Structural gendered racism and preterm birth inequities in the United States.

Structural gendered racism - the "totality of interconnectedness between structural racism and sexism" - is conceptualized as a fundamental cause of the persistent preterm birth inequities experienced by Black and Indigenous people in the United States. Our objective was to develop a state-level latent class measure of structural gendered racism and examine its association with preterm birth among all singleton live births in the US in 2019. Using previously-validated inequity indicators between White men and Black women across 9 domains (education, employment, poverty, homeownership, health insurance, segregation, voting, political representation, incarceration), we conducted a latent profile analysis to identify a latent categorical variable with k number of classes that have similar values on the observed continuous input variables. Racialized group-stratified multilevel modified Poisson regression models with robust variance and random effects for state assessed the association between state-level classes and preterm birth. We found four distinct latent classes that were all characterized by higher levels of disadvantage for Black women and advantages for White men, but the magnitude of that difference varied by latent class. We found preterm birth risk among Black birthing people was higher across all state-level latent classes compared to White birthing people, and there was some variation of preterm birth risk across classes among Black but not White birthing people. These findings further emphasize the importance of understanding and interrogating the whole system and the need for multifaceted policy solutions.

Feasibility Testing of a Web-Based Reproductive Decision Support Tool for Cystic Fibrosis.

BACKGROUND: People with cystic fibrosis (CF) are increasingly considering their reproductive goals. We developed MyVoice:CF, a web-based patient-centered reproductive decision support tool and assessed its implementation in CF care. METHODS: We conducted a feasibility trial among 18-44-year-old women with CF and multidisciplinary CF providers. Prior to CF clinic visit, patient participants completed a baseline survey, used MyVoice:CF, and assessed acceptability, appropriateness, and usability. After clinic, participants rated impact on reproductive health communication. At 3 months post-use, participants assessed impact on reproductive health outcomes. Provider participants completed a survey and focus group regarding MyVoice:CF feasibility/implementation. We assessed outcomes descriptively. We compared MyVoice:CF's impact on outcomes from baseline to follow-up using McNemar's and Wilcoxon signed rank tests as appropriate. RESULTS: Forty-three patient participants completed baseline surveys and 40 rated MyVoice:CF's feasibility; 10 providers participated. Patient participants rated MyVoice:CF's acceptability as 4.48±0.50 out of 5, appropriateness as 4.61±0.48 out of 5, and usability as 82.25±11.02 ('A'/excellent). After MyVoice:CF use, participants reported improved reproductive health communication self-efficacy vs. baseline (3.54±1.17vs.3.95±0.93, p<0.001). At baseline, 36% of participants reported any discussion of reproductive goals/plans with their CF team in the past year compared to 59% after first visit post-MyVoice:CF use (p=0.049). Provider participants similarly rated MyVoice:CF as feasible and reported no negative impacts on clinic flow after implementation. CONCLUSIONS: MyVoice:CF is acceptable, appropriate, and usable for those with CF. Preliminary effectiveness evaluation suggests that MyVoice:CF improves self-efficacy in and frequency of reproductive health communication. Future studies should further assess MyVoice:CF's impact on reproductive health communication and outcomes.

"I Wasn't Presented With Options": Perspectives of Black Veterans Receiving Care for Uterine Fibroids in the Veterans Health Administration.

INTRODUCTION: Black women with uterine fibroids experience greater symptom severity and worse treatment outcomes compared with their White counterparts. Black veterans who use Veterans Health Administration (VA) health care experience similar disparities. This study investigated the experiences of Black veterans receiving care for uterine fibroids at VA. METHODS: We identified Black veterans aged 18 to 54 years with newly diagnosed symptomatic uterine fibroids between the fiscal years 2010 and 2012 using VA medical record data, and we recruited participants for interviews in 2021. We used purposive sampling by the last recorded fibroid treatment in the data (categorized as hysterectomy, other uterine-sparing treatments, and medication only/no treatment) to ensure diversity of treatment experiences. In-depth semistructured interviews were conducted to gather rich narratives of veterans' uterine fibroid care experiences. Transcribed interviews were analyzed using content analysis. RESULTS: Twenty Black veterans completed interviews. Key themes that emerged included the amplified impact of severe fibroid symptoms in male-dominated military culture; the presence of multilevel barriers, from individual to health care system factors, that delayed access to high-quality treatment; insufficient treatments offered; experiences of interpersonal racism and provider bias; and the impact of fertility loss related to fibroids on mental health and intimate relationships. Veterans with positive experiences stressed the importance of finding a trustworthy provider and self-advocacy. CONCLUSIONS: System-level interventions, such as race-conscious and person-centered care training, are needed to improve care experiences and outcomes of Black veterans with fibroids.

Racial Disparities in Uterine Fibroid Treatment Among Veterans Using VA Health Care.

INTRODUCTION: Uterine fibroids are common, nonmalignant tumors that disproportionately impact Black patients. We aimed to examine Black and White differences in receipt of any treatment and type of first treatment in the Department of Veterans Affairs, including effect modification by severity as approximated by anemia. METHODS: We used Department of Veterans Affairs administrative data to identify 5,041 Black and 3,206 White veterans with symptomatic uterine fibroids, identified by International Classification of Diseases, 9th edition, Clinical Modification, codes, between fiscal year 2010 and fiscal year 2012 and followed in the administrative data through fiscal year 2018 for outcomes. Outcomes included receipt of any treatment, hysterectomy as first treatment, and fertility-sparing treatment as first treatment. We stratified all analyses by age (<45, ≥45 years old), used generalized linear models with a log link and Poisson error distribution, included an interaction term between race and anemia, and used recycled predictions to estimate adjusted percentages for outcomes. RESULTS: There was evidence of effect modification by anemia for receipt of any treatment but not for any other outcomes. Across age and anemia sub-groups, Black veterans were less likely to receive any treatment than White veterans. Adjusted racial differences were most pronounced among veterans with anemia (<45 years, Black-White difference = -10.3 percentage points; 95% confidence interval, -15.9 to -4.7; ≥45 years, Black-White difference = -20.3 percentage points; 95% confidence interval, -27.8 to -12.7). Across age groups, Black veterans were less likely than White veterans to have hysterectomy and more likely to have a fertility-sparing treatment as their first treatment. CONCLUSIONS: We identified significant Black-White disparities in receipt of treatment for symptomatic uterine fibroids. Additional research that centers the experiences of Black veterans with uterine fibroids is needed to inform strategies to eliminate racial disparities in uterine fibroid care.

Early Pregnancy Loss Management in the Emergency Department vs Outpatient Setting.

Importance: Early 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. Objective: To compare the management and outcomes of patients with EPL who present to the ED vs outpatient clinics. Design, Setting, and Participants: This 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. Exposures: The 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 Measures: The 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. Results: A 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 Relevance: In 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.

Women's Health Provider Perspectives on Reproductive Services Provision in the Veterans Health Administration.

OBJECTIVES: Women veterans are a fast-growing population in the Veterans Health Administration (VHA), and ensuring reproductive service availability is a VHA priority. As such, we sought to explore barriers and facilitators to VHA reproductive service provision across a catchment area from women's health providers' perspectives. METHODS: We performed a mixed-methods study, including semistructured, qualitative provider interviews with a quantitative survey on training, comfort, and knowledge of reproductive services. All women's health providers and their support staff from the Salt Lake City Veterans Affairs Medical Center and nine VHA community-based outpatient clinics were asked to participate. We conducted qualitative interviews and knowledge surveys with providers and staff to explore training, care processes, and improvement opportunities in reproductive service provision. We completed descriptive analyses of all of the quantitative data and used an open, iterative process to analyze provider interviews for emergent themes. RESULTS: We interviewed 15 providers (7 advanced practice nurses, 4 registered nurses, and 4 physicians) across nine sites (50% response rate). The commonly identified barriers included provider training and staffing, scheduling/referral processes, inconsistent services/supplies, and lack of veteran awareness of reproductive services. Facilitators included prior non-VHA reproductive health experience among providers, invested support staff, and the integrated VHA health system. CONCLUSIONS: Addressing barriers to VHA reproductive healthcare provision may overcome reproductive service variations related to clinic location and improve reproductive health outcomes for women veterans.

Reproductive health services: A missed opportunity in VA primary care?

OBJECTIVE: Integration of reproductive health services into comprehensive primary care is increasingly viewed as a strategy to address service gaps and improve patient-centered care. We assess receipt of contraceptive and prepregnancy health counseling among pregnancy-capable Veterans within Veterans Affairs (VA) primary care. STUDY DESIGN: Data are from 1076 participants in a nationally representative, cross-sectional survey of women Veterans ages 18 to 45 with an overall survey response rate of 28%. Descriptive analyses and chi square tests of association were performed. RESULTS: Only 44% of pregnancy-capable Veterans reported receiving any contraceptive and/or prepregnancy care from a VA primary care provider in the past year. CONCLUSIONS: Although VA guidelines include reproductive services as a core component of primary care, additional efforts may be needed to promote routine provision of this care in practice.

"We Are Working Harder, Not Smarter": A Qualitative Inquiry into Care Coordination for Department of Veterans Affairs Mammograms Referred to the Community.

INTRODUCTION: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Abortion Care for Veterans-A Historic Step Forward.

This Viewpoint discusses the US Department of Veterans Affairs' decision to offer abortion counseling and care to veterans in cases of rape, incest, and life or health endangerment, and how insights from this decision may be shared with other health care systems.

Evaluating the MyPath web-based reproductive decision support tool in VA primary care: Protocol for a pragmatic cluster randomized trial.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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. TRIAL REGISTRATION: http://ClinicalTrials.gov Identifier: NCT04584294 Trial Status: Recruiting.

Oral Emergency Contraception Provision in the Veterans Health Administration: a Retrospective Cohort Study.

BACKGROUND: In the USA, oral emergency contraception (EC) use to prevent unintended pregnancy is increasing. Oral EC methods include levonorgestrel (LNG) and ulipristal acetate (UPA), with increased UPA efficacy over LNG in high BMI users and those beyond 3 days post intercourse. The Veterans Health Administration (VHA) provides oral EC at low or no cost, yet prescription-level Veteran data are lacking. OBJECTIVE: To describe oral EC provision in VHA, including method type and Veteran user and prescriber characteristics. DESIGN: A retrospective cohort study using VHA administrative data. PARTICIPANTS: All VHA oral EC prescriptions from January 1, 2016, to December 31, 2020. MAIN MEASURES: We linked Veteran-level sociodemographic and military characteristics and provider-level data with each prescription to identify variables associated with oral EC method. KEY RESULTS: A total of 4280 EC prescriptions (85% LNG) occurred for 3120 unique Veterans over 5 years. While prescriptions remained low annually, the proportion of UPA prescriptions increased from 12 to 19%. Compared to LNG users, UPA users were older (34% vs 25% over age 35 years, p <0.001); more likely to identify as white (57% vs 46%) and non-Hispanic (84% vs 79%) (p <0.001); and more likely to have a BMI ≥ 25 (76% vs 67%, p <0.001). UPA prescriptions originated most frequently from VA Medical Centers (87%) and women's health clinics (76%) compared to community-based or other clinic types. In multivariable regression models, race, ethnicity, BMI ≥30, and prescriber facility type of a VA Medical Center or a women's clinic location were predictive of UPA prescription. CONCLUSIONS: Oral EC provision in VHA remains low, but UPA use is increasing. LNG prescription occurs frequently in high BMI Veterans who would benefit from increased efficacy of UPA. Interventions to expand oral EC access in VHA are essential to ensure Veterans' ability to avert unwanted pregnancies.

Perceived Contraceptive Counseling Quality Among Veterans Using VA Primary Care: Data from the ECUUN Study.

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.

Experiences of racism and postpartum depression symptoms, care-seeking, and diagnosis.

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.

A Framework for Femtech: Guiding Principles for Developing Digital Reproductive Health Tools in the United States.

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.

Uterine Weight as a Modifier of Black/White Racial Disparities in Minimally Invasive Hysterectomy Among Veterans with Fibroids in the Veterans Health Administration.

Introduction: Uterine fibroids are the most common indication for hysterectomy. Minimally invasive hysterectomy (MIH) confers lower risk of complications and shorter recovery than open surgical procedures; however, it is more challenging to perform with larger fibroids. There are racialized differences in fibroid size and MIH rates. We examined the role of uterine size in black-white differences in MIH among Veterans in the Department of Veterans Affairs (VA). Methods: Using VA clinical and administrative data, we conducted a cross-sectional study among black and white Veterans with fibroids who underwent hysterectomy between 2012 and 2014. We abstracted postoperative uterine weight from pathology reports as a proxy for uterine size. We used a generalized linear model to estimate the association between race and MIH and tested an interaction between race and postoperative uterine weight (≤250 g vs. >250 g). We estimated adjusted marginal effects for racial differences in MIH by postoperative uterine weight. Results: The sample included 732 Veterans (60% black, 40% white). Postoperative uterine weight modified the association of race and MIH (p for interaction=0.05). Black Veterans with postoperative uterine weight ≤250 g had a nearly 12-percentage point decrease in MIH compared to white Veterans (95% CI -23.1 to -0.5), with no difference by race among those with postoperative uterine weight >250 g. Discussion: The racial disparity among Veterans with small fibroids who should be candidates for MIH underscores the role of other determinants beyond uterine size. To eliminate disparities in MIH, research focused on experiences of black Veterans, including pathways to treatment and provider-patient interactions, is needed.

Redefining Primum Non Nocere to Include Reproductive Autonomy: A New Paradigm in Subspecialty Medicine.

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.

Early pregnancy loss in the emergency department, 2006-2016.

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.

Veteran-Reported Receipt of Prepregnancy Care: Data from the Examining Contraceptive Use and Unmet Need (ECUUN) Study.

OBJECTIVES: To identify the prevalence of women Veterans reporting receipt of counseling about health optimization prior to pregnancy, topics most frequently discussed, and factors associated with receipt of this care. METHODS: We analyzed data from a nationally representative, cross-sectional telephone survey of women Veterans (n = 2302) ages 18-45 who used VA for primary care in the previous year. Our sample included women who were (1) currently pregnant or trying to become pregnant, (2) not currently trying but planning for pregnancy in the future, or (3) unsure of pregnancy intention. Multivariable logistic regression was used to examine adjusted associations of patient- and provider-level factors with receipt of any counseling about health optimization prior to pregnancy (prepregnancy counseling) and with counseling on specific topics. RESULTS: Among 512 women who were considering or unsure about pregnancy, fewer than half (49%) reported receiving any prepregnancy counseling from a VA provider in the past year. For those who did, the most frequently discussed topics included healthy weight (29%), medication safety (27%), smoking (27%), and folic acid use before pregnancy (27%). Factors positively associated with receipt of prepregnancy counseling include history of mental health conditions (aOR = 1.96, 95% CI: 1.28, 3.00) and receipt of primary care within a dedicated women's health clinic (aOR = 2.07, 95% CI: 1.35, 3.18), whereas factors negatively associated include far-future and unsure pregnancy intentions (aOR = 0.35, 95% CI: 0.17, 0.71 and aOR = 0.33, 95% CI: 0.16, 0.70, respectively). CONCLUSIONS FOR PRACTICE: Routine assessment of pregnancy preferences in primary care could identify individuals to whom counseling about health optimization prior to pregnancy can be offered to promote patient-centered family planning care.