Contraception 88 (2013) 263 – 268

Original research article

Contraception counseling, pregnancy intention and contraception use in
women with medical problems: an analysis of data from the Maryland
Pregnancy Risk Assessment Monitoring System (PRAMS)
Jamila B. Perritt a,⁎, Anne Burke a , Roxanne Jamshidli a , Jiangxia Wang b , Michelle Fox a
The Johns Hopkins University, Baltimore, MD, 21224, USA
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21224, USA
Received 17 August 2011; revised 7 November 2012; accepted 7 November 2012


Background: Data from the Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) were used to evaluate whether women
with selected medical comorbidities are less likely than healthier women to report receiving contraceptive counseling during pregnancy and
to report using contraception postpartum.
Methods: We analyzed de-identified data from the 2004–2007 Maryland PRAMS using logistic regression to evaluate these outcomes:
undesired pregnancy, self-reported antepartum contraceptive counseling and postpartum contraceptive use for women with and without
hypertension, diabetes or heart disease. Survey data were used to estimate response frequency within the Maryland birth population.
Results: Patient self-report of contraceptive use increased overall during the postpartum period as compared to the antepartum period, from
44.3%–90.1% (pb.001). Almost one fourth (23%) of 6361 respondents reported receiving no contraceptive counseling. There was no
difference in reported contraceptive counseling in women with selected medical comorbidities as compared to those without, and only
women with preconception diabetes mellitus were significantly less likely than healthier women to report postpartum contraceptive use.
Conclusions: Overall, there was no difference in the report of receiving contraceptive counseling in women with selected medical
comorbidities as compared to than those without. In addition, they were not more likely to report receiving contraceptive counseling
either despite higher risk of pregnancy complications. These results indicate lost opportunities for effective counseling that could improve
health outcomes.
© 2013 Elsevier Inc. All rights reserved.

Keywords: Pregnancy Risk Assessment Monitoring System: Contraceptive counseling; Medical comorbidities; PRAMS; Contraception

1. Introduction intended pregnancies, mothers who describe their pregnancy
as unwanted or mistimed are more likely to engage in
By age 45, more than half of women in the United States unhealthy perinatal behaviors and to have poorer maternal
(US) will have had at least one unintended pregnancy with and birth outcomes [7,8]. This problem is compounded in
half of these ending in abortion [1,2]. Studies suggest that the women with medical comorbidities, such as hypertension,
rates of unintended pregnancy among women with some diabetes and cardiovascular disease, which may worsen
chronic conditions are similar to or may even exceed rates in during pregnancy and further compromise maternal and
the general population [3,4]. Women with some medical child health.
problems who carry their pregnancies to term are often more The ability to plan a pregnancy is a key factor in
vulnerable to pregnancy-related complications than their improving all pregnancy outcomes, especially those for
healthier counterparts [5,6]. Compared to women with women with medical disorders. The American College of
Obstetricians and Gynecologists (ACOG) and the US
Centers for Disease Control and Prevention (CDC) recom-
⁎ Corresponding author. The Johns Hopkins University, OB/GYN, mend that women with medical comorbidities optimize their
4940 Eastern Ave., Baltimore, MD 202224. Tel.: +1-202-225-5992. health prior to conception [9,10]. Consistent use of effective
E-mail address: (J.B. Perritt). contraceptives is crucial to obtaining this goal. Many
0010-7824/$ – see front matter © 2013 Elsevier Inc. All rights reserved.

Perritt et al. and disease. specific method they were using. tubal ligation and vasectomy as ways naire. contraceptive use and pregnancy intention in selecting contraceptives for women with medical comorbid. talk with you about birth control methods to use after your pregnancy?” Respondents were asked to report their contraceptive use (yes/no) at the time of conception and 2. We analyzed limited by misperceptions of risk by both health care a limited de-identified data set collected by the Maryland providers and patients [11]. currently administered in respondents were asked to consider methods such as natural 37 states. women's options for contraception are often compared to women without these disorders. include a core set of standardized questions. We tal visits are often centered on acute medical management chose hypertension.15]. as compared to women without report of these opportunities for counseling are often limited by time disorders. ACOG and land PRAMS data to examine self-reported contraceptive the CDC have issued guidelines to assist clinicians in counseling. condoms. nurse or other health care worker likely to use contraception during the postpartum period. for example. counseling that women with specific medical comorbidities (hyperten. the pill. a Each month. as well as the responses to PRAMS survey clinicians dissuaded them from using hormonal contracep. she did not want to be pregnant “then or at any time in the mately 3 months postpartum. Providers' lack of knowledge PRAMS program between 2004 and 2007. / Contraception 88 (2013) 263–268 clinicians are hesitant to administer hormonal contraceptive low birth weight (b 2500 g) or who are 35 years of age methods to women with cardiovascular disorders partially or older. diabetes or heart visits in the antepartum period. pregnancy intention (desired/undesired/mistimed) in Though most pregnant women have 10 or more clinician women with self-reported hypertension. sion. due to product labeling that cautions against prescribing to We conducted a retrospective analysis using the Mary- women with these comorbidities.264 J.” Spanish. For women with medical comorbidities. antena. Our primary hypothesis is influence contraception prescribing patterns. Surveys are administered in both English and pregnant “later. contraceptive methods or use no contraceptive method at all. placing them at increased risk for unintended We defined our primary outcomes as self-reported pregnancy [11. the visits. If mail is unsuccessful. intrauterine device. Prior to this and discomfort counseling about contraceptive options may timeframe. withdrawal. diabetes and heart disease. files. The PRAMS surveys. as well family planning. The limited data set included basic demographic pregnancies [12]. Similar analyses were performed to examine the . about the existence of a number of health problems. This study tive methods due to their medical problems. Our secondary hypothesis is that considered to have received counseling: “During any of your women with the above-mentioned comorbidities are less prenatal visits. pregnancy intention. For our analysis. did a doctor. the Maryland PRAMS survey asks constraints. contraceptive use and counseling PRAMS survey did not ask respondents to identify which received on a variety of issues during routine prenatal care. a stratified. Women often inform us that their information. Other studies was approved by the institutional review boards of the Johns have also found that women with some medical problems Hopkins University School of Medicine and the Maryland receive less contraceptive counseling or inappropriate Department of Health and Mental Hygiene. contraceptive counseling during pregnancy than their women who responded “yes” to the following question were healthier counterparts.13]. medication adjustment) as we felt these comorbidities would be most likely to rather than preventive counseling. They often rely on less effective barrier antenatal contraceptive counseling (yes/no). Of note. the survey is conducted via respondent answered the question that she wanted to be telephone. counseling. questions that addressed our a priori hypotheses. as state-specific questions. higher risk hypotheses. sufficient data were not available to test our place women at greater risk for unplanned. were you or your husband or The Pregnancy Risk Assessment Monitoring System partner doing anything to keep from getting pregnant?” and (PRAMS) is a survey administered during the postpartum “Are you or your husband or partner doing anything now to period via the CDC in collaboration with state health keep from getting pregnant?” In each of these questions.. However. diabetes and heart disease) are less likely to receive For our analysis of antenatal contraception counseling. Multiple follow-up attempts future. However. ities.” A pregnancy was considered mistimed if the are made. Data are collected via a mailed survey sent approxi. Respondents are entered into a monthly gift card Multiple logistic regression analysis was used to estimate raffle to encourage participation.e. The Maryland PRAMS question. random sample of approximately pregnancy was classified as undesired if the respondent 200 live births is selected from Maryland's birth certificate answered that “at the time you found out you were pregnant. thus use prior to pregnancy and postpartum (yes/no) and increasing their risk of unintended and undesired pregnancy. Participant selection is the odds of receiving contraception counseling during stratified by age and birth weight and is designed to pregnancy as a function of the medical comorbidities listed oversample mothers who have delivered an infant with a above. vaginal ring. diabetes and heart disease for analysis (i. review of blood sugar logs. and use [14. departments. More recently. women with hypertension. most visits are brief. asks women about frequency of prenatal they might be trying to prevent pregnancy. Methods postpartum with the following questions: “When you got pregnant with your new baby.B.

7 one fifth of respondents (21. Multinomial Table 1.4 were non-Hispanic Caucasian women (57. Results were considered Demographic characteristics of survey respondents: (PRAMS.1 A total of 260.018 43.2 (0.9–4.368 3.1 (0.9 6361 women (n) surveyed by PRAMS during this time Education (2.7 47.B.1% reported being When applicable.6% and 8.4 71.7 125.459 27. medical history and contraceptive 6124) use and were therefore tested for inclusion in the multiple Variables PRAMS Statewide estimate no. were reported by 11.6%) c Low SES is defined as being uninsured. Participants must be low income as defined by federal within the total Maryland birth population are as follows: poverty guidelines.720 38.3±. pregnancy versus planned pregnancy. non-Hispanic 1. In addition.1%).954 46. Because hypertension responses are linked to birth certificate data.542 24.5%.1% 68 b 0.9–1.4) 1.665 48.765 27. care was funded by Medicaid. survey data may Gestational 687 22. estimated rates of medical comorbidities for each disorder infants and children.268 9. gestational hypertension and gestational diabetes relationship of selected medical comorbidities to contracep.6–1.426 28.230 women (N) had a live birth in Asian 439 6.6 response rate for the Maryland PRAMS survey was between Some college 1. ORs and RRRs were Adjusted for age.5 on the survey sampling method. 30–39 3. Logistic regression statewide estimates models were used to estimate the sample sizes required to Characteristics PRAMS % in Estimated Estimated detect a statistically significant OR between the women with sample PRAMS total % in and without medical problems for receiving contraception sample population population a counseling.0 (0.9 78.2 Black.0 113. respectively. race and SES.3 74. non-Hispanic 3. and 8. All percentages ratios (RRRs) of undesired pregnancy and mistimed are weighted to reflect the PRAMS sampling strategy.8 Maryland during the study period.187 18.2 36. pregestational and gestational diabetes and logistic regression was used to estimate the relative risk hypertension were examined separately. J. Heart disease 91 2247 (87.683 38.8) be weighted for analysis to estimate response frequency diabetes within the total state birth population [16].823 14.6 N49 5 b0. having had prenatal care paid for by public frequency counseling a (%) assistance or having received benefits from the Women. A percentage of 4.05.2 148.0 Table 1 shows selected demographic characteristics for Prenatal care payment source the PRAMS respondents as well as statewide estimates based Public assistance/Medicaid 1. preconception diabetes (1.119 5. non-White 319 5. / Contraception 88 (2013) 263–268 265 Table 1 adjusted for age. having had their prenatal care paid for by public assistance or having received WIC benefits.0 18.3 Low SES c 2.5 (0.4 had at least one of these medical disorders prior to pregnancy. Data from the sample of Other. Perritt et al. .9 15. which provides benefits to Diabetes mellitus 126 2829 (83. n= 6361) and significant at a two-sided p value b . and cardiac disease (1.388 18.222 35.4) 1. uninsured during their recent pregnancy. More than college 2. chronic hypertension (2.1 (0. More than No health insurance 540 8. race and SES.2 70% and 73% for each birth year between 2004 and 2007. race and socioeconomic status (SES) were Adjusted OR of self-reported antenatal contraceptive counseling in women considered possible confounders of the relationship between with selected medical problems as compared to those without (PRAMS. The Less than high school 649 10.359 (77) Infants and Children (WIC) program. USA) to incorporate sample weights and reflect the Medical problems during pregnancy Gestational 1109 17.3 (0.3%).6) 1.594 39.9) 1. n= contraception counseling. Total 6124 193.4% of birth population) are included in this analysis.634 57. a federally funded Preconception medical problems Hypertension 337 5020 (76.060 6. Results Race White.2 Completed high school 1.653 (80.334 21. The majority of women WIC b 1. As noted in tive use prior to pregnancy and postpartum. pregnancy intention and contraceptive use Age (years. b confidence intervals (CIs).180 (79. adjusting for the medical comorbidities listed above.0) 1.5%) reported that their prenatal a Estimated statewide rates are based on the weighted surveyed responses.6) supplemental nutrition program.7 99. above TX. In all cases.6 25.462 9.8) All statistical analyses were performed using the survey At least one of the 475 8545 (79.2%). The weighted b WIC is a federally funded supplemental nutrition program for women. mean 28.5) strata in the PRAMS survey sampling method.8–1.7–3.3 level [17].1 3.2 100.7) 2.3 20–29 1.7 40–49 655 10.2) low-income women and children.6 101.9–1.852 57.921 30.199 30.6 24.1) postpartum with an 80% power at the 5% significance b20 360 5.965 30. Results were a Values are weighted and reflect estimated statewide rates from the calculated as odds ratios (ORs) or RRRs reported with 95% surveyed population. percentages may not sum to 100 due to missing data. Demographic details Table 2 including age.3 9.576 56. Adjusted OR b logistic regression models.7) commands in Stata-11 statistical software (College Station. Low SES (yes/no) was defined as data of respondents reporting (95% CI) being uninsured.

mellitus Heart disease 29 1170 (40.675 (15. An estimated 90% of women at risk for pregnancy 3.5) 2.3) hypertension Gestational 306 4066 (39.6–1.7–1.8) 313 5205 (83.5 (0.6 (0.6–2.1.4 (0.3–0. desired) achieved borderline Diabetes 24 879 (26. abstinent or sterilized were excluded.389 (31.1–1.9) Heart disease 51 950 (63.4 (0.8) 1. diagnosis of pregestational hypertension were half as likely b A pregnancy was considered mistimed if the respondent reported that she wanted to be pregnant later at the time of conception.956 (88.4) 1.8) .0) 3.5) 0.5) 1.1) 1.1) – Preconception medical problems Hypertension 187 1193 (27. As Women who reported being currently pregnant.9–2. 77% of women indicated that they had received from contraceptive use prior to conception (pb.1) 1.B.4%. d Women who were pregnant.1) Diabetes mellitus 68 455 (24. race and SES.9) Preconception medical problems 3.8) 0.2). / Contraception 88 (2013) 263–268 Table 3 hypertension.7) 0.2) above Medical problems (during pregnancy) Gestational 544 6933 (42. Mistimed 1405 79.8 (. Perritt et al.554 (41.001).2 (0.4) 0. 95% CI: 1. 95% surveyed population.4) 0.7) 84 2344 (93. contraceptive counseling during their recent pregnancy.0–3.3) – 5558 d 209.4 (0. There were no significant differences in self-reported counseling between Variables PRAMS Statewide estimate no. There were no other statistically significant d Adjusted for age.247 (19. b Adjusted for age.6% and 87.3–1.4–5.0) 0.9) statistical significance.9) At least one of the 263 2376 (35.9) 0.165 (9.5. c Women trying to conceive were excluded.1 (. representing a significant increase Overall. an estimated 41% of those with a live birth in mellitus Maryland described their most recent pregnancy as either Heart disease 17 340 (11.9–5.2) 603 16.2) diabetes a Values are weighted and reflect estimated statewide rates from the surveyed population.65 (0.2) 109 2205 (77.7) mistimed or undesired.8 (0.8. Contraceptive use At least one 101 3257 (29. differences in odds of reported preconception contraceptive use for women with the other comorbidities studied.8 (1.3–1. As demonstrated in Table 4.7 (0.4) 1.8) of the above Overall. CI: 0.5–1. . Total 6209 104.3–0.1) undesired pregnancies (vs.7 (0. Table 3 shows the RRRs for self- At least one 94 1.885 (44.0–3.4–1.3) 1015 23.531 (90.1) 0.3–1. not sexually shown in Table 2.1 (.3) Overall. respectively. race and SES.2.849 (88. diabetes or heart disease 3 months or more Adjusted RRR of reporting the most recent pregnancy as undesired a/ prior to pregnancy report contraceptive counseling rates of mistimed bversus desired in women with selected medical problems as compared to those without (n= 6209) 76. trying to conceive.9 (0.3) reporting a mistimed or undesired pregnancy according to the of the above presence of the preexisting medical comorbidities studied. (RRR: 1.5 (0.8 (0. women with a conception. women with a self-reported diagnosis of active or desiring pregnancy were excluded from this Table 4 Adjusted OR a of contraception use preconception and postpartum in women with selected medical problems as compared to those without Variables Preconception Postpartum PRAMS data Statewide estimate no.1) Undesired 733 25.1) 432 8551 (86. an estimated 44% of women not intending a A pregnancy was considered undesired if the respondent reported that pregnancy were using contraception at the time they she did not want to be pregnant then or at any time in the future at the time of conceived. Pregnancy intention Hypertension 74 1. of Adjusted PRAMS data Statewide estimate no.4–1.0) 0.266 J. of Adjusted frequency contraception use a (%) OR b (CI) frequency contraception use a (%) OR b (CI) Total 2816 c 57.7 (.8).6 (0. Antenatal contraception counseling reported using contraception or sterilization roughly 3 months postpartum.2) Diabetes 21 321 (9.9) 1.7%. 83.3.6–4. to report using any form of contraception at the time of c Values are weighted and reflect estimated statewide rates from the conception than those without hypertension (OR: 0.1–0.7–4.7–1.6) 0.9 (0. Adjusted RRR d women with and without these chronic medical disorders or data of reported undesired/ (95% CI) frequency mistimed pregnancy c (%) between women with and without gestational hypertension or diabetes.8) 0.2) Preconception medical problems Only the results for chronic hypertensive women reporting Hypertension 63 1727 (26.5–1.

we performed counseling vary widely. postpartum than those without diabetes (OR: 0. D'Angelo et al. the categories of undesired (defined as 0. no statistically significant relation. Results may be to the time constraints of prenatal visits. No other results were statistically significant. / Contraception 88 (2013) 263–268 267 calculation as they were not presumed to be at risk for Program that covers contraceptives for low-income women. our analysis could not control for compliance. Finally. unintended Other studies show that reported rates of antepartum pregnancy and postpartum contraceptive use. women may have been eligible for the state Family Planning our analysis is limited by the relatively small number of . however. whether undesired or just mistimed. contraceptive options. 95% CI: pregnancies that are undesired with those that are desired but 1. Less than 10% of of 0.2–2. have a greater impact on contraceptive use in other states They were less likely to report using contraception with limited contraceptive coverage.9. which is fertility intention is needed. unintended pregnancy. however. The retrospective nature of this study failure to act despite this knowledge.1–0. as these conditions may have an effect on pregnancy-related maternal and neonatal complications and contraceptive counseling and prescribing patterns. may mask ships were identified. only 77% of women reported receiving antepartum opted to evaluate pregnancy intention using three categories. J. Finally. control population used in this analysis includes the study especially in women with chronic medical conditions. Discussion opposed to mistimed were more likely to engage in behavioral risk factors that could negatively affect their In our analysis of data from the Maryland PRAMS pregnancy [20]. Further exploration of makes it difficult to draw conclusions regarding causality. also indicate women's lack of understanding of their terminated their pregnancies or had a live birth but did not contraceptive options or the health risks of pregnancy or answer the survey. there is substantial debate regarding the differing iate logistic regression was performed to evaluate whether impact of mistimed versus unwanted pregnancies on the effect of counseling varied by the presence of one or maternal and fetal outcomes. Even if women were counseled regarding their direct cardiovascular or end-organ risks. This may suggest that we.. SES may contraception use in women with pregestational diabetes.0) compared to those who did not. hypertension and Women with medical comorbidities are at higher risk for heart disease. In Maryland. analyses specific to women with diabetes. important differences in these groups of women. While most receiving contraceptive counseling were more likely to studies evaluating unintended pregnancies have grouped report using contraception postpartum (OR: 1. pregnancies. mistimed. need to find more effective ways to and. In pregnancy being unwanted now or anytime in the future) and analyzing the impact that contraceptive counseling may have mistimed (defined as wanting a pregnancy later) were had on postpartum contraception use. evaluated PRAMS data from 15 states and found that women who reported their pregnancy as unwanted as 4. and many of these women with at least one of the medical disorders of interest. This is not recall and report it.6. we rates of contraceptive counseling. contraception counseling despite recommendations that Unlike Chor et al. For example.B.0 for contraceptive counseling and an OR private insurers cover all contraceptives. has no true control population. as health an evaluation of data from a previously administered survey care providers. women's motivation to avoid unplanned pregnancy and Survey responses are dependent on self-report. sociodemo- access to contraceptives likely also interact with the effect graphic factors).9).5 for pregnancy intention and contraceptive use in our sample reported being uninsured. parity. 95% CI: In this analysis. The emphasize the prevention of future unplanned pregnancy. It is population. We chose a more conservative approach and survey. from 4% [18] to 77% [19]. subject to recall bias. cally significant effect of SES on reported contraception use though the PRAMS sample achieved 80% power overall to in the women sampled. women who reported constructed as proxies for pregnancy intention. relationship between chronic medical illness. Our findings may different for those women who experienced fetal loss. it is concerning that hypothesized that these chronic diseases would have a lesser reported counseling was not increased in this high-risk impact on contraceptive counseling and use than those with group. Medicaid and most detect an OR of 2. we found that there was no statisti. While we were relieved to find that the asthma or anemia denoted in the PRAMS data set would presence of medical comorbidities did not decrease reported have increased our sample size and statistical power. We attempted to adjust for potential Socioeconomic factors such as insurance status and confounding variables in our analysis (i. almost one fourth of all women did We acknowledge several limitations of this study. There is growing evidence to more medical conditions or other possible confounders such suggest that the use of one category for all unplanned as low SES. Perritt et al. [21] who also examined the contraception counseling be a routine part of prenatal care. Table 4 shows that there was a Almost 4% of respondents cited “could not pay for birth statistically significant difference in reported postpartum control” as a reason for not using contraception.e. While the have higher rates of unintended pregnancy than those inclusion of women with other chronic diseases such as without [7.4. multivar. however.11]. other factors may have biased of contraceptive counseling on patient behavior and results. The comparison group is limited to those with also possible that some were in fact not counseled at all due live births in Maryland who responded. as this was not asked in the PRAMS survey. as it was designed.

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