, injection, implant and intrauterine device). Results Of 1345 obese respondents, 21.5% used no method, 10.3% behavioral methods, 20.8% barrier methods and 47.4% prescription methods. Only 42.4% of respondents overall and 20.4% of nonprescription method users reported discussing contraception with a provider in the past year. Similar to findings in the general population, behavioral method users were more likely to have previously discontinued a contraceptive method due to dissatisfaction [adjusted RR (aRR), 1.93; 95% confidence interval (CI), 1.09–3.44], and nonusers were more likely to perceive difficulty becoming pregnant (aRR, 3.86; 95% CI, 2.04–7.29), compared to prescription method users. Respondents using nonprescription methods were significantly less likely to have discussed contraception with a healthcare provider (nonusers: aRR, 0.16; 95% CI, 0.10–0.27; behavioral methods: aRR, 0.13; 95% CI, 0.06–0.25, barrier methods: aRR, 0.15; 95% CI, 0.09–0.25) than prescription method users. Conclusions Obese women who discuss contraception with a provider are more likely to use effective contraception and may be less likely to experience unintended pregnancy; however, over half report no recent discussion of contraception with a provider. Implications Efforts are needed to increase contraceptive counseling for obese women, who face increased risks of morbidity from unintended pregnancy.