Deirdre A. Quinn, PhD, MSc.
PITTSBURGH — The integration of reproductive health services into primary care practices is increasingly recognized as critical to the advancement of patient-centered care and improving reproductive outcomes. Primary care providers have therefore increasingly adopted protocols to expand provision of reproductive health services.
In the VA, policy dictates that women are offered assignment to trained, designated women’s health providers who provide general primary care in addition to gender-specific care such as preconception care, contraception and menopause care. Through VA’s national women’s health mini-residency program, more than 10,000 VA clinicians have received updated training in women’s gender-specific care.
Primary care is provided in hospital-based clinics within VA medical centers or in community-based outpatient clinics, which are often located in rural areas and are less likely to have coverage by a gynecologist than hospital-based clinics.
While national VA practice guidance recommends regular assessment of veterans’ reproductive goals with individualized delivery of desired services at primary care clinical encounters, and evidence suggests that veterans value these opportunities to discuss reproductive goals and needs with their primary care providers, a new study shows the actual utilization of these services is surprisingly low, said the study’s lead author, Deirdre A. Quinn, PhD, MSc.
The study, which was published in Contraception, analyzed a subset of the survey data concerning the receipt of reproductive health services in VA from the Examining Contraceptive Use and Unmet Need (ECUUN) study. ECUUN is a nationally representative, cross-sectional telephone survey of women Veterans ages 18 to 45 who accessed VA primary care in the preceding year.1
Reproductive Health Services Underused
Lisa Callegari, MD, MPH, Center for Veteran-Centered and Value-Driven Care at VA Puget Sound Healthcare System in Seattle, Associate Professor of Obstetrics and Gynecology University of Washington
The researchers found that fewer than half (44%) of veterans in the sample who were capable of pregnancy reported receiving any reproductive health services (i.e., contraceptive services, pre-pregnancy counseling or both) from a VA primary care provider in the prior year, said Quinn, core investigator at the Center for Health Equity Research & Promotion (CHERP) at VA Pittsburgh and assistant professor of medicine at the University of Pittsburgh.
“Veterans who accessed VA primary care at a dedicated Women’s Health Clinic were more likely to have received any reproductive health services than veterans who accessed care at a general primary care clinic,” she said. “Veterans who were older, had one or more previous birth or who reported being uninterested in a future pregnancy were less likely to have received any reproductive health services in VA primary care.”
Among the 56% who reported not receiving any of these services in VA primary care, only about a quarter said they received reproductive healthcare outside of VA, Quinn said. “That means that three-quarters of veterans in our sample who didn’t receive reproductive health services in VA primary care in the past year also didn’t receive that care outside of VA.”
Quinn told U.S. Medicine that she was surprised to see that so many veterans in their sample who didn’t receive reproductive health services in VA primary care also didn’t report receiving that care outside the VA.
“It’s very plausible that some veterans will choose to go outside the VA for this care, but we found less evidence of this than we expected,” she said, adding that there may be a few reasons for this. “It’s possible that some of those veterans who didn’t get this care from primary care did actually receive this care from a VA gynecologist, which we did not capture. It’s also plausible that some veterans in our sample who didn’t receive reproductive health services in the past year didn’t actually need them—even though we identified them as being ‘pregnancy-capable,’” she said. “For example, a veteran assigned female sex who does not have a partner who produces sperm and does not desire pregnancy or a veteran who is well-established on a long-acting reversible method might not need or desire these services”.
“Our findings suggest that some veterans who are engaged in VA care and who would benefit from reproductive health services may not be receiving them, and that additional efforts to promote these discussions in primary care are needed,” Quinn said.
One such effort is a novel web-based patient-facing decision support tool called MyPath. The tool is designed to be used by veterans before primary care visits to promote patient-centered conversations about reproductive goals and needs for services, said senior author Lisa Callegari, MD, MPH, core investigator at the Center for Veteran-Centered and Value-Driven Care at VA Puget Sound Healthcare System in Seattle and associate professor of obstetrics and gynecology at the University of Washington. “A clinical trial of MyPath is underway at 11 VA sites nationally, with a plan to expand the intervention in partnership with the VA Office of Women’s Health if found to be effective,” Callegari said.
- Quinn DA, Sileanu FE, Borrero S, Callegari LS. Reproductive health services: A missed opportunity in VA primary care? Contraception. 2023 Apr;120:109957. doi: 10.1016/j.contraception.2023.109957. Epub 2023 Jan 14. PMID: 36649750.