Perceived Barriers and Facilitators to Contraceptive Use Among Women Veterans in the ECUUN Study

Abstract

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

Semi-structured telephone interviews with a national sample of 189 women veterans at risk of unintended pregnancy who receive care in 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 while 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 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.

Introduction

In recent years, the number of reproductive-aged women veterans seeking care in the Veterans Affairs (VA) Healthcare System has grown, expanding the need for provision of contraceptive care. To better address the needs of this population, VA policy requires that all women patients have access to a primary care provider who is proficient and certified in providing both gender-neutral and gender-specific care, including contraceptive care. Such providers are designated as women’s health primary care providers (WH-PCPs) and see female patients in either separate women’s health clinics or in all-gender clinics. Approximately 44% of facilities have a gynecologist on site, and referrals can be made as needed to this gynecologist or one off-site (either another VA site or via contract care at a non-VA site) for contraceptive procedures such as sterilization or insertion of intrauterine devices (IUDs) or subdermal implants (Katon et al., 2013). The full range of contraceptive methods is offered through the VA. Veterans may be exempt from medication copays based on financial means and service-connection (defined as an illness or injury caused or made worse by military service); those who are not exempt pay a flat fee for all contraceptive medications (the 2019 copay is $8 for a 30 day supply), while contraceptive devices such as IUDs and implants do not incur any copay. Thus, women who use VA for primary care largely have access to low-cost or no-cost contraception. Despite coverage of the full range of effective contraceptive methods through the Veterans Affairs Healthcare System (VA), however, women veterans experience a high burden of unintended pregnancy, with proportions comparable to the general United States population (Borrero et al., 2017).

Previous work in the non-veteran population suggests that numerous personal-, provider- or system-level barriers to contraceptive use may contribute to persistently high rates of unintended pregnancy in the US. For example, some women experience personal barriers to contraceptive use due to inaccurate beliefs about their fertility (Biggs, Karasek, & Foster, 2012), gaps in knowledge about contraception (Polis & Zabin, 2012), or barriers stemming from relationship factors such as reproductive coercion or sexual assault (Borrero et al., 2015). Other patients experience barriers related to healthcare providers, as when a physician lacks knowledge or expertise to deliver optimal contraceptive care, or causes patient discomfort or self-consciousness while discussing contraceptive use (Tyler et al., 2012; Politi et al., 2016; Hoggart, Walker, Newton, & Parker, 2018). Still others experience systemic barriers, as when a patient must travel considerable distances to access contraceptive care, or her preferred method is not financially feasible or simply unavailable (American College of Obstetrics and Gynecology, 2015; Politi, Sonfield, & Madden, 2016). Conversely, convenient and high-quality care has been shown to facilitate contraceptive use, such that access to personalized contraceptive counseling by competent providers and same-day contraceptive provision increase both contraceptive uptake and patient satisfaction with their chosen method (Weisman, Maccannon, Henderson, Shortridge, & Orso, 2002; Secura, Allsworth, Madden, Mullersman, & Peipert, 2010; Goodman et al., 2008).

Although there is a growing understanding of factors influencing contraceptive use in the general population, little work has been done to elucidate provider- and system- level barriers and facilitators that may be specific to or prevalent among women VA users. Women veterans are a diverse and vulnerable population, with nearly 40% belonging to racial/ethnic minority groups and high rates of medical and psychiatric conditions (Frayne et al., 2012). Due to the frequency of medical comorbidities, women veterans also have a high rate of medical contraindications to estrogen, which limits contraceptive options and may contribute to unintended pregnancy (Judge, Zhao, Sileanu, Mor, & Borrero, 2018). These factors, in addition to exposure to combat zones and military sexual trauma (MST), shape contraceptive use and risk of unintended pregnancy among women veterans (Borrero et al., 2017; Judge-Golden, Borrero, Zhao, Mor, & Callegari, 2018). Characterizing barriers and facilitators of contraceptive use at VA facilities is thus an important step in enabling women veterans to better achieve their ideal reproductive goals. This analysis seeks to use qualitative methods to deepen understanding of how provider- and system-level variables influence contraceptive use among women veteran VA users and elicit women’s suggestions to improve VA contraceptive care.

Materials and Methods

Sample

Our sample was drawn from the larger study population of women veterans who participated in the Examining Contraceptive Use and Unmet Needs (ECUUN) study (Borrero et al., 2017). ECUUN was a nationally representative survey among women veterans aged 18–44 who received primary care in the VA in the 12 months prior to interview. We asked all participants at risk of unintended pregnancy (i.e., sexually active in the prior 3 months and not pregnant, trying to get pregnant, or infertile) of their interest in participating in a qualitative survey about their experience with VA care. Among those interested, we selected participants for key informant interviews based on a sampling matrix of subpopulations at elevated risk of poor contraceptive or reproductive health outcomes, including women with medical illness, mental illness, history of military sexual trauma (MST), and women in ethnic/racial minority groups, groups, namely Hispanic and non-Hispanic African-American women. For each vulnerable subpopulation, we sampled women not using contraception, women using non-prescription contraception, and women using prescription contraception obtained from both within VA and outside of VA. The sampling matrix is thus a four (contraception use) by six (five vulnerable populations and one non-vulnerable population) crosstab to ensure we sampled a range of perspectives across vulnerable and non-vulnerable groups of women (Table 1). We sought to interview at least 12 women per group, as thematic saturation is typically reached at 12 to 16 interviews (Crabtree & Miller, 1992). A single woman could be included in the matrix more than once if she met criteria for multiple groups. Though we did not reach that goal for non-vulnerable women (nearly all women identified had at least one vulnerability), themes emerging from the interviews were consistent enough to determine that we had reached thematic saturation regardless. This study was approved by the Institutional Review Board and the Research and Development Office at VA Pittsburgh Healthcare System.

Table 1:

Sampling Matrix for Qualitative Interviews

Total n=189	Vulnerable Population n=158 (83.6%)					Non-Vulnerable Population n=31 (16.4%)
	Hispanic n=44	Non-Hispanic AA n=55	Presence of medical illness n=72	Presence of mental illness n=89	Positive history of MST n=79
Using prescription method obtained in VA (n=56)	13	14	17	26	21	13
Using prescription method obtained outside of VA† (n=51)	15	13	17	19	16	11
Using non-prescription method (n=46)	10	15	21	23	23	4
Not using contraception (n=36)	6	13	17	21	19	3

^†Male sterilization included in sample of women using prescription method obtained outside of VA

^‡Participant risk factors are not mutually exclusive. For example, a woman may be both Hispanic and have a medical illness and may be counted once for each risk factor; she would be included twice in the matrix.

Data Collection

Telephone-based interviews were approximately 30 minutes in length and conducted by two female research assistants. Participants received a $20 honorarium for their time. Using a semi-structured open-ended interview guide, we asked participants about VA-specific experiences with contraceptive care, including perceived barriers to and facilitators of care, as well as their ideas about strategies to ensure effective family planning for VA patients. Prior to data collection, all interviewers participated in mock interviews and were trained on effective communication concerning sensitive topics such as pregnancy, contraception, and sexuality. Interviews were audio-recorded, transcribed verbatim (redacting identifying information [e.g., provider names, locations]), and verified independently by a second transcriber.

Using an established thematic analysis approach, we assessed data to determine barriers, facilitators, and suggestions regarding VA contraceptive care (Crabtree & Miller, 1992). Two independent coders created codes and indexed the data. The first 10% of interviews were double-coded and inter-rater agreement was established by calculating Cohen’s kappa coefficients for each code. Any codes with agreement less than 0.60 were resolved with group consensus by the remainder of the study team. The mean kappa was thus >0.60 for all codes, signifying “substantial agreement” (Cohen, 1960). Once inter-coder reliability was established, additional transcripts were single-coded by one of the two independent coders. Transcripts were analyzed using Atlas.ti version 7.5 (Scientific Software Development GmbH, Berlin, Germany).

The finalized codebook and applied coding categories identified quotes containing barriers, facilitators, and suggestions for VA contraceptive care. We then performed a thematic analysis among each category to determine specific barriers, facilitators, and suggestions that were most prevalent, to identify broader themes that overlapped between categories, and to evaluate for content differences between sub-populations. Using the constant comparison method we underwent an ongoing analysis to refine the specifics of each theme and tabulate the number of participants addressing each theme (Glaser & Strauss, 1967). Given no content differences between the vulnerable and non-vulnerable populations, and the small sample size for the non-vulnerable population, the tabulated results were presented for the total only.

Results

A total of 1115 women at risk of unintended pregnancy voiced interest in future interviews and were thus eligible for qualitative sampling. Of the 381 women invited, 189 women completed the interview, for a response rate of 49.6%. The average age of participants was 33.2 years; 29.1% were non-Hispanic Black, 47.6% were non-Hispanic White, and 23.3% were Hispanic (Table 2). A total of 38.1% reported history of medical illness, 47.1% reported history of mental illness, 41.8% reported experiencing MST, and 16.4% did not report any of the specified vulnerabilities.

Table 2:

Demographic Characteristics

	n=189 (100%)
Age
20–24	8 (4.2)
25–29	48 (25.4)
30–34	51 (27.0)
35–39	53 (28.0)
40–45	29 (15.3)
Race
Non-Hispanic White	90 (47.6)
Non-Hispanic Black	55 (29.1)
Hispanic	44 (23.3)
Other	-
Medical illness	72 (38.1)
Mental illness	89 (47.1)
MST	79 (41.8)

Participants expressed a broad range of provider- and system- specific barriers and facilitators to contraceptive use. We organized the elicited barriers and facilitators into five distinct themes and included suggestions from participants about how to improve care pertaining to each theme (Table 3).

Table 3:

Tabulated Barriers and Facilitators to Contraceptive Use

	Number† (n=189)	Percent (%)
Efficiency of Care	105	56
Time consuming/ inefficient (B)	55	29
Timely appointment scheduling (B)	26	14
Geographic barriers (B)	27	14
Limited office hours (B)	5	3
Efficiency (F)‡	25	13
Improve appt efficiency/ convenience (S)	35	19
Contraceptive Counseling and Educational Resources	73	39
Access to information (F)	15	8
Contraceptive counseling resources (S)	36	19
Educational opportunities (S)	27	14
Patient Awareness of Services	64	34
Unaware of services offered (B)	32	17
Advertise services (S)	53	28
Provider Characteristics	59	31
Poor relationship with provider (B)	25	13
Poor provider communication (B)	8	4
Attentive provider (F)	27	14
Communication between provider and patient (S)	23	12
Woman-Friendly Environment	58	31
Unwelcoming environment for women (B)	20	11
Physically separate women’s clinic (F)	12	6
Female provider (F)	8	4
Woman-friendly environment (S)	40	21
Provider specializing in women’s health (S)	14	7

Selected barriers (B), facilitators (F), and suggestions (S) among identified codes

^†Denotes the number of participants who identified the specific code or alluded to the overall theme during their interviews

^‡Includes availability of confidential telemedicine (n=3)

Efficiency of Care

Efficiency of care was the most commonly elicited theme among participants, with 56% identifying efficiency and convenience as important aspects of contraceptive care. Many noted that the VA system was difficult to navigate, particularly regarding reproductive health services:

There’s a lot of veteran females that do not seek help because they keep going through all of this. Who wants to be jumping through hoops, and then hoops that are lit on fire? And then having to jump through a pool? You know? Nobody wants to go—we’re not in the circus [laughter].

Specifically, many patients expressed concern about difficulty obtaining appointments, with several women noting having to wait a month or more to see a physician for contraceptive refills, while others described the inconvenience of only receiving a one-month supply of oral contraceptives because their provider did not offer three-month prescriptions. Others (11%) reported geographic barriers to accessing contraceptive care, such as driving an hour or more to a VA women’s clinic that they felt comfortable visiting. Still others noted difficulty accessing care due to limited office hours. One woman explains:

I want to move to the shot, but the VA only sees people up until 5:00, so it’s kind of a pain to go and see somebody. I wish they would implement some evening hours, or weekend hours. What’s the point of having a women’s clinic if you never have time to go?

However, not all women described negative experiences regarding efficiency, with several reporting that the ability to communicate with providers via confidential telemedicine or My HealtheVet, VA’s web-based patient portal, was a positive aspect of VA care. As one participant noted, “I’ve gotten great care with the doctors and specialists, and I like the systems that are in place in terms of My HealtheVet to be able to communicate with my doctors and do online prescription refills and things like that.”

Suggestions to improve contraceptive care included easier access to a WH-PCP, as many women noted they struggled to make an appointment at their VA’s women’s clinic and/or believed that a referral was required to be seen by a women’s health provider. One woman notes, “…it’s not like you can just go to the women’s clinic and set up an appointment and say, ‘I want the Depo shot’ or ‘I want the pill.’ You always have to go through your primary care.” Other suggestions included providing at least a three-month supply for oral contraceptives and ensuring evening and weekend clinic hours.

Contraceptive Counseling and Educational Resources

The importance of frequent and high-quality contraceptive counseling, as well as availability of educational resources regarding contraceptive options, was identified by 39% of participants. Many women noted that contraceptive counseling was not routinely initiated or performed at VA health maintenance visits. One woman explains, “I guess I feel if I wanted it, I would have to approach them about it, not the other way around.” Others note that they lacked the information necessary to make informed contraceptive choices and would have benefited from provider guidance.

To aid women in learning about contraceptive options, participants offered a broad range of suggestions, including providing brochures and posters in the waiting room that explain the details of available methods. Several also suggested implementing classes or support groups like those available for other health topics:

There’s a lot of like, PTSD, there’s a lot of depression, anxiety, or how to stop smoking classes. I don’t really see a lot of classes for women to talk about birth control or family planning... It’s always about, you know, MST, and I know that’s a big deal, but it’s always geared towards that rather than the woman just…at her present moment, like more of empowerment, I guess? To me, birth control is empowerment. Because it gives me the ability to make the choice whether I’m ready to have a child or not.

In terms of contraceptive counseling, many women emphasized the importance of making patients feel comfortable when approaching contraceptive conversations, as the topic may be sensitive for some patients. As one participant suggested, “… [have] doctors actually approach it, because I think that there’s a lot of women that are very, I don’t know, embarrassed, or shy, or like, ‘Oh, I don’t want to ask.’” Other participants recommended that providers ask about contraceptive needs at regular intervals, much like screening for other medical conditions.

…they always ask, ‘Are you suicidal?’ or whatever. ‘When was the last period?’ You know, they ask us those questions when we come in there for our annual. That can be a question on the assessment and everything. ‘Would you like more information? Are you using contraceptives?’

Still others desired support for choosing alternative methods of contraception and suggested enhancing education for women seeking natural contraceptive methods. One woman explained, “I guess the biggest thing is that chemical contraception is not the only method. There should be other methods championed… Especially when it comes to helping patients understand the rhythm methods.” These participants expressed feeling isolated due to their contraceptive preferences and desiring more open dialogue with providers on this topic.

Patient Awareness of Services

Approximately a third (34%) of participants identified lack of awareness about VA contraceptive services among veteran women or suggested increased advertising of these services. One woman noted, “I didn’t even know you could go to the VA for women’s health care until I got the thing in the mail from you guys and was reading about it.” Women had several suggestions to help combat low awareness of services, including sending emails to eligible women veterans and advertising to all female soldiers during or at the end of military service:

…there’s a lot of debriefings that happen and, ‘Hey, you’re getting out the military, here’s all these services available to you.’ When I got back from deployment and I knew about my injury and everything, ‘So, okay, well you have five years of services at the VA.’ But, maybe that would be the time to be like, ‘Hey, and women, you also have this available to you during that time.’

Others recommended using the internet to clarify which services are available to women, as well as to schedule appointments with the appropriate provider. Yet another suggested, “Even if they have a link for women that can give information. All information issues for women. I think that would be helpful, because it’ll also make women more trusting of the VA.”

Provider Behaviors

Participants frequently (32%) described provider behaviors influencing contraceptive care. Though some women described positive provider interactions, many noted that feeling disrespected by their provider negatively impacted their care. One participant recalled, “I just want to be on contraceptives to get more regulated, and I felt like he didn’t really hear what I was saying. So, I kind of ignored the issue. I just dropped it and didn’t seek contraceptives after that.” Another participant felt criticized for her chosen method of natural family planning:

I’ve seen two doctors in the past that even though I’m fairly knowledgeable about my choice in birth control—were incredibly critical because it did not fall into their idea of acceptable forms of birth control… I can’t describe it any better than say they give me a crazy look and say, ‘Are you sure you don’t want the pill or the ring? These are very effective.’ It’s as if I tell them I’m taking snake oil. It’s just a very adverse reaction.

Many patients noted that poor communication with their provider may be due to provider discomfort with the topic of contraception, particularly if providers were male or PCPs without specific training in women’s health. Others perceived that a lack of provider knowledge and expertise were barriers to contraceptive care. One woman questioned, “So, how good of care am I really getting when my doctor has seen eight Vietnam vets who are in their seventies, and then I come along.” Another expressed concern that her provider lacked confidence in prescribing contraceptives:

…when I first saw her I wanted to get on the birth control pill, and she was very held back by that or because she deals with men mainly…it kind of made it awkward. She’s like, ‘I haven’t ordered this in a really long time,’ and she had to do research on what to order, so she wasn’t really as knowledgeable on birth control as she could be.

Suggestions to improve interactions with providers included enhancing PCP education regarding basic women’s healthcare, including contraceptive care, to avoid unnecessary referrals to OB/GYN. Others suggested that fostering a trusting patient-provider relationship will improve contraceptive care. “Just make them [patients] feel really comfortable. Just, you know, just letting them know that everything’s confidential, and this is for their health.”

Woman-friendly Environment

Finally, 31% of participants identified promoting a woman-friendly environment as a critical component of care. This included concerns about the physical space where women receive care, the provider’s gender, and the general experience of being a woman receiving contraceptive care at VA. Unfortunately, many participants’ experiences left them feeling that VA is an unwelcoming environment for women, and that “women veterans are considered outsiders.” Another patient noted, “It feels like when you go into the VA it’s a men’s club,” while others suggest that women are considered “second-class citizens” and thought to be “malingerers.”

Many of these women commented that having a physically separate women’s clinic within VA is important in facilitating contraceptive access. One woman suggested, “Set up a clinic that’s dedicated to women, especially for women who have gone through traumatic experiences while they’re in the military. There is already a distrust of men that happened.” These participants noted that separate women’s clinics offered greater discretion for women seeking care for sensitive issues and were frequently more amenable to mothers with children.

Women with a history of MST had particularly strong comments about having a separate clinic to foster an environment that is comfortable for and respectful of women veterans. One survivor noted:

… even having a facility that’s not within the VA would make it more comfortable, because when you go the VA, especially as a girl, you’re always asked, ‘Are you— are you the veteran or are you just a dependent?’ So, that just makes it a little bit like a slap in the face.

Other MST survivors expressed preference for a female provider. One woman explained that having a female provider was a “sensitive issue from when I first got out. You just don’t want to be around those people, and once you are out it’s just like you want nothing to do with it.” Another survivor suggested “having more female physicians that are capable of doing women’s health things, because there are going to be some women—like myself—who just feel more comfortable with a female doing that sort of thing.”

Those who were satisfied with their contraceptive care reported feeling safe and welcome in the women’s clinic and appreciating the “kid-friendly” layout. One woman explained, “…the women’s wellness clinic has always treated me with dignity and respect and has always listened to my concerns and my needs and helped me be at a place that I want to be with my body.”

Discussion

This analysis of interviews with purposefully sampled VA users revealed five distinct aspects of VA contraceptive care that veterans described to act as either barriers or facilitators to contraceptive use, including 1) efficiency of care, 2) contraceptive counseling and educational resources, 3) patient awareness of services, 4) provider characteristics, and 5) woman-friendly environment. Though participant experiences were system- and provider- specific, they illustrate general themes of VA contraceptive care and indicate specific areas of improvement.

Concerns related to appointment access were among those most commonly elicited. Many patients expressed difficulty obtaining appointments at VA women’s clinics, as patients believed that seeing a WH-PCP required referral from their VA primary care provider. This likely reflects a misunderstanding of the difference between WH-PCPs, who can be seen without referral, and gynecologists who may require referral. As discussed previously, VA policy dictates that all women veterans have a designated WH-PCP; if patients choose a non-designated provider, they must have access to a WH-PCP at the same site for gender-specific care as necessary (Department of Veterans Affairs Veterans Health Administration, 2017). The suggestion by several participants to ensure convenient access to a women’s health provider without referral thus aligns with current VA policy and indicates a need for both greater adherence to this policy by individual VA facilities as well as improved education of women veterans on the availability of women’s health providers.

Low patient awareness of contraceptive services emerged as another barrier, with veterans frequently learning of contraceptive services from friends or co-workers. Prior research has established this pattern, reporting that many women first learn of VA healthcare and feel encouraged to seek care through informal social networks (Wagner, Dichter, & Mattocks, 2015; Callegari et al., 2015). Though recent VA initiatives have sought to address low awareness of services, these findings underscore the need for ongoing outreach (Washington, Farmer, Mor, Canning, & Yano, 2015). Our participants’ suggestions, such as advertising to soldiers at the end of active duty or sending email to all women veterans of reproductive age, may improve knowledge of VA contraceptive services. In addition, efforts are ongoing within VA to build prompts in the electronic medical record for PCPs to routinely ask women about their need for contraceptive services and educate women about the full range of contraceptive options available through VA [personal communication, Caitlin Cusak, Women’s Health Services].

Participants also commonly expressed concerns regarding providers’ approach to contraceptive counseling, both in terms of their knowledge of available methods as well as their willingness to elicit patients’ values and preferences while assisting patients in making individualized contraceptive choices. Though increased access to WH-PCPs may improve access to providers with expertise in contraceptive counseling and provision, education for all PCPs who interface with reproductive-age women is warranted. Other issues related to provider behaviors included participants feeling criticized by providers for their choice of less effective methods, such as natural family planning methods. Our findings support provider education about the importance of eliciting women’s values and preferences beyond method effectiveness and supporting women in using their chosen methods consistently and correctly to reduce the likelihood of undesired pregnancy. Efforts are ongoing to develop innovative tools, such as the “MyPath” decision support tool, to promote informed, preference-aligned decisions and high-quality provider-patient communication about contraception.

Beyond individual providers, participants frequently reported VA culture as detrimental to their contraceptive care and suggested improving access to physically-separate women’s health clinics to facilitate comfort discussing sensitive health issues. The role of women’s clinics within VA facilities has previously been examined, with recent studies finding that veterans who receive care in a women’s health clinic are significantly more likely to report using contraception and are three times more likely to be offered the full range of women’s health services compared to those seen in traditional primary care clinics (Borrero et al., 2012; Reddy, Rose, Burgess, Charns, & Yano, 2016). However, per VA policy several models of Women’s Clinics are acceptable—including integrated Women’s Health Clinics that share space with all-gender clinics— though all models emphasize privacy, physical comfort, and high-quality gender-specific care (Department of Veterans Affairs Veterans Health Administration, 2017).

Finally, this study assessed how perceived barriers and facilitators to contraceptive use may vary across vulnerable subpopulations. Our observation that women with a history of MST may have different concerns than those without a history of MST is consistent with recent qualitative work that found gender-related distress, such as feeling anxious or out of place and a desire for separate facilities, to be common among women veterans with MST (Monteith et al., 2018). As sexual and reproductive healthcare may be particularly triggering for these veterans, the provision of compassionate and trauma-informed care is critical to ensure women’s safety, privacy, and dignity (Kehle-Forbes et al., 2017; deKleijn, Lagro-Janssen, Canelo, & Yano, 2015).

Strengths of this study include a diverse and relatively large qualitative sample. Limitations include difficulty distinguishing the scope of a given barrier or facilitator, as facilities differ in quality of care and reported patient experience. As a result, individual VA facilities must pursue internal analyses to determine how best to improve the patient experience. Finally, given that this study was completed within VA, our findings are specific to the VA system and cannot be generalized to the private sector. However, VA is an exemplar system in which to investigate provider and system barriers to contraceptive use as there may be fewer cost-related barriers than in the general population.

Implications for Practice and/or Policy

Overall, this work indicates that women VA users experience inconsistent quality of contraceptive care across VA facilities due to both provider- and system-level factor. These findings suggest the need for internal evaluation of individual VA facilities and more uniform adherence to VA policy. However, women also suggested a number of concrete, actionable areas of improvement at the system level, including: facilitating appointment access for contraceptive services; training in patient-centered contraception counseling and care for providers who interface with women veterans of reproductive age; expanding advertising of contraceptive services; ensuring provision of multiple months’ supply of contraceptive method; enhancing patient education and decision support regarding contraceptive choices; and ensuring a dedicated women’s clinic space within VA facilities whenever possible.

Conclusion

This study provides important insights into veteran-reported barriers and facilitators affecting the contraceptive care of women using the VA system, and highlights women’s perspectives on how VA could improve access to and quality of contraceptive care. The variation of barriers and facilitators across facilities suggests that, in addition to ongoing national efforts, individual VA facilities and practitioners must undertake rigorous internal evaluations and efforts to ensure that women veterans consistently receive respectful, high-quality contraceptive care.

Author Biography

Tierney Wolgemuth, BS, is a medical student at the University of Pittsburgh School of Medicine. She is currently studying patient- and system-level factors influencing contraceptive use in the female veteran population.

Maris Cuddeback, BA, is a medical student at the University of Pittsburgh studying contraceptive use in the female Veteran population.

Lisa Callegari, MD, MPH, is an Assistant Professor of Obstetrics and Gynecology, University of Washington and a Core Investigator, VA HSR&D Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care.

Keri Rodriguez, PhD, is a research health scientist at the Department of Veterans Affairs and a core investigator at CHERP Pittsburgh. She works at the interface of medicine, sociology, palliative care, and linguistics.

Xinhua Zhao, PhD, MPH, is a research health scientist at the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System.

Sonya Borrero, MD, MS, is an Associate Professor of Medicine and Clinical and Translational Sciences and Director, Center for Women’s Health Research and Innovation (CWHRI), University of Pittsburgh School of Medicine. She is the principal investigator of the ECUUN study.