Original Article

Pregnancy Risk Screening and Counseling for Women Veterans: Piloting the One Key Question in the Veterans Healthcare Administration

Authors: Lori M. Gawron, MD, MPH, Sara Simonsen, PhD, Morgan M. Millar, PhD, Jessica Lewis-Caporal, PhD, Shardool Patel, PharmD, Rebecca G. Simmons, PhD


Objectives: Women veterans have a high prevalence of comorbidities that increase the risk of adverse pregnancy outcomes. Screening for pregnancy desires in primary care provider (PCP) visits offers an opportunity to optimize preconception health. This pilot quality improvement initiative sought to assess Veterans Healthcare Administration provider preferences on One Key Question (OKQ) implementation, identification of veterans’ reproductive needs, and the effect of training on documentation in a women’s primary care clinic in Salt Lake City, Utah.

Methods: We hosted OKQ training sessions for providers and staff, audio recorded group discussions on implementation barriers, and explored themes. Women veterans presenting for a PCP visit in July 2018 self-completed a paper OKQ screening tool. We calculated summary statistics on responses. We conducted a pre-post analysis, with respect to training sessions, to measure for changes in family planning documentation during PCP visits.

Results: Nineteen providers and staff completed the training. They acknowledged the importance, but believed that the screening tool should be completed by veterans and not be provider prompted. Forty-two women veterans completed the screening tool: 21% desired pregnancy in the next year and 26% desired contraceptive information. Chart reviews found a nonsignificant increase in current contraceptive method documentation between periods (20% vs 37%; P = 0.08), a decline in documentation of reproductive goals (22% vs 3%; P = 0.02), and no significant change in counseling.

Conclusions: Veterans identify reproductive needs via the OKQ screening tool, but provider documentation did not reflect changes in care following training. Further study is necessary to develop an optimal, patient-centered tool and implementation plan to support women veterans in their reproductive goals.
Posted in: Pregnancy22

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1. Berg CJ, Mackay AP, Qin C, et al. Overview of maternal morbidity during hospitalization for labor and delivery in the United States: 1993-1997 and 2001-2005. Obstet Gynecol 2009;113:1075–1081. 2. Chuang CH, Velott DL, Weisman CS. Exploring knowledge and attitudes related to pregnancy and preconception health in women with chronic medical conditions. Matern Child Health J 2010;14:713–719. 3. Axinn WG, Barber JS, Thornton A. The long-term impact of parents' childbearing decisions on children's self-esteem. Demography 1998;35:435–443. 4. Barber JS, Axinn WG, Thornton A. Unwanted childbearing, health, and mother-child relationships. J Health Soc Behav 1999;40:231–257. 5. Hellerstedt WL, Pirie PL, Lando HA, et al. Differences in preconceptional and prenatal behaviors in women with intended and unintended pregnancies. Am J Public Health 1998;88:663–666. 6. Kost K, Lindberg L. Pregnancy intentions, maternal behaviors, and infant health: investigating relationships with new measures and propensity score analysis. Demography 2015;52:83–111. 7. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States, 2008-2011. N Engl J Med 2016;374:843–852. 8. Chor J, Rankin K, Harwood B, et al. Unintended pregnancy and postpartum contraceptive use in women with and without chronic medical disease who experienced a live birth. Contraception 2011;84:57–63. 9. Harper CC, Rocca CH, Thompson KM, et al. Reductions in pregnancy rates in the USA with long-acting reversible contraception: a cluster randomised trial. Lancet 2015;386:562–568. 10. American College of Obstetricians and Gynecologists' Committee on Health Care for Underserved Women. Committee Opinion No. 654: Reproductive Life Planning to Reduce Unintended Pregnancy. Obstet Gynecol 2016;127:e66–e69. 11. Gavin L, Moskosky S, Carter M, et al. Providing quality family planning services: recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep 2014;63:1–54. 12. Frayne S, Haskell S, Hayes P, Saechao F. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 4. Washington DC: Women’s Health Services, Veterans Health Administration, Department of Veterans Affairs; 2019. 13. Department of Veterans Affairs. Women veterans population. http://www.va.gov/womenvet/docs/WomenVeteransPopulationFactSheet.pdf. Published November 2, 2017. Accessed January 3, 2021. 14. Gawron LM, Redd A, Suo Y, et al. Long-acting reversible contraception among homeless women veterans with chronic health conditions: a retrospective cohort study. Med Care 2017;55(suppl 9 2):S111–S120. 15. Callegari LS, Zhao X, Nelson KM, et al. Contraceptive adherence among women veterans with mental illness and substance use disorder. Contraception 2015;91:386–392. 16. Goyal V, Mattocks K, Bimla Schwarz E, et al. Contraceptive provision in the VA healthcare system to women who report military sexual trauma. J Womens Health 2014;23:740–745. 17. Katon JG, Hoggatt KJ, Balasubramanian V, et al. Reproductive health diagnoses of women veterans using Department of Veterans Affairs health care. Med Care 2015;53:S63–S67. 18. Rosenfeld E, Callegari LS, Sileanu FE, et al. Racial and ethnic disparities in contraceptive knowledge among women veterans in the ECUUN study. Contraception 2017;96:54–61. 19. Callegari LS, Zhao X, Schwarz EB, et al. Racial/ethnic differences in contraceptive preferences, beliefs, and self-efficacy among women veterans. Am J Obstet Gynecol 2017;216:504.e1–504.e10. 20. Schwarz EB, Parisi SM, Williams SL, et al. Promoting safe prescribing in primary care with a contraceptive vital sign: a cluster-randomized controlled trial. Ann Fam Med 2012;10:516–522. 21. Lee JK, Parisi SM, Akers AY, et al. The impact of contraceptive counseling in primary care on contraceptive use. J Gen Intern Med 2011;26:731–736. 22. Callegari LS, Borrero S, Reiber GE, et al. Reproductive life planning in primary care: a qualitative study of women veterans' perceptions. Womens Health Issues 2015;25:548–554. 23. Chuang E, Brunner J, Mak S, et al. Challenges with implementing a patient-centered medical home model for women veterans. Womens Health Issues 2017;27:214–220. 24. Akers AY, Gold MA, Borrero S, et al. Providers' perspectives on challenges to contraceptive counseling in primary care settings. J Womens Health 2010;19:1163–1170. 25. Bellanca HK, Hunter MS. ONE KEY QUESTION®: preventive reproductive health is part of high quality primary care. Contraception 2013;88:3–6. 26. Oregon Foundation for Reproductive Health. One Key Question. https://www.chcs.org/media/OKQ-Webinar-618.pdf. Accessed August 8, 2020. 27. Allen D, Hunter MS, Wood S, et al. One Key Question®: first things first in reproductive health. Matern Child Health J 2017;21:387–392. 28. Hipp S, Carlson A, McFarlane E, et al. Insights in public health: improving reproductive life planning in Hawai'i: One Key Question®. Hawaii J Med Public Health 2017;76:261–264. 29. Stulberg DB, Dahlquist IH, Disterhoft J, et al. Increase in contraceptive counseling by primary care clinicians after implementation of One Key Question® at an urban community health center. Matern Child Health J 2019;23:996–1002. 30. Baldwin MK, Overcarsh P, Patel A, et al. Pregnancy intention screening tools: a randomized trial to assess perceived helpfulness with communication about reproductive goals. Contracept Reprod Med 2018;3:21. 31. Stulberg DB, Datta A, White VanGompel E, et al. One Key Question® and the Desire to Avoid Pregnancy Scale: a comparison of two approaches to asking about pregnancy preferences. Contraception 2020;101:231–236. 32. Schexnayder CD, King S, Emelogu O. Documentation of contraceptive counseling in female veterans of reproductive age. Am J Health Syst Pharm 2020;77(suppl 3):S71–S77. 33. Callegari LS, Aiken AR, Dehlendorf C, et al. Addressing potential pitfalls of reproductive life planning with patient-centered counseling. Am J Obstet Gynecol 2017;216:129–134. 34. Envision Sexual & Reproductive Health. Patient-centered reproductive goals counseling. https://www.envisionsrh.com/path-questions. Accessed January 16, 2019. 35. Callegari LS, Edmonds SW, Borrero S, et al. Preconception care in the Veterans Health Administration. Semin Reprod Med 2018;36:327–339. 36. Patterson ES, Nguyen AD, Halloran JP, et al. Human factors barriers to the effective use of ten HIV clinical reminders. J Am Med Inform Assoc 2004;11:50–59. 37. Saleem JJ, Patterson ES, Militello L, et al. Exploring barriers and facilitators to the use of computerized clinical reminders. J Am Med Inform Assoc 2005;12:438–447. 38. Fung CH, Tsai JS, Lulejian A, et al. An evaluation of the Veterans Health Administration's clinical reminders system: a national survey of generalists. J Gen Intern Med 2008;23:392–398. 39. Mayo-Smith MF, Agrawal A. Factors associated with improved completion of computerized clinical reminders across a large healthcare system. Int J Med Inform 2007;76:710–716. 40. Patterson ES, Doebbeling BN, Fung CH, et al. Identifying barriers to the effective use of clinical reminders: bootstrapping multiple methods. J Biomed Inform 2005;38:189–199. 41. Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014:CD001431. 42. Callegari LS, Nelson KM, Arterburn DE, et al. Integrating reproductive goals assessment with contraceptive decision support in primary care: a pilot test of the MyPath tool. Contraception 2019;100:341. Available at: https://escholarship.org/content/qt6tj2m46d/qt6tj2m46d_noSplash_9114af5ad168c4db7b6a00662b313b78.pdf?t=q1lnuw. Accessed January 12, 2021. 43. Fielstein EM, Brown SH, McBrine CS, et al. The effect of standardized, computer-guided templates on quality of VA disability exams. AMIA Annu Symp Proc 2006:249–253. 44. Power to Decide: campaign to prevent unintended pregnancy. Home page. https://powertodecide.org. Accessed August 13, 2020.