Associations Between Contraceptive Counseling Quality and Contraceptive Use in a National Survey of Women Veterans

Abstract

Background:

Contraceptive counseling quality is associated with trust in providers, method satisfaction, and method continuation. Little is known, however, about associations between counseling quality and method choice, particularly for methods requiring a high level of involvement of providers to initiate and stop the method.

Objective(s):

Investigate associations between experiences of high- or low-quality counseling and contraceptive method type.

Research Design:

We analyzed data from a national survey of women veterans ages 18–44 receiving care at the Veterans Health Administration (VA). Among participants who received contraceptive services at VA in the past year (n = 358), counseling quality was assessed with six Likert-scale items capturing key elements of patient-centered care. We explored two independent counseling quality variables: (1) high-quality (strongly agree on all items) versus all other responses and (2) low-quality (neutral/disagree/strongly disagree on ≥4 items) versus all other responses. Contraceptive methods were categorized based on the level of provider involvement required for initiation and discontinuation: long-acting reversible contraceptive (LARC) procedures, prescription methods, and those that require no provider involvement. We examined associations between quality and method type used using logistic regression models, controlling for potential confounding covariates.

Results:

Veterans reporting high-quality counseling were more likely (aOR: 1.95; 95% CI: 1.09, 3.48), and those reporting low-quality counseling were less likely (aOR: 0.12; 95% CI: 0.02, 0.90), to have undergone LARC placement. Veterans reporting low-quality counseling were more likely to have used a method that required no provider involvement (aOR: 2.71; 95% CI: 1.26, 5.83).

Conclusions:

High-quality contraceptive counseling is associated with use of LARC methods, while low-quality counseling is associated with use of contraceptives that require no provider involvement.

Introduction

Contraceptive counseling in clinical settings can support individuals’ reproductive autonomy and improve health outcomes.^1
–3 National guidelines highlight key elements of quality in contraceptive counseling, which include using person-centered approaches that elicit and prioritize individuals’ values and preferences and that offer tailored information about contraceptive options to enable individuals to make choices aligned with their preferences.^2,4 Studies demonstrate that experiences of high-quality, person-centered contraceptive care lead to greater trust in providers and the health care system.^5,6 In addition, when individuals rate a contraceptive counseling encounter highly on dimensions of person-centeredness, they are more likely to be satisfied with their contraceptive method and continue using it.^7,8

Poor quality contraceptive counseling has the potential to cause harm, especially among groups that have faced and continue to face systemic violations of their reproductive autonomy.^9

–13 Qualitative and survey-based studies highlight experiences of Black, Latina, and low-income women being pressured to use contraception, in particular long-acting reversible contraceptive (LARC) methods, or to continue LARC methods even when they desire removal.^14

–17 Recent data from the National Survey of Family Growth have demonstrated disparities in receipt of person-centered contraceptive counseling, with women of color and low-income women being less likely to report person-centered contraceptive counseling.^18,19 A qualitative study of the contraceptive counseling experiences of Black and Latina women found that low-quality counseling eroded trust between women and their providers, reduced openness to using contraception, and resulted in method discontinuation.¹⁴

We examined the associations between an individual’s recent experiences of contraceptive counseling quality and the type of contraceptive method they used the last time they had sex with a male partner among a national sample of women veterans receiving health care from the Veterans Health Administration (VA).

Materials and Methods

Population and sample

We analyzed data from the “Examining Contraceptive Use and Unmet Need” (ECUUN) survey, a national, cross-sectional telephone survey of 2,302 veterans, administered between April 2014 and January 2016. Women veterans ages 18 to 44 and with a VA primary care appointment in the year prior to the survey were identified using VA administrative data and randomly selected to receive study invitations on a rolling basis until the desired sample size was achieved. Survey non-responders and responders were demographically similar based on analyses of VA administrative data, indicating that the survey was representative of the larger population of reproductive-age women veterans who use VA. The survey assessed veterans’ current contraceptive use, pregnancy history, experiences receiving contraceptive counseling at VA, health conditions, and demographics. Detailed survey methodology has been previously described.²⁰ The ECUUN study was approved by the VA Pittsburgh Institutional Review Board.

For this analysis, we limited our sample to participants who reported receiving contraceptive services (i.e., contraceptive counseling or a contraceptive prescription or procedure) from their VA primary care provider (PCP) in the past 12 months. We focused on Veterans using contraception for pregnancy prevention, excluding participants with a history of hysterectomy, sterilization (of themselves or their partner), or infertility; participants who were currently pregnant, postpartum, or seeking pregnancy; and participants who had not had sex with a male partner for more than a year. In addition, we excluded participants who did not answer one or more of the questions about their experiences of contraceptive counseling quality.

Measures

Our predictor of interest was veteran-reported experiences of contraceptive counseling quality. The ECUUN survey included six Likert-scale questions. Four were adapted from questions found on the Consumer Assessment of Healthcare Providers and Systems Patient-Centered Medical Home Version 2.0 survey and address components of person-centered counseling.²¹ These four questions ask the degree to which the participant’s provider (1) “listened carefully to your questions and/or concerns about contraception,” (2) “explained things in a way that was easy to understand,” (3) “spent enough time discussing things with you,” and (4) “asked you which contraceptive choice you thought was best for you.” The two remaining questions measured receipt of information about a range of contraceptive options, which is another component of contraceptive counseling quality.² These questions ask the degree to which the participant’s provider (5) “talked about more than one type of contraception option,” and (6) “talked to you about pros and cons of various types of contraceptive methods.” Of note, although a negative response to these two questions could still represent person-centered care if an individual preferred to receive information only about one option, these items approximate best practices in many cases to ensure individuals understand their options.²

Response options for all questions were “strongly agree,” “agree,” “neutral,” “disagree,” and “strongly disagree.” We created two dichotomous independent variables, first defining “high-quality counseling” (responded strongly agree to all six questions) and “low-quality counseling” (responded neutral, disagree, or strongly disagree to 4 or more questions), using cutoffs based on previously published work.²² Responses to health care experience surveys tend to be skewed with the majority of responses at the positive end of the scale;²³ therefore, studies often use the proportion of top scores to characterize high-quality health care experiences. Examining negative responses is also important, as it may better discriminate differences in patient experience. Choosing cut-points such that negative responses comprise 10–15% of the sample are recommended.^24,25

Our primary outcome was the type of contraceptive method the participant reported using the last time they had vaginal intercourse with a male partner (hereafter referred to as “at last sex”). Participants were read a list of contraceptive methods and asked to indicate with a yes/no response whether they had used each method. We collapsed responses into three categories for this analysis based on the amount of provider involvement required for initiation and discontinuation of each method. LARC methods (intrauterine devices and subdermal implants) require a potentially painful medical procedure for initiation and discontinuation, making them the methods with the highest level of provider involvement and the lowest level of autonomous patient control over decisions over initiation and discontinuation. Prescription methods (pills, patches, rings, and injections) require an intermediate level of provider involvement because (at the time of the ECUUN study) these methods all required a prescription, yet patients were free to discontinue methods autonomously. Finally, non-prescription methods (condoms, spermicide, withdrawal, fertility awareness, and emergency contraception) and use of no method were categorized as the contraceptive methods requiring the least or no provider involvement for initiation, use, and discontinuation. For participants who reported multiple methods, we considered the method requiring the highest level of provider involvement to be their primary method.

Veteran-level covariates included age, race/ethnicity, marital status, education, annual household income, history of one or more medical conditions that might affect contraceptive counseling and method choice (hypertension, history of thromboembolic disease, breast cancer, stroke, liver disease, HIV/AIDS, obesity, diabetes, migraines, systemic lupus erythematosus, seizure disorders, or tobacco use), history of one or more mental health conditions (major depression, bipolar, posttraumatic stress disorder, schizophrenia, or anxiety/panic disorder), history of military sexual trauma (MST), parity, and time since last sexual activity. Mental health conditions and experience of MST were assessed separately and collapsed into a single variable (both, one, and neither) to capture the additive effect of mental health conditions and MST on health care decisions and outcomes.^26,27

Provider-level covariates included whether the veteran sees their PCP for all or almost all of their medical care, whether they see their PCP for routine gynecological care such as Pap smears (an indicator of provider comfort providing sex-specific care), and PCP gender. Facility-level covariates included geographic region (Northeast, Midwest, South, and West) and a single variable capturing a veteran’s report of whether they receive care at a VA Women’s Health Clinic (WHC), a specialized clinic designed to provide comprehensive care to women veterans, including both primary care and sex-specific care.²⁸

Analysis

We calculated means or frequencies and percentages to describe the study population, their experience of contraceptive counseling quality, and the contraceptive method used at last sex. We used chi-squared tests to describe associations (1) between veteran, provider, and facility covariates and contraceptive method used at last sex, (2) between answers to each counseling quality question and contraceptive method used at last sex, and (3) between overall counseling quality (high-quality, low-quality, and neither high- nor low-quality) and contraceptive method used at last sex.

We constructed four logistic regression models to test for associations between counseling quality and the type of method used at last sex. Models 1 and 2 examined the association between receipt of high-quality counseling (Model 1) or low-quality counseling (Model 2) and use of LARC methods versus all other methods at last sex. Models 3 and 4 examined the associations between receipt of high-quality counseling (Model 3) or low-quality counseling (Model 4) and use of non-prescription/no method versus all other methods at last sex. Following the purposeful variable selection process,²⁹ we included covariates as adjustment variables in the models if they were deemed clinically relevant or found to be associated with the contraceptive method used at last sex in bivariate analyses at the level of p ≤ 0.20. Because age and race/ethnicity are often associated with experiences of contraceptive counseling quality and other contraceptive outcomes,^19,30 we selected these as a priori adjustment variables.

Results

Description of the sample

The ECUUN study included 543 women veterans ages 18–44 who received contraceptive services from a VA provider in the past year. We excluded 4 with missing data for one or more questions about contraceptive counseling quality; 33 with a history of hysterectomy or infertility; 44 who reported sterilization of themselves or their partner; 34 who were currently pregnant, postpartum, or seeking pregnancy; and 70 who had not been sexually active with a male partner in the past year, yielding a final analytic sample of 358 veterans.

The majority of the sample were under age 35 (70%), and nearly half identified with a race or ethnicity other than White (47%) (Table 1). Three-quarters of the sample reported having a mental health condition or MST, with 43% reporting both. Over half of the sample had a history of at least one live birth (56%), and most had been sexually active in the past month (69%). The majority saw their PCP for most or all of their care (88%), had a PCP who performs Pap smears (80%), and were seen in a WHC (61%).

Table 1.

Veteran, Provider, and Facility Characteristics by Type of Contraceptive Method Used at Last Sex among a U.S. sample of Veterans, 2014–2016

	Total N (% of total)	LARC method^a N (% by column)	Prescription method^b N (% by column)	Method requiring no provider involvement^c N (% by column)
Total	358 (100%)	62 (17.3%)	223 (62.3%)	73 (20.4%)
Veteran-level characteristics
Age (years)^*
20–29	116 (32.4)	20 (32.3)	75 (33.6)	21 (28.8)
30–34	134 (37.4)	21 (33.9)	91 (40.8)	22 (30.1)
35–39	72 (20.1)	16 (25.8)	35 (15.7)	21 (28.8)
40–44	36 (10.1)	5 (8.1)	22 (9.9)	9 (12.3)
Race/Ethnicity
Non-Hispanic White	191 (53.4)	36 (58.1)	125 (56.1)	30 (41.1)
Non-Hispanic Black	98 (27.4)	16 (25.8)	57 (25.6)	25 (34.2)
Hispanic	48 (13.4)	6 (9.7)	29 (13.0)	13 (17.8)
Other	21 (5.9)	4 (6.5)	12 (5.4)	5 (6.8)
Married	120 (33.5)	26 (41.9)	67 (30.0)	27 (37.0)
Heterosexual^*	342 (95.8)	61 (98.4)	210 (94.2)	71 (98.6)
Received Bachelor’s degree or higher	190 (53.1)	36 (58.1)	113 (50.7)	41 (56.2)
Income
<$20,000	71 (19.9)	8 (12.9)	46 (20.7)	17 (23.6)
$20,000–<$40,000	136 (38.2)	29 (46.8)	87 (39.2)	20 (27.8)
$40,000–<$60,000	70 (19.7)	11 (17.7)	42 (18.9)	17 (23.6)
≥$60,000	79 (22.2)	14 (22.6)	47 (21.2)	18 (25.0)
≥1 Medical conditions	198 (55.3)	37 (59.7)	124 (55.6)	37 (50.7)
Mental health condition and/or Military sexual trauma (MST)
Neither	88 (24.6)	15 (24.2)	59 (26.5)	14 (19.2)
Mental health condition only	78 (21.8)	15 (24.2)	46 (20.6)	17 (23.3)
MST only	37 (10.3)	2 (3.2)	26 (11.7)	9 (12.3)
Both mental health condition and MST	155 (43.3)	30 (48.4)	92 (41.3)	33 (45.2)
Parity ≥1^**	202 (56.4)	44 (71.0)	115 (51.6)	43 (58.9)
Sexual activity within past month^*	246 (68.7)	46 (74.2)	151 (67.7)	49 (67.1)
Provider-level characteristics
Sees VA primary care provider (PCP) for almost all care	311 (87.6)	52 (86.7)	193 (86.9)	66 (90.4)
VA PCP performs Pap smears	280 (79.1)	48 (77.4)	177 (80.5)	55 (76.4)
VA PCP is female	301 (84.3)	51 (82.3)	189 (85.1)	61 (83.6)
Facility-level characteristics
Geographic census region
Northeast	34 (9.5)	6 (9.7)	22 (9.9)	6 (8.2)
Midwest	67 (18.7)	11 (17.7)	45 (20.2)	11 (15.1)
South	180 (50.3)	26 (41.9)	112 (50.2)	42 (57.5)
West	77 (21.5)	19 (30.6)	44 (19.7)	14 (19.2)
Receives care in VA women’s health Clinic	217 (60.6)	44 (71.0)	131 (58.7)	42 (57.5)

p < 0.20.

p < 0.05.

LARC method refers to intrauterine devices and subdermal implants.

Prescription method refers to pills, patches, rings, and injections.

Method requiring no provider involvement refers to condoms, spermicide, fertility awareness, withdrawal, emergency contraception, and use of no method.

Overall, a high proportion of veterans in our sample strongly agreed that their provider listened carefully (74%), explained things in a way that was easy to understand (75%), and spent enough time discussing things (70%) during contraceptive counseling. A lower proportion strongly agreed that their provider talked about more than one contraception option (57%), talked about the pros and cons of different options (45%), or asked them which contraceptive choice they thought was right for them (64%). The majority of veterans used a prescription method at last sex (62%), with the remainder split between using LARC methods (17%), non-prescription methods (17%), and no method (4%) (Fig. 1).

FIG. 1.

Contraceptive methods used at last sex with a male partner among a U.S. Sample of Veterans, 2014–2016.

Bivariate associations between counseling quality and contraceptive method

Compared with prescription method users and non-prescription/no method users, a higher proportion of LARC method users strongly agreed with each of the counseling quality items (Fig. 2). One counseling quality item was significantly associated with the type of contraceptive method chosen at last sex, and three others showed a trend toward significance (Fig. 2). These questions assessed whether a provider explained things in a way that was easy to understand (p = 0.08; 86% of LARC users, 75% of prescription method users, and 67% of non-prescription/no method users strongly agreed), spent enough time discussing things (p = 0.08; 82%, 69%, and 60% strongly agreed), talked about more than one type of contraception option (p = 0.05; 73%, 53%, and 53% strongly agreed), and asked them which contraceptive choice they thought was right for them (p ≤ 0.01; 86%, 61%, and 53% strongly agreed). Type of contraceptive method used also varied significantly by experiences of overall counseling quality, using the composite measures of high- and low-quality counseling (Table 2; p = 0.02).

FIG. 2.

Responses to contraceptive counseling quality questions by contraceptive method type used at last sex among a U.S. Sample of Veterans, 2014–2016.

Table 2.

Bivariate Association between Overall Contraceptive Counseling Quality and Type of Contraceptive Method Used at Last Sex among a U.S. sample of Veterans, 2014–2016

	LARC method^a N (% by row)	Prescription method^b N (% by row)	Method requiring no provider involvement^c N (% by row)	p-value^d
Total	62	223	73
Overall counseling quality				0.02
High-quality counseling^e	28 (23.1)	70 (57.9)	23 (19.0)
Neither high- nor low-quality counseling	33 (16.7)	128 (64.6)	37 (18.7)
Low-quality counseling^f	1 (2.6)	25 (64.1)	13 (33.3)

LARC method refers to intrauterine devices and subdermal implants.

Prescription method refers to pills, patches, rings, and injections.

Method requiring no provider involvement refers to condoms, spermicide, fertility awareness, withdrawal, emergency contraception, and use of no method.

Chi-squared test for bivariate association.

High-quality counseling defined as answering strongly agree to all six questions.

Low-quality counseling defined as answering neutral, disagree, or strongly disagree to four or more questions.

Logistic regression models

Veterans who reported high-quality counseling had significantly higher odds of using LARC methods at last sex (aOR: 1.95; 95% CI: 1.09, 3.48, Model 1, Table 3), while those who reported low-quality counseling had significantly lower odds of using a LARC method (aOR: 0.12; 95% CI: 0.02, 0.90, Model 2). Although high-quality counseling was not associated with using non-prescription contraception or no method at last sex (aOR: 0.91; 95% CI: 0.51, 1.60, Model 3), veterans who reported low-quality counseling had significantly higher odds of using non-prescription contraception or no method (aOR: 2.71; 95% CI: 1.26, 5.83, Model 4).

Table 3.

Multivariate Associations between High- and Low-Quality Contraceptive Counseling and Type of Contraceptive Method Used at Last Sex among a U.S. sample of Veterans, 2014–2016

	Unadjusted or (95% CI)	p-value	Adjusted OR^b (95% CI)	p-value
Use of long-acting reversible contraception (LARC)^a at last sex versus all other methods
Model 1: High-Quality counseling (yes versus no)^c	1.80 (1.03, 3.14)	0.039	1.95 (1.09, 3.48)	0.025
Model 2: Low-Quality Counseling (yes versus no)^c	0.11 (0.02, 0.83)	0.037	0.12 (0.02, 0.90)	0.039
Use of a method requiring no provider involvement^d at last sex versus all other methods
Model 5: High-Quality Counseling (yes versus no)^c	0.88 (0.51, 1.52)	0.64	0.91 (0.51, 1.60)	.74
Model 6: Low-Quality Counseling (yes versus no)^c	2.16 (1.05, 4.45)	0.037	2.71 (1.26, 5.83)	0.011

LARC refers to intrauterine devices and subdermal implants.

Adjusted models control for age, race/ethnicity, sexual orientation, parity, and recency of sex with a male partner.

High-quality counseling is defined as answering strongly agree to all six quality items assessed by the survey; low-quality counseling is defined as answering neutral, disagree, or strongly disagree to four or more quality items assessed by the survey.

Method requiring no provider involvement refers to condoms, spermicide, fertility awareness, withdrawal, emergency contraception, and use of no method.

Discussion

Using data from a national survey of women veterans, we found that individuals who experienced high-quality contraceptive counseling were significantly more likely to have used LARC methods that require a high level of provider involvement, compared with those who rated their counseling experiences lower. Conversely, those who experienced low-quality counseling were significantly less likely to report using LARC methods and more likely to report using non-prescription contraception methods that do not require involvement of providers or no method, compared with those who rated their counseling experiences higher.

Previously published qualitative and quantitative data provide insight into potential mechanisms underlying these findings. A trusting relationship with a provider is particularly critical for LARC methods, as a provider is required for both initiation and discontinuation.¹⁵ Qualitative studies demonstrate that high-quality, person-centered contraceptive counseling is associated with higher trust in providers’ intentions and recommendations,^5,6 while counseling that directs or pressures people toward particular methods erodes or breaks trust in providers, reducing individuals’ openness to using LARC or prescription methods.^14,15 Furthermore, many individuals have reported feeling pressured by providers to continue using LARC methods even when they prefer to have them removed.³¹ Counseling that fails to prioritize individual preferences and priorities has been associated with lower method satisfaction and higher method discontinuation.^7,32 Thus, higher continuation of LARC methods among those experiencing high-quality counseling and discontinuation of LARC methods among veterans experiencing low-quality counseling may also have contributed to our findings.

A large body of literature highlights that racialized minority and low-income populations are at disproportionately high risk of experiencing low-quality contraceptive counseling, including pressure to use contraception, pressure to use long-acting methods including tubal sterilization, and pressure to continue using a LARC method when they request removal.^10,13,14 Contraceptive counseling experiences occur within the context of historic and ongoing oppressive reproductive health policies and practices, such as coercive sterilization practices as recently as 2006–2010 in the California prison system, family caps on cash assistance to limit reproduction in marginalized groups, and public health campaigns promoting long-acting contraception in communities of color.^10,13,33 A randomized trial using standardized patients documented systematic differences in provider counseling about IUDs by race and class.³⁴ In a prior analysis using the same ECUUN study data, however, there were no significant associations between race or socioeconomic status and contraceptive counseling quality among veterans.²² In this study, we did not have a sufficient sample size to examine whether race and socioeconomic status modified the effect of counseling quality on method choice. Additional research is needed to examine whether the strength of the associations observed in this study differs among these groups.

Our study has multiple strengths, including a nationally representative sample of women veterans and detailed assessments of contraceptive counseling quality. However, this study also has a number of limitations. The survey data are cross-sectional and do not capture whether a participant’s contraceptive method was initiated before or after the index contraceptive counseling encounter; thus, we are limited to commenting on associations rather than causality and are unable to examine variations in observed associations by new or continuing user status. Recall bias is also a possible concern, as the duration from a veteran’s last contraceptive counseling experience or contraceptive use may have been up to a year. While provider recommendations about specific contraceptive methods can influence individual contraceptive method choices, they were not captured in the ECUUN survey. It is also important to note that the survey’s measure of contraceptive counseling quality has not been validated. Since ECUUN was fielded, other measures of person-centered contraceptive counseling have been validated, including the National Quality Forum-endorsed Person-Centered Contraceptive Counseling measure.^35,36 These newer measures provide opportunities for health care systems, including the VA, to assess the quality of their care and compare results with other systems. Finally, there are limitations to the generalizability of our results stemming from the study population. First, our sample was limited to participants who were sexually active with a male partner in the past year; this group may not be representative of the broader population of contraceptive users. Second, ECUUN was conducted among veterans using VA health care, who carry a higher burden of medical and mental health conditions and sexual and other trauma histories compared with the non-Veteran population.

Conclusions

Findings from this study add to the literature demonstrating the importance of contraceptive counseling in shaping contraceptive use. Efforts to track contraceptive counseling quality within and across health care systems must be paired with continuing education to ensure all patients receive high-quality, person-centered contraceptive care.

Footnotes

Acknowledgments

The authors would like to acknowledge the contributions of study staff who coordinated the project and collected data and the women veterans who contributed to these data.

Authors’ Contributions

S.K.B.: Methodology, visualization, writing—original draft (lead), writing—review and editing (equal); S.M.: Writing—original draft (supporting), writing—review and editing (equal), visualization; X.Z.: Data curation, methodology, formal analysis (lead), writing—review and editing (equal); E.B.S.: Conceptualization, investigation, writing—review and editing (equal); S.B.: Conceptualization, funding acquisition, investigation, methodology, writing—review and editing (equal); L.S.C.: Conceptualization, investigation, methodology, supervision, writing—original draft (supporting), writing—review and editing (equal).

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the VA Health Systems Research Service (Merit Review Award IIR12-124). The contents of this article do not represent the views of the Department of Veterans Affairs or the United States Government.

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