DESCRIPTION (provided by applicant): Unintended pregnancy is a prevalent problem in the U.S. that is associated with significant adverse health and social consequences for women and their children. Contraception is a highly effective way to prevent unintended pregnancy, and contraceptive counseling and management is an integral component of primary care for women of reproductive age. The number of female Veterans of reproductive age is rapidly increasing, yet we have very little information about the quality of contraceptive care within the VA. Prior research using VA administrative data suggests that the prevalence of contraceptive use among women receiving care in the VA is quite poor compared to the larger US female population. However, because administrative data cannot provide information about women's sexual orientation, sexual activity, pregnancy intention, or their partner's vasectomy status, all of which may obviate the need for contraception, the true unmet need for contraception in this population cannot be accurately assessed. Furthermore, administrative data cannot accurately capture methods obtained outside of the VA making it impossible to obtain accurate contraceptive use rates. Therefore, we propose to conduct a study to evaluate the current state of contraceptive provision and use within the VA and provide actionable findings to improve the quality of contraceptive care for women Veterans. The proposed project is a cross-sectional, mixed methods study with 2,300 female Veterans aged 18-45 years who have received primary care within the VA Healthcare System in the previous 12 months. All eligible and enrolled participants will complete a telephone-based quantitative survey. In addition, approximately 200 of the participants will be purposefully selected for additional open-ended (qualitative) questions. To ensure that we hear the perspectives from the subpopulations with the poorest contraceptive use and query about key patient and system variables that appear to impact contraceptive use, the start of the qualitative component will be delayed until the second half of data collection so that there is adequate time to collect and examine the quantitative survey data and adapt the qualitative sampling matrix and interview guide accordingly. The specific aims of this study are to examine contraceptive use patterns (prevalence of use, unmet need, and rate of unintended pregnancy) among women Veterans using the VA for primary care (Aim 1); determine which subpopulations of women Veterans are at particularly high risk for unintended pregnancy (Aim 2); and identify key modifiable barriers and facilitators to contraceptive use and how these vary across subpopulations (Aim 3). This proposal will provide critical first evidence on the current state of contraceptive provision and use among women Veterans and how patient and system factors impact contraceptive use. The novel mixed methods approach not only allows for an understanding of which patient and system factors are statistically relevant but also the precise mechanism through which they may produce good or poor contraceptive outcomes for individual women. Therefore, this study will generate clinically meaningful, patient-centered strategies to improve contraceptive care and decrease risk of unintended pregnancy in the growing population of women Veterans of childbearing age.

Information about reproductive services in the VA is limited. Research is needed to guide capacity planning around reproductive services for the rapidly expanding population of women Veterans of childbearing age. This study will provide a necessary and critical needs assessment to help guide program and policy development and steer quality improvement efforts around contraceptive care in the VA. This study will also illuminate specific pathways for intervention to improve contraceptive use and decrease unintended pregnancy for all women Veterans.