INTRODUCTION

In the United States (U.S.), the prevalence of chronic health conditions and multi-morbidity are increasing, in part due to high rates of obesity and increased longevity for individuals with chronic conditions.1 This change in overall prevalence, along with the increasing age at first childbirth, contributes to maternal morbidity and mortality.2,3,4,5 Even when well controlled, maternal chronic health conditions can increase the risk of adverse outcomes during pregnancy.4, 6 Nearly half of all pregnancies in the U.S. are unintended.7 Pregnancy intention is an independent risk factor for preterm birth, low-birth-weight infants, and other adverse physical and mental childhood health outcomes.8,9,10,11 Consistent and correct use of contraception effectively prevents unintended pregnancy and allows women to optimize their health prior to pregnancy.7 Unfortunately, women with chronic health conditions have greater risk for unintended pregnancy than healthy women,12 in addition to increased risk of adverse maternal and neonatal outcomes related to their condition.13 Contraceptive safety is a central concern for women and medical providers. The Centers for Disease Control published valuable practice guidelines called the U.S. Medical Eligibility Criteria for Contraceptive Use (US MEC) to support healthcare providers in making the safest recommendations of contraceptive methods for women with specific medical or reproductive characteristics. The US MEC lists over 200 health condition and ranks the safety of use of estrogen-based methods (pills, patches, or rings), short-acting progestin-only methods (pills or injectable), and long-acting reversible contraceptives (LARC), such as intrauterine devices (IUDs) and contraceptive implants. LARC methods are the most effective (e.g., < 1% failure rate vs. 8% failure with pills) and safest contraceptives for the majority of women, as they are not estrogen-based.14 The US MEC recommends LARC as first-line reversible contraceptives for women with chronic health conditions in which an unintended pregnancy would pose unacceptable risks.14 Alternatively, for women who do not desire future fertility, permanent contraceptive (PC) options have included tubal ligation (< 1% failure rate) and hysteroscopic sterilization.

Reproductive-age women are more likely to seek routine care from a general medical provider than from an obstetrician gynecologist.15 Unfortunately, many women with chronic health conditions receive misinformation regarding contraceptive safety. Limited attention to the reproductive health needs of women with chronic conditions16 may lead to disease-related disparities in LARC and PC use.17, 18

A recent study of commercially insured women estimated that 12.1% of U.S. reproductive-age women had at least one of the chronic conditions listed by the US MEC for which LARC is recommended, yet use of either LARC or PC was low.18 As contraceptive access can be more challenging for women without commercial insurance, we sought to determine the prevalence of and relationship between chronic health conditions and use of LARC and PC among reproductive-age women in a regional, mixed-payer health system.

METHODS

We conducted a retrospective cohort study utilizing the University of Utah Health Care (UUHC) and Intermountain Healthcare (IHC) Data Warehouses. The Utah Population Database (UPDB) served to aggregate all inpatient, outpatient, and ambulatory surgery billing codes across institutions. UUHC and IHC provide care to > 85% of the state population and are regional, tertiary care centers for the Intermountain West, which accounts for ~ 10% of the U.S. land mass. The UUHC and IHC Institutional Review Boards approved this study.

We included all women, ages 16–49 years, with any encounter type at either UUHC or IHC occurring between January 2010 and December 2014. The study group included women with one or more chronic health condition known to increase the risk of adverse outcomes in the setting of an unintended pregnancy14 and conditions that are more prevalent among reproductive-age women than in men and can be impacted by pregnancy, such as depression, asthma, obesity, and autoimmune diseases.5 The investigative team identified chronic health conditions via International Classification of Diseases, Ninth Revision (ICD-9) codes. We included chronic condition diagnoses that occurred at any time from 1996 to 2014 (based on data warehouse limitations), but contact with the health system in 2010–2014 was required for study eligibility. No minimum number of visits was required for inclusion, except in defining the study population with chronic disease. Study subjects identified as chronic-condition prevalent cases must have the same diagnosis coded at least twice, with a minimum interval of 30 days, to avoid false positives from coding error. We confirmed first date of diagnosis whenever possible, especially for chronic conditions associated with time (e.g., bariatric surgery or solid organ transplant within the past 2 years). We completed a manual chart review on a random sample of 2% of the study group to narrow or refine specific diagnosis codes for final cohort inclusion. For example, chart reviews found the code listed for bariatric surgery was also used for other, non-weight loss indications. In response, we required both an obesity code and the surgical procedure code to identify the bariatric surgery cohort.

We used ICD-9 and Current Procedural Terminology (CPT®) codes for IUD and contraceptive implant device insertion, surveillance, removal, and exchange, as well as related device orders and current and historical medication records to identify LARC use within the 5-year2010–2014 capture frame. We considered LARC “use” as an outcome, rather than limiting to “insertion.” Differing LARC devices are FDA approved for use for 3–12 years and may be managed at other facilities or family planning clinics; thus, all events related to care may not be captured within a health system, due to insurance changes or lack of coverage. CPT® codes flagged tubal sterilization and hysterectomy procedures, including procedure dates at any time from 1996 to 2014. While recognizing that hysterectomy is not done for contraceptive purposes, we identified these women as no longer at risk for unintended pregnancy.19 Women with a code for sterilization or hysterectomy were excluded from the LARC cohort when analyzed separately, even if they received a LARC method post-procedure for non-contraceptive benefits.

We summarized descriptive characteristics with frequencies and proportions and conducted chi-square tests for comparisons within groups, stratifying by presence or absence of chronic health conditions. We used multinomial logistic regression to relate demographic and disease status to LARC use, sterilization, and hysterectomy. We report relative-risk ratios with robust standard errors in the adjusted models, controlling for age, insurance, race, and ethnicity. We set the significance threshold at p < 0.05, flagged the level of on each variable, and defined them in the table footnote. We used Stata 15 to conduct all analyses.

RESULTS

A total of 741,612 reproductive-age women accessed care at UUHC and/or IHC between 2010 and 2014. Of these women, 32.4% (n = 240,483) had at least one chronic health condition (Table 1). Women with chronic conditions had greater likelihood of being older, non-Hispanic, and White and having public insurance. Women with chronic health conditions had greater likelihood of having a hysterectomy (1.2 vs. 0.4%, p < 0.001) or tubal sterilization (2.2 vs. 1.1%, p < 0.001), compared to healthy women. Women with a chronic condition were more likely to use an IUD (4.9% vs 3.7%, p < 0.001) and contraceptive implant (0.5% vs 0.3%, p < 0.001) than women without chronic conditions.

Table 1 Characteristics of Reproductive-Age Women Who Accessed the Intermountain West Healthcare Systems between 2010 and 2014, by Chronic Disease Status
Full size table

Depression was the most common chronic condition, impacting 15% of women of reproductive age. LARC and PC use varied by chronic health condition. Of all chronic health conditions, women with malignant liver tumors had the lowest proportion of either LARC or PC use (3.0% combined). Those with thrombogenic mutations had the highest proportion of LARC use (9.5%) and PC (3.6%). Women with breast cancer had the lowest proportion of LARC use (2.3%) (Table 2).

Table 2 Prevalence of Chronic Health Conditions and Use of Long-Acting Reversible or Permanent Contraception by Women Who Accessed the Intermountain West Healthcare Systems Between 2010 and 2014
Full size table

Multi-morbidity impacted 7.3% of the cohort and prevalence increased with age: 5.0% of those under 35 years had two or more health conditions, compared to 10.8% of those aged 35–49 years. As the number of chronic health conditions increased, public payer reliance increased. As the number of chronic conditions increased, the proportion of women using LARC decreased, from 5.8% of women with one condition down to 3.2% of women with five or more conditions. LARC use, sterilization, and hysterectomy were all associated with one or more chronic condition, compared to healthy women in models controlling for age, race, ethnicity, and payer, but the strength of association did not increase with multi-morbidity burden. (Table 3)

Table 3 Effect of Number of Chronic Conditions on Use of Highly Effective Contraception Among Reproductive-Age Women in the Intermountain West Healthcare Systems Between 2010 and 2014
Full size table

After adjusting for age, race, ethnicity, and payer type, we found women with a chronic health condition were more likely to use LARC (aRR 1.4; 95% CI 1.4–1.5), or have had a hysterectomy (aRR 2.1; 95% CI 2.0–2.3) or permanent contraception (aRR 1.7; 95% CI 1.7–1.8) compared to women without a chronic condition. Women without insurance were less likely to use highly effective contraception, whether or not they had a chronic condition (Table 4).

Table 4 Multivariable Logistic Regression Models Assessing Probability of Use of Highly Effective Contraception by Reproductive-Age Women Who Accessed the Intermountain West Healthcare Systems Between 2010 and 2014
Full size table

DISCUSSION

This 5-year cross-sectional study of two large health systems found that nearly 1/3 of reproductive-age female patients had one or more chronic health conditions that could increase risk of adverse pregnancy outcomes, especially in the setting of an unintended pregnancy. Potentially further increasing health and pregnancy risks,20 7.3% of reproductive-age women had multiple chronic conditions. However, only 7.6% of women with a chronic health condition were using highly effective contraception. These findings are similar to a prior study of commercially insured US women, which reported that 12.1% of women of reproductive age had one or more chronic condition, and that few were using LARC and PC.18

In addition, we found that public insurance was an important predictor of use of highly effective contraception, particularly among women with multiple chronic conditions. As implementation of the Patient Protection and Affordable Care Act (ACA) of 2010 and subsequent Medicaid expansion vary by state, opportunities remain in many states to improve consistent public funding for comprehensive contraceptive services. As it is estimated that 45% of all U.S. births are publicly funded,21 national efforts to improve preconception health and reduce maternal mortality need to remain focused on health insurance coverage that allows access to the full range of contraception for U.S. women of reproductive age.

Limitations of this study include our inability to control for number of visits or provider type or standardize the period of observation for each individual. Further, we relied on structured billing data to identify chronic conditions and LARC use or PC procedures. Although we focused on LARC and PC because they are typically more effective than short-acting contraceptives, we recognize that with many chronic conditions these are safe and reasonable options. We attempted to minimize false positives through manual chart reviews to validate codes and requiring recurrent codes > 30 days apart to meet criteria for a condition, but it is possible that some women identified as having no chronic conditions received care for a chronic condition in other settings. In particular, diagnoses with relapsing and remitting courses, such as asthma, may have been missed. We also could not capture disease severity. Although this 5-year study captured all healthcare visits at two large institutions, we lack data from free-standing family planning clinics where contraceptive services may have occurred. We opted to define our outcome as LARC “use,” rather than limiting to insertions, which precludes direct comparison with studies using LARC insertion as an outcome.

In conclusion, many women of reproductive age are burdened by chronic health conditions, yet relatively few are using highly effective contraception. As primary care providers care for many women with chronic conditions, efforts to ensure effective reproductive planning and prompt access to contraceptive services are needed. Our findings also highlight the importance of public insurance that allows women with chronic conditions to access comprehensive reproductive health services.