Army Unintended Pregnancy Study

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Army Unintended Pregnancy Study

• PIs Dr Kathleen ORourke, PhD COL Michael
  Custer, DrPH
• Co-investigators Mary Roddy, PhD Jonas Almeida,
  PhD
• Funded by CDC/AAMC

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Army Unintended Pregnancy Study

• Assistance LTC Wayne Coombs, PhD, MAJ Georgia
  Delacruz, DDS,
• Ms Judith Harris, Ms Donna Williams, Ms Ericka
  Evans, Ms Joy Coates
• Funded by CDC/AAMC

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All Services Gender Distribution

• In the Army 15.3 officers and 14.6 enlisted are
  female as of Sept 2004
• Air Force has highest percentage of women.

Includes Warrant Officers
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Background

• With 15 of our soldiers women
• Need to address specific social, medical, and
  physical needs of female soldiers
• Unintended pregnancy among soldiers, especially
  new recruits, can be disruptive to unit readiness
  as well as the soldiers physical, social,
  mental, and economic well-being.

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Pregnancy intention

• To date, most data on pregnancy intention is
  collected retrospectively, after the birth of a
  baby.
• Subject to recall bias as the birth of a baby is
  a highly emotional experience and may impact on a
  womans ability to accurately recollect
  intention.
• Does not include women who have induced or
  spontaneous abortions.

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Pregnancy intention

• A variety of terms have been used to define
  pregnancy intention
• Intended
• Planned
• Wanted
• A civilian study of 110 women receiving prenatal
  care showed
• 35 of pregnancies were planned
• 91 were wanted

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Measurement of pregnancy intention

• Measured through national surveys
• PRAMS Pregnancy Risk Assessment Monitoring System
• Data are collected retrospectively and asked 2-3
  months after delivery
• NSFG National Survey of Family Growth
• Within 5 years of having infant
• NMIHS National Maternal and Infant Health Survey
• Self Administered Survey

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Measurement of pregnancy intention

• Measured through national surveys
• PRAMS
• Data are collected retrospectively and asked 2-3
  months after delivery
• Questions Used Unintended Pregnancy Thinking
  back to just before you were pregnant, how did
  you feel about becoming pregnant? Responses (1)
  I wanted to be pregnant sooner, (2) I wanted to
  be pregnant later, (3) I wanted to be pregnant
  then, (4) I didnt want to be pregnant then or
  any time in the future, (5) I dont know. Dont
  know responders were excluded from the analysis.

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Risks of unintended pregnancy

• Approximately 57 (3.1 million) U.S. pregnancies
  are classified as unintended
• 1.6 million of these end in abortion
• Unintended pregnancies are associated with
• Inadequate prenatal care
• Alcohol use and smoking during pregnancy
• Low birth weight
• Obstetric complications
• Child abuse
• Poor child development
• Lower educational attainment for the child

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PRAMS pregnancy intention data
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Rates of pregnancy in the Army

• 14,012 soldiers delivered babies in 2001.
• This represented 18.9 of the total number of
  women in the Army Sep 2001
• Two studies indicate that approximately 50 of
  soldiers who deliver infants reported they were
  mistimed or undesired
• No available data on rates of elective abortions
  or miscarriages in this population. No available
  data on rates of elective abortions or
  miscarriages in this population.

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Prevalence of Unintended Pregnancy in the
Army- Clark

No contraception
Intended Pregnancy
Unintended Pregnancy
Contraception Use
n344
Clark, et al., 1997
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Prevalence of Unintended Pregnancy in the Army-
Custer

No contraception
Intended Pregnancy
Contraception Use
Unintended Pregnancy
Ambivalent
n212
Custer, et al., 1999
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Impact of Pregnancy in the Army

• Women made up 40 of the hospitalizations of
  soldiers in 1999
• 58.3 of the hospitalizations among women were
  related to pregnancy, delivery or postpartum
  complications
• Medical Surveillance and Monthly Report, July
  2001.

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Rates of unintended paternities in the Army

• Currently no data are available
• One study1 found 70 agreement between intention
  status a mothers intention status and her report
  of the fathers.
• LTC Michael Custer, Kim Waller, Kathleen
  ORourke, Sally Vernon, Anne Sweeney. 2002
  Unintended pregnancy rates among a US military
  population. Under review for publication

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Complexity of pregnancy intention

• Pregnancy intention is a complex measure
• Changes over time
• Measures are complex
• Planned and wanted pregnancy to unplanned and
  unwanted
• Issue of fatalism, religiosity
• Interpretation is subject to biases
• Impacted by cultural norms and beliefs
• Potential bias in retrospective analysis

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Purpose of this study

• Obtain data on rates of unintended preg/patern
  among soldiers during first two years following
  Initial Entry Training (IET).
• Evaluate the impact of a preg/patern prevention
  curriculum, designed for a military population.
• To identify factors associated with unintended
  preg/patern among soldiers during first two years
  following IET.

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Intervention Curriculum

• Based upon Reducing the Risk
• Refined for a military population
• One four hour class

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Intervention Curriculum

• The Army made this program available at
  USACHPPMs web site http//chppm-www.apgea.army.mi
  l/dhpw/Population/Pregnancy.aspx
• This study will evaluate the impact of the
  curriculum

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Original Study design

• Prospective cohort
• Community-based evaluation design of a
  pregnancy/paternity and STD prevention program
• Two groups
• Soldiers assigned to a base with the intervention
  program (Ft. Campbell, KY)
• Those assigned to bases without the intervention
  program (Fort Stewart, Fort Bliss, Fort Jackson)
• Follow approximately 1200 soldiers (50 female)
  for two years

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Original Study design

• Follow approximately 1200 soldiers (50 female)
  for two years
• Baseline Survey
• Pre Post Test measures learning during
  intervention
• Follow-up Surveys
• 6 Months
• 12 Months
• 18 Months
• 24 Months

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Enrollment status

• Intervention (Ft. Campbell)
• Total 680
• 345 men
• 335 women
• Comparison (Fts. Jackson, Stewart, Bliss)
• Total - 589
• 333 men
• 236 women
• We are 64 women short of our initial projection
  due to difficulties enrolling because of the
  military action in Iraq

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Data collection

• Questions include demographic factors,
  contraceptive use, pregnancy history, pregnancy
  intention, STD treatment
• Questions gender specific
• Additional questions if a pregnancy occurred
  during the target period
• Follow-up data collected through a WEB-based
  survey with privacy protection

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Utilizes adaptation of PRAMS question for
prospective collection

• If you are (your partner is) not pregnant, do you
  want/plan to become pregnant (father a child)
  within the next 6 months?
• 1. Yes, I definitely want to become pregnant
  (father a child) in the next 6 months
• 2. No, I dont want to become pregnant
  (father a child) in the next 6 months though I
  will probably get pregnant (father a child)
  sometime in my life.
• 3. No, I dont ever want to become pregnant
  (father a child)
• 4. I dont know

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Additional pregnancy intention measures

• How would you feel if you (your partner) became
  pregnant now?
• 1. Very happy
• 2. Somewhat happy
• 3. Not very happy
• 4. Not happy at all
• Would having a baby now be a problem for you?
• 1. Yes, very much
• 2. Yes, a little
• 3. No, not very much
• 4. No, not at all

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Unintended paternity

• Very little data to date in all populations
• Should provide baseline information for
  participants in the military setting

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Potential benefits

• Prospective measure of unintended pregnancy
• Can compare prospectively reported pregnancy
  intention with retrospective reporting for women
  who have a pregnancy
• May have implication for other studies on
  pregnancy intention

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Challenges

• Issue of deployment
• Military deployment to Iraq
• Began Data Collection Early 2003
• IRAQ invaded March 2003
• Ft Campbell home to 101st Airborne
• Two-fold effect
• Enrollment activities
• Follow-up activities

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Impact of deployment on enrollment

• Difficulty in expanding enrollment to additional
  bases
• At times, entire units closed due to deployment
  of all soldiers
• Study is lower priority
• Currently have one intervention site and three
  non-intervention sites
• Expanded enrollment period

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Impact of deployment on follow-up

• Loss to follow-up for 6 months surveys gt90
• Initial plan was on-line survey
• Access to computers/internet is limited
• Changed to both internet and mail survey
• Many e-mail addresses expire if not used
• Eg. Yahoo
• Addresses are by unit assigned
• Individuals get reassigned
• 25 mail returned due to incorrect addresses
• Greatest challenge is lack of information on
  reasons for loss to follow-up

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Follow-up strategies implemented

• Continue sending out follow-up surveys in both
  formats
• Use troop locator system to identify incorrect
  addresses
• Change the 12 month survey to collect data on the
  entire period.
• At least one follow up survey
• 1149 Baseline surveys
• 690 Follow-up surveys
• One year follow-up ends Sept 2005

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Study issues and adjustments

• Loss of six-month follow-up data, including the
  impact of deployment on contraceptive use and
  pregnancy intention Added a qualitative component
• , interviewing 32 subjects about the effect of
  deployment on sexual decision making
• 8 men who intended a paternity in 6 months
• 8 men who did not intend paternity in 6 months
• 8women who intended pregnancy in 6 months
• 8 women who did not intend pregnancy in 6 months

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Dimensions of pregnancy intention

• Qualitative study
• In depth, semi-structured interviews with 16
  women
• Introductory question How do you feel about this
  pregnancy?
• Explored how women related to intended,
  unintended, planned, unplanned, wanted, and
  unwanted
• Social and cultural context was important in how
  women defined these factors.
• Planned and wanted were very different but not
  planned and intended
• Partners reaction was very important
• Fisher R, Stanford J et al. Exploring the
  concepts of intended, planned, and wanted
  pregnancy. The journal of Family Practice 1999
  48(2)pp 117-122

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Preliminary analysis of in-depth interviews

• To date, we have 10 surveys, 8 female and 2 male
• Themes
• Deployment has a major impact on pregnancy
  intention for women and paternity for men
• Attempts to become pregnant before deployment to
  avoid going
• Avoiding pregnancy because of deployment
• Changes in relationships after deployment
• Concerns about exposures to chemicals/agents in
  Iraq

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Attempting pregnancy to avoid deployment

• How often do you think female soldiers attempted
  pregnancy to avoid deployment?
• Probably very frequently. I dont know how many
  but I know it happens.
• In my unit a lot of females got pregnant because
  they didnt want to go to war. Then they got
  faced with having their babies and then having to
  leave them.

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Avoiding pregnancy because of deployment

• The reason why he wants us to get pregnant is
  to try and get me out of a deployment. I dont
  want to bring a child into the world just because
  I am trying to avoid a deployment.
• We want to wait.. Him being away and me may-be
  getting deployed and us both being in the army is
  hard.

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Changes in relationships after deployment

• Several soldiers indicated they were in a
  different relationship after deployment than
  before
• My wife said I wanted to get things done faster.
  She said I would get mad at her if she took more
  time.
• Its made our relationship stronger. Because
  when he was in Iraq I was sent down to Kuwait so
  we had that distance and now hes deployed
  again so its made us stronger.
• It became very different in how I handled friends
  I had prior to deploying I found it hard to
  communicate with them for awhile.

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Concern about exposure to chemicals/agents in Iraq

• I think we were all exposed to things. Like
  right now, I came back from Iraq TB positive.
• The stuff we ate and dealt with over there is
  concerning.
• I was exposed to the sulfur fires ... So I think
  that has effected me. I dont think it has
  effected my babys health.
• Yes I worry about it. I remember when we were
  coming home, our plane landed in Italy and they
  would not let us get off the plane because the
  soldiers were some from a chemical unit and the
  sand from Iraq may have been on or boots or
  something.

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Men stating delay in parenting due to deployment

• I probably would have had a kid by now if I had
  not been deployed.
• If I had not been deployed I probably would have
  had a kid sooner.

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Baseline data analysis

• In process 1149 records
• Evaluate the relationship of contraceptive use
  with pregnancy intention
• Three measures of pregnancy intention
• Three categories of contraceptive use, as defined
  by Cates
• CATES Sex Transm Dis, Volume 29(3).March
  2002.168-174

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Categorization of contraceptives

• Highly effective and do not depend on user
  adherence (sterilization, implants, injectables,
  IUDs)
• Oral contraceptive pill (highly effective during
  perfect and typical use)
• Less effective methods, unforgiving of imperfect
  use (barrier methods)

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Categorization of pregnancy intention

• Using PRAMS question
• Intends to become pregnant
• Intends to become pregnant in future but not
  presently
• Never intends to become pregnant
• Dont know
• Incorporating other dimensions
• Happy
• Difficulty

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Monitoring pregnancy in cohort

• Availability of ICD 9 codes for pregnancy-related
  outcomes using SSNs and Defense Medical
  Surveillance Activity (DMSA)
• Preliminary analysis 20-25 pregnancy prevalence
• No difference in rates between intervention and
  non-intervention groups unless you take out those
  that intended to get pregnant

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Monitoring pregnancy in cohort

• Availability of ICD 9 codes for pregnancy-related
  outcomes
• Preliminary analysis intervention and
  non-intervention groups not statistically
  significant although 5 lower in intervention
  group

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Monitoring pregnancy in cohort

• Total cohort shows 79 of males and females
  desire pregnancy later or do not want at all.
• Males are less sure about their attitude toward
  pregnancy at twice the number than females

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Descriptive Data in cohort

• Among group of IET soldiers the ever having a
  reproductive associated medical events
• Elective/spontaneous abortion, STD (5 years), 3
  more sexual partner in 12 months, sexual
  intercourse with another soldier 12 months.

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Descriptive Data in cohort

• Among group of IET soldiers how easy is it to get
  over the counter birth control.

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Descriptive Data in cohort

• During your most recent sexual intercourse did
  you or your partner use any kind of birth
  control?

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Descriptive Data in cohort

• Main reasons for not using birth control by
  gender.
• I didnt think I was going to have sex
• I didnt care if I/my partner got pregnant
• Partner didnt want to use BC

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Future plans

• Attempt to obtain at least one follow-up survey
  on everyone
• Determine unintended pregnancy rates as possible
• Use ICD 9 codes to identify which factors are
  associated with pregnancy

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Future plans

• Complete the qualitative analysis to identify the
  impact of deployment on pregnancy intention
• Use Qualitative Analysis to develop valid and
  reliable tools to determine impact of deployment
  and assess militarily unique issues
• Continue to develop means to meaningfully measure
  pregnancy intent and identify means to insure
  those that do not intend to get pregnant do not

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