Transcript Predicting Pregnancy Risk among Women Attending an

Predicting Pregnancy Risk
among Women Attending an
STD Clinic
Judith Shlay MD, MSPH
Denver Public Health
September 21, 2008
CityMatCH Conference
Background
• Unintended pregnancy is an important and
complex problem with significant public health
consequences
• Conditions leading to STDs and unintended
pregnancy are similar
• Few programs provide initial family planning
services in an STD clinic; most STD clinics focus
solely on STD treatment and prevention
Why Consider Providing Initial Family
Planning Services in an STD Clinic?
• We screen sexually active women who are at
risk for unintended pregnancy
• We obtain a menstrual history, sexual history
and current use of contraception
• Women seen in STD clinics are at high risk for
unintended pregnancy
Our Current Integrated STD/Family
Planning Program
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Established an integrated family planning
program within an existing STD clinic
(Denver Metro Health Clinic) which
compliments STD clinical services
Provides initial evaluation of family planning
services for men and women, with referral
to primary care for ongoing
contraceptive/reproductive health care
needs
Offer continuity services for teens and highrisk women who require additional support
to avoid unintended pregnancy and
STD/HIV
Services for Women
• Seen by STD clinicians trained in family
planning services
• Preconception counseling, pregnancy testing,
emergency contraception, and initial
contraception (3-months)
• Contraception available: oral contraceptives,
transdermal patch, emergency contraception,
DMPA, vaginal ring, condoms, and
spermicide
• Referrals: to obtain IUDs, implants, and tubal
ligations
• Clinician determines if client meets eligibility
criteria for being at high-risk of unintended
pregnancy
Services for Women
• If low-risk, clinician facilitates a referral to a
PCP for ongoing reproductive health care
needs
• If high-risk or teen, eligible to receive ongoing
contraceptive services through our
teen/continuity clinic
• High-risk for subsequent pregnancy:
– homeless/transitional housing or drug
user/drug treatment
– based on having >6 of 9 risk characteristics
at presentation
Risk Factors Correlated with
Incident Pregnancy
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Age <19 years of age
Non-Caucasian
< High school diploma or general
equivalency diploma
Previous pregnancy history
No use of birth control method with last
intercourse
Sex at least once a week
Previous abortion
> 3 partners within the past month
< 17 years of age with first pregnancy
Findings
• Services provided 2001-June 2008
– 9,425 women and 7,745 men
– In 2007 40% of heterosexual clients seen received FP
services
– Majority of clients <24 years (63%)
• Among women seen 2003-2006-changes among clientele
provided services:
– Increase percentage of women classified as lower
socioeconomic status
– Increase in teens provided services; fewer 20-29 year old
women seen
– Hispanic clients increased significantly
– Clients characterized as being high-risk for subsequent
pregnancy declined over the four years
– Clients with a current or past STD increased
– Traditional methods of condoms and oral contraceptives
provided decreased with provision of newer methods
increasing
Assumptions of Program
• Program reduces incident pregnancy
– No evaluation has been conducted on the program’s
effectiveness
• Difficult to conduct ongoing follow-up of women
seen only for initial services and then
subsequently referred to a primary care provider
for ongoing care
Objective of Study
• To examine the relationship between baseline
demographic and clinical characteristics and
incident pregnancy among women provided
initial contraceptive services in an STD clinic
who subsequently returned for STD/family
planning services
Methods
• Computerized record review of women attending
an STD clinic between 2003-2006 who met
inclusion criteria were included in these
analyses:
– between 12-44 years, provided a method of
contraception at the initial STD clinic visit, indicated
no interest in pregnancy, and had complete baseline
pregnancy history information
• Association between baseline demographic,
behavioral, and clinical characteristics and
incident pregnancy were assessed using
multivariate logistic regression
Results
• Among 4,617 women who met the inclusion criteria,
3907 (85%) seen only during a single year (single
visitors) and 710 (15%) women were seen at least two
separate years (repeat visitors)
• Most clients do not return for repeat services (15%
repeaters vs. 85% single year visit)
• Comparing two groups:
– repeat visitors were younger, more often AA, reported
a smaller family size, had lower FPL, less likely to
have public insurance, had fewer pregnancies,
reported more drug use, were more often considered
at higher risk for pregnancy (previously described
criteria), and reported more prior STDs
Impact of Program
• Assessment of pregnancy risk among repeat
users not wanting subsequent pregnancy:
– Of the 710 repeat visitors, 642 had complete
follow-up information and indicated no intention of
pregnancy at any subsequent visit
– 642 women; 59 (9.2%) high-risk and 583 (90.8%)
low-risk for pregnancy
– 19.3% had a least one pregnancy (N=124)
– 37.3% among high-risk women vs. 17.5% among
low-risk women (P<0.01)
Predicting Pregnancy Risk
• Using multivariate analysis and controlling for
age and race/ethnicity, incident pregnancy
associated with:
– Previous pregnancy-OR 2.57, 95% CI: 1.63-4.04
– <150% Federal Poverty Level-OR 2.22, 95%CI:
1.05-4.71
– No contraceptive use at last sex-OR 1.67, 95%CI:
1.11-2.52
– Incident pregnancy not associated with
educational level, sexual frequency, age of first
pregnancy, number of partners, prior therapeutic
abortion, current STD, prior STD, or provision of
effective contraception at the initial STD clinic visit
Limitations
• Since follow-up information unavailable on
single visitors, limits generalizability of our
findings to the entire population seen for initial
family planning services
• Without follow-up information on women referred
to a PCP, unclear whether our current referral
process enables all low-risk women to
successfully transition to primary care
• No information available on the duration of use
of the birth control methods provided which may
affect risk of subsequent pregnancy more than
the type of method initially provided
Conclusions
• Women presenting to an STD clinic are at risk for
pregnancy
• Overall, incident pregnancy occurred in 19% of repeat
visitors, with higher rates among high-risk women
• By examining the association between baseline
demographic and clinical characteristics with incident
pregnancy, certain characteristics were found to be
associated with incident pregnancy:
– lower income
– having been previously pregnant
– not having used contraception with the most recent
sexual act
Future Studies
• Findings suggest that continued use of effective
contraception or factors affecting continued
contraceptive use should be a target for future
research and program development -likely more
of a predictor of incident pregnancy
• Future studies are also needed to explore other
factors which may be more amendable to
change in addition to our current risk
stratification
Questions?
Email address: [email protected]
Telephone: 303-436-7337