Predicting Pregnancy Risk among Women Attending an STD Clinic

1. Predicting Pregnancy Risk among Women Attending an STD Clinic Judith Shlay MD, MSPH Denver Public Health September 21, 2008 CityMatCH Conference

2. 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

3. 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

4. Our Current Integrated STD/Family Planning Program • 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 high-risk women who require additional support to avoid unintended pregnancy and STD/HIV

5. 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

6. 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

7. Risk Factors Correlated with Incident Pregnancy • 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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)

14. 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

15. 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

16. 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

17. 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

18. Questions? Email address: jshlay@dhha.org Telephone: 303-436-7337