Improving Contraceptive Care for Pregnancy-Capable Veterans with Autoimmune Conditions

Abstract

Pregnancy-capable Veterans face elevated risk of adverse reproductive health outcomes relative to non-Veterans, driven by a high prevalence of comorbid mental, physical, and psychosocial conditions shaped by trauma, combat exposure, and other experiences. Veterans' unique trauma and stress experiences may influence the development or severity of other health conditions that pose challenges for reproductive health outcomes and care access, such as autoimmune conditions, in which a person’s immune system attacks healthy tissue, cells, and body systems. Pregnancy can introduce elevated risks for people with autoimmune conditions because many of these conditions are managed with teratogenic medications, which can harm a developing fetus, and pregnancy may exacerbate disease activity. Access to ongoing contraceptive care is especially vital for people with autoimmune conditions because it allows them to mitigate the potential health risks of pregnancy and control whether and when they want to become pregnant. These conditions often require regular, ongoing care from multiple clinicians, which may lead to fragmentation and gaps in contraceptive care access and quality. Subspecialists (e.g., rheumatologists, gastroenterologists), who often provide most care for this population, may have limited expertise in contraception and have concerns about the possible implications of pregnancy for their patients. The underlying elevated risk of adverse reproductive health outcomes, coupled with the unique challenges of autoimmune conditions, may be further compounded within Veterans Health Administration (VA), where pregnancy-capable Veterans remain a minority and the availability and quality of contraceptive care are variable. This mixed methods dissertation, using both quantitative and qualitative electronic health record (EHR) data, examines VA contraceptive documentation patterns and care practices for Veterans with autoimmune conditions. Using quantitative data, we estimated the association between autoimmune condition diagnosis and documented contraceptive coverage (Aim 1) and examined whether the association between autoimmune condition and contraceptive coverage gap was modified by mental health diagnosis (Aim 3). Aim 2 analyzed clinical note data using thematic qualitative analysis to understand how contraceptive counseling unfolds in real-world clinical settings and explore nuance not captured in the other EHR components. Aim 1 found that among a national sample of pregnancy-capable Veterans, Veterans with autoimmune conditions had a higher probability of documented procedural (e.g., intrauterine device) or prescription (e.g., oral contraceptives) contraception than those without these conditions. Aim 2 findings highlighted tensions between balancing teratogenic medication safety and patient reproductive autonomy, as well as unintended access barriers in response to safety measures. Aim 3 found that mental health diagnosis does not modify the positive association between autoimmune condition and contraceptive coverage; however, this finding was not consistent for Veterans with substance use disorder, where the positive association was less pronounced. This dissertation suggests that the VA integrated care environment may lead to increased documentation of, and potentially access to, contraception for people with autoimmune conditions compared to other health care systems. However, increased documentation may not reflect patient preferences. Our qualitative findings also highlight that the increased documentation may be partially due to the counseling practices used when clinicians must balance safety and reproductive autonomy. VA has multiple avenues to improve this care, including subspecialist training in contraception and shared decision-making guidelines, centralizing and clarifying contraceptive counseling steps for teratogenic medications, and investing in research to understand whether contraceptive care meets the preferences of Veterans with autoimmune conditions through surveys and interviews.