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
a
The Johns Hopkins University, Baltimore, MD, 21224, USA
b
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21224, USA
Received 17 August 2011; revised 7 November 2012; accepted 7 November 2012

Abstract

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 20042007 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

By age 45, more than half of women in the United States
(US) will have had at least one unintended pregnancy with
half of these ending in abortion [1,2]. Studies suggest that the
rates of unintended pregnancy among women with some
chronic conditions are similar to or may even exceed rates in
the general population [3,4]. Women with some medical
problems who carry their pregnancies to term are often more
vulnerable to pregnancy-related complications than their
healthier counterparts [5,6]. Compared to women with
Corresponding author. The Johns Hopkins University, OB/GYN,
4940 Eastern Ave., Baltimore, MD 202224. Tel.: +1-202-225-5992.
E-mail address: jamila_perritt@hotmail.com (J.B. Perritt).
0010-7824/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.contraception.2012.11.009
as unwanted or mistimed are more likely to engage in
unhealthy perinatal behaviors and to have poorer maternal
and birth outcomes [7,8]. This problem is compounded in
women with medical comorbidities, such as hypertension,
diabetes and cardiovascular disease, which may worsen
during pregnancy and further compromise maternal and
child health.
The ability to plan a pregnancy is a key factor in
improving all pregnancy outcomes, especially those for
women with medical disorders. The American College of
Obstetricians and Gynecologists (ACOG) and the US
Centers for Disease Control and Prevention (CDC) recom-
mend that women with medical comorbidities optimize their
health prior to conception [9,10]. Consistent use of effective
contraceptives is crucial to obtaining this goal. Many
264 J.B. Perritt et al. / Contraception 88 (2013) 263268
clinicians are hesitant to administer hormonal contraceptive
methods to women with cardiovascular disorders partially
due to product labeling that cautions against prescribing to
women with these comorbidities. More recently, ACOG and
the CDC have issued guidelines to assist clinicians in
selecting contraceptives for women with medical comorbid-
ities. However, women's options for contraception are often
limited by misperceptions of risk by both health care
providers and patients [11]. Providers' lack of knowledge
and discomfort counseling about contraceptive options may
place women at greater risk for unplanned, higher risk
pregnancies [12]. Women often inform us that their
clinicians dissuaded them from using hormonal contracep-
tive methods due to their medical problems. Other studies
have also found that women with some medical problems
receive less contraceptive counseling or inappropriate
counseling, placing them at increased risk for unintended
pregnancy [11,13]. They often rely on less effective barrier
methods or use no contraceptive method at all, thus
increasing their risk of unintended and undesired pregnancy.
Though most pregnant women have 10 or more clinician
visits in the antepartum period, most visits are brief, and
opportunities for counseling are often limited by time
constraints. For women with medical comorbidities, antena-
tal visits are often centered on acute medical management
(i.e., review of blood sugar logs, medication adjustment)
rather than preventive counseling. Our primary hypothesis is
that women with specific medical comorbidities (hyperten-
sion, diabetes and heart disease) are less likely to receive
contraceptive counseling during pregnancy than their
healthier counterparts. Our secondary hypothesis is that
women with the above-mentioned comorbidities are less
likely to use contraception during the postpartum period.
2. Methods
The Pregnancy Risk Assessment Monitoring System
(PRAMS) is a survey administered during the postpartum
period via the CDC in collaboration with state health
departments. The PRAMS surveys, currently administered in
37 states, include a core set of standardized questions, as well
as state-specific questions. The Maryland PRAMS question-
naire, for example, asks women about frequency of prenatal
visits, pregnancy intention, contraceptive use and counseling
received on a variety of issues during routine prenatal care.
Each month, a stratified, random sample of approximately
200 live births is selected from Maryland's birth certificate
files. Data are collected via a mailed survey sent approxi-
mately 3 months postpartum. Multiple follow-up attempts
are made. If mail is unsuccessful, the survey is conducted via
telephone. Surveys are administered in both English and
Spanish. Respondents are entered into a monthly gift card
raffle to encourage participation. Participant selection is
stratified by age and birth weight and is designed to
oversample mothers who have delivered an infant with a
low birth weight (b 2500 g) or who are 35 years of age
or older.
We conducted a retrospective analysis using the Mary-
land PRAMS data to examine self-reported contraceptive
counseling, contraceptive use and pregnancy intention in
women with hypertension, diabetes and heart disease,
compared to women without these disorders. We analyzed
a limited de-identified data set collected by the Maryland
PRAMS program between 2004 and 2007. Prior to this
timeframe, sufficient data were not available to test our
hypotheses. The limited data set included basic demographic
information, as well as the responses to PRAMS survey
questions that addressed our a priori hypotheses. This study
was approved by the institutional review boards of the Johns
Hopkins University School of Medicine and the Maryland
Department of Health and Mental Hygiene.
We defined our primary outcomes as self-reported
antenatal contraceptive counseling (yes/no), contraceptive
use prior to pregnancy and postpartum (yes/no) and
pregnancy intention (desired/undesired/mistimed) in
women with self-reported hypertension, diabetes or heart
disease, as compared to women without report of these
disorders. Of note, the Maryland PRAMS survey asks
about the existence of a number of health problems. We
chose hypertension, diabetes and heart disease for analysis
as we felt these comorbidities would be most likely to
influence contraception prescribing patterns, counseling
and use [14,15].
For our analysis of antenatal contraception counseling,
women who responded yes to the following question were
considered to have received counseling: During any of your
prenatal visits, did a doctor, nurse or other health care worker
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
postpartum with the following questions: When you got
pregnant with your new baby, were you or your husband or
partner doing anything to keep from getting pregnant? and
Are you or your husband or partner doing anything now to
keep from getting pregnant? In each of these questions,
respondents were asked to consider methods such as natural
family planning, withdrawal, the pill, condoms, vaginal ring,
intrauterine device, tubal ligation and vasectomy as ways
they might be trying to prevent pregnancy. However, the
PRAMS survey did not ask respondents to identify which
specific method they were using. For our analysis, a
pregnancy was classified as undesired if the respondent
answered that at the time you found out you were pregnant,
she did not want to be pregnant then or at any time in the
future. A pregnancy was considered mistimed if the
respondent answered the question that she wanted to be
pregnant later.
Multiple logistic regression analysis was used to estimate
the odds of receiving contraception counseling during
pregnancy as a function of the medical comorbidities listed
above. Similar analyses were performed to examine the
 J.B. Perritt et al. / Contraception 88 (2013) 263268 265

Table 1 adjusted for age, race and SES. Results were considered
Demographic characteristics of survey respondents: (PRAMS, n= 6361) and significant at a two-sided p value b .05. 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, pregnancy intention and contraceptive use
Age (years; mean 28.3.1)
postpartum with an 80% power at the 5% significance
b20 360 5.6 24,462 9.3
2029 1,765 27.7 125,665 48.3 level [17].
3039 3,576 56.2 100,683 38.7
4049 655 10.3 9,368 3.6
N49 5 b0.1% 68 b 0.1
3. Results
Race
White, non-Hispanic 3,634 57.2 148,852 57.2
Black, non-Hispanic 1,965 30.9 78,199 30.1 A total of 260,230 women (N) had a live birth in
Asian 439 6.9 15,119 5.8 Maryland during the study period. Data from the sample of
Other, non-White 319 5.0 18,060 6.9 6361 women (n) surveyed by PRAMS during this time
Education
(2.4% of birth population) are included in this analysis. The
Less than high school 649 10.2 36,823 14.2
Completed high school 1,542 24.3 74,426 28.6 response rate for the Maryland PRAMS survey was between
Some college 1,187 18.7 47,388 18.2 70% and 73% for each birth year between 2004 and 2007.
More than college 2,954 46.6 101,594 39.0 Table 1 shows selected demographic characteristics for
Prenatal care payment source the PRAMS respondents as well as statewide estimates based
Public assistance/Medicaid 1,334 21.4 71,459 27.5
on the survey sampling method. The majority of women
WIC b 1,921 30.7 99,720 38.3
Low SES c 2,222 35.0 113,018 43.4 were non-Hispanic Caucasian women (57.2%). More than
No health insurance 540 8.6 25,268 9.7 one fifth of respondents (21.5%) reported that their prenatal
a
Estimated statewide rates are based on the weighted surveyed responses.
care was funded by Medicaid, and 8.1% reported being
When applicable, percentages may not sum to 100 due to missing data. uninsured during their recent pregnancy. The weighted
b
WIC is a federally funded supplemental nutrition program for women, estimated rates of medical comorbidities for each disorder
infants and children. Participants must be low income as defined by federal within the total Maryland birth population are as follows:
poverty guidelines. preconception diabetes (1.3%), chronic hypertension (2.6%)
c
Low SES is defined as being uninsured, having had their prenatal care
paid for by public assistance or having received WIC benefits.
and cardiac disease (1.1%). A percentage of 4.4 had at least
one of these medical disorders prior to pregnancy. In
addition, gestational hypertension and gestational diabetes
relationship of selected medical comorbidities to contracep- were reported by 11.6% and 8.5%, respectively. As noted in
tive use prior to pregnancy and postpartum. Multinomial Table 1, pregestational and gestational diabetes and
logistic regression was used to estimate the relative risk hypertension were examined separately. All percentages
ratios (RRRs) of undesired pregnancy and mistimed are weighted to reflect the PRAMS sampling strategy.
pregnancy versus planned pregnancy, adjusting for the
medical comorbidities listed above. Demographic details Table 2
including age, 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, n=
contraception counseling, medical history and contraceptive 6124)
use and were therefore tested for inclusion in the multiple Variables PRAMS Statewide estimate no. Adjusted OR b
logistic regression models. Low SES (yes/no) was defined as data of respondents reporting (95% CI)
being uninsured, having had prenatal care paid for by public frequency counseling a (%)
assistance or having received benefits from the Women, Total 6124 193,359 (77)
Infants and Children (WIC) program, a federally funded Preconception medical problems
Hypertension 337 5020 (76.4) 1.0 (0.61.6)
supplemental nutrition program, which provides benefits to
Diabetes mellitus 126 2829 (83.6) 1.5 (0.73.2)
low-income women and children. Heart disease 91 2247 (87.7) 2.1 (0.94.8)
All statistical analyses were performed using the survey At least one of the 475 8545 (79.4) 1.2 (0.81.7)
commands in Stata-11 statistical software (College Station, above
TX, USA) to incorporate sample weights and reflect the Medical problems during pregnancy
Gestational 1109 17,180 (79.0) 1.1 (0.91.5)
strata in the PRAMS survey sampling method. Because
hypertension
responses are linked to birth certificate data, survey data may Gestational 687 22,653 (80.9) 1.3 (0.91.8)
be weighted for analysis to estimate response frequency diabetes
within the total state birth population [16]. 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.
b
confidence intervals (CIs). In all cases, ORs and RRRs were Adjusted for age, race and SES.
266 J.B. Perritt et al. / Contraception 88 (2013) 263268

Table 3 hypertension, 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)
76.4%, 83.6% and 87.7%, respectively. There were no
significant differences in self-reported counseling between
Variables PRAMS Statewide estimate no. 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.
Total 6209 104,554 (41.1)
Undesired 733 25,165 (9.9)
Preconception medical problems 3.2. Pregnancy intention
Hypertension 74 1,247 (19.1) 1.8 (1.03.2)
Diabetes 21 321 (9.8) 0.65 (0.31.3) 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) 1.6 (0.64.7) mistimed or undesired. Table 3 shows the RRRs for self-
At least one 94 1,675 (15.1) 1.4 (0.92.3) reporting a mistimed or undesired pregnancy according to the
of the above
presence of the preexisting medical comorbidities studied.
Mistimed 1405 79,389 (31.2)
Preconception medical problems Only the results for chronic hypertensive women reporting
Hypertension 63 1727 (26.5) 1.1 (.62.1) undesired pregnancies (vs. desired) achieved borderline
Diabetes 24 879 (26.8) .8 (.31.9) statistical significance. (RRR: 1.8, 95% CI: 1.03.2).
mellitus
Heart disease 29 1170 (40.8) 1.7 (.74.0) 3.3. Contraceptive use
At least one 101 3257 (29.4) 1.1 (.71.8)
of the above Overall, 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. As demonstrated in Table 4, women with a
conception. 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.
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: 0.5, 95%
surveyed population. CI: 0.30.8). There were no other statistically significant
d
Adjusted for age, race and SES. differences in odds of reported preconception contraceptive
use for women with the other comorbidities studied.
An estimated 90% of women at risk for pregnancy
3.1. Antenatal contraception counseling reported using contraception or sterilization roughly 3
months postpartum, representing a significant increase
Overall, 77% of women indicated that they had received from contraceptive use prior to conception (pb.001).
contraceptive counseling during their recent pregnancy. As Women who reported being currently pregnant, not sexually
shown in Table 2, 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. of Adjusted PRAMS data Statewide estimate no. of Adjusted
frequency contraception use a (%) OR b (CI) frequency contraception use a (%) OR b (CI)
Total 2816 c 57,885 (44.3) 5558 d 209,531 (90.1)
Preconception medical problems
Hypertension 187 1193 (27.8) 0.5 (0.30.8) 313 5205 (83.4) 0.6 (0.31.1)
Diabetes mellitus 68 455 (24.6) 0.4 (0.11.2) 109 2205 (77.0) 0.4 (0.10.9)
Heart disease 51 950 (63.5) 2.2 (0.95.7) 84 2344 (93.4) 1.5 (0.45.9)
At least one of the 263 2376 (35.7) 0.7 (0.41.1) 432 8551 (86.4) 0.7 (0.41.2)
above
Medical problems (during pregnancy)
Gestational 544 6933 (42.5) 0.9 (0.71.3) 1015 23,956 (88.9) 0.9 (0.61.3)
hypertension
Gestational 306 4066 (39.1) 0.8 (0.51.2) 603 16,849 (88.0) 0.8 (0.51.2)
diabetes
a
Values are weighted and reflect estimated statewide rates from the surveyed population.
b
Adjusted for age, race and SES.
c
Women trying to conceive were excluded.
d
Women who were pregnant, trying to conceive, abstinent or sterilized were excluded.
 J.B. Perritt et al. / Contraception 88 (2013) 263268
calculation as they were not presumed to be at risk for
unintended pregnancy. Table 4 shows that there was a
statistically significant difference in reported postpartum
contraception use in women with pregestational diabetes.
They were less likely to report using contraception
postpartum than those without diabetes (OR: 0.4, 95% CI:
0.10.9). No other results were statistically significant. In
analyzing the impact that contraceptive counseling may have
had on postpartum contraception use, women who reported
receiving contraceptive counseling were more likely to
report using contraception postpartum (OR: 1.6, 95% CI:
1.22.0) compared to those who did not. Finally, multivar-
iate logistic regression was performed to evaluate whether
the effect of counseling varied by the presence of one or
more medical conditions or other possible confounders such
as low SES; however, no statistically significant relation-
ships were identified.
4. Discussion
In our analysis of data from the Maryland PRAMS
survey, only 77% of women reported receiving antepartum
contraception counseling despite recommendations that
contraception counseling be a routine part of prenatal care.
Other studies show that reported rates of antepartum
counseling vary widely, from 4% [18] to 77% [19].
Women with medical comorbidities are at higher risk for
pregnancy-related maternal and neonatal complications and
have higher rates of unintended pregnancy than those
without [7,9,11]. While we were relieved to find that the
presence of medical comorbidities did not decrease reported
rates of contraceptive counseling, it is concerning that
reported counseling was not increased in this high-risk
group. Even if women were counseled regarding their
contraceptive options, almost one fourth of all women did
not recall and report it. This may suggest that we, as health
care providers, need to find more effective ways to
emphasize the prevention of future unplanned pregnancy,
especially in women with chronic medical conditions. It is
also possible that some were in fact not counseled at all due
to the time constraints of prenatal visits. Our findings may
also indicate women's lack of understanding of their
contraceptive options or the health risks of pregnancy or
failure to act despite this knowledge. Further exploration of
women's motivation to avoid unplanned pregnancy and
fertility intention is needed.
Socioeconomic factors such as insurance status and
access to contraceptives likely also interact with the effect
of contraceptive counseling on patient behavior and
compliance; however, we found that there was no statisti-
cally significant effect of SES on reported contraception use
in the women sampled. In Maryland, Medicaid and most
private insurers cover all contraceptives. Less than 10% of
our sample reported being uninsured, and many of these
women may have been eligible for the state Family Planning
267
Program that covers contraceptives for low-income women.
Almost 4% of respondents cited could not pay for birth
control as a reason for not using contraception. SES may
have a greater impact on contraceptive use in other states
with limited contraceptive coverage.
In this analysis, the categories of undesired (defined as
pregnancy being unwanted now or anytime in the future) and
mistimed (defined as wanting a pregnancy later) were
constructed as proxies for pregnancy intention. While most
studies evaluating unintended pregnancies have grouped
pregnancies that are undesired with those that are desired but
mistimed, there is substantial debate regarding the differing
impact of mistimed versus unwanted pregnancies on
maternal and fetal outcomes. There is growing evidence to
suggest that the use of one category for all unplanned
pregnancies, whether undesired or just mistimed, may mask
important differences in these groups of women. D'Angelo
et al. evaluated PRAMS data from 15 states and found that
women who reported their pregnancy as unwanted as
opposed to mistimed were more likely to engage in
behavioral risk factors that could negatively affect their
pregnancy [20]. We chose a more conservative approach and
opted to evaluate pregnancy intention using three categories.
Unlike Chor et al. [21] who also examined the
relationship between chronic medical illness, unintended
pregnancy and postpartum contraceptive use, we performed
analyses specific to women with diabetes, hypertension and
heart disease, as these conditions may have an effect on
contraceptive counseling and prescribing patterns. While the
inclusion of women with other chronic diseases such as
asthma or anemia denoted in the PRAMS data set would
have increased our sample size and statistical power, we
hypothesized that these chronic diseases would have a lesser
impact on contraceptive counseling and use than those with
direct cardiovascular or end-organ risks.
We acknowledge several limitations of this study. This is
an evaluation of data from a previously administered survey
and, as it was designed, has no true control population. The
control population used in this analysis includes the study
population. The comparison group is limited to those with
live births in Maryland who responded. Results may be
different for those women who experienced fetal loss,
terminated their pregnancies or had a live birth but did not
answer the survey. The retrospective nature of this study
makes it difficult to draw conclusions regarding causality.
Survey responses are dependent on self-report, which is
subject to recall bias. We attempted to adjust for potential
confounding variables in our analysis (i.e., sociodemo-
graphic factors); however, other factors may have biased
results. For example, our analysis could not control for
parity, as this was not asked in the PRAMS survey. Finally,
though the PRAMS sample achieved 80% power overall to
detect an OR of 2.0 for contraceptive counseling and an OR
of 0.5 for pregnancy intention and contraceptive use in
women with at least one of the medical disorders of interest,
our analysis is limited by the relatively small number of
268 J.B. Perritt et al. / Contraception 88 (2013) 263268
respondents afflicted by the medical comorbidities studied.
To show statistical significance for the smaller differences
that were detected in our study, a larger sample (e.g.,
multistate PRAMS data) may be needed.
The results of our analyses have important clinical and
public health implications. Findings demonstrate the need to
improve ante- and postpartum contraceptive counseling in
women at risk for unplanned pregnancy, especially those
with medical comorbidities. Though contraceptive counsel-
ing is often deferred to the reproductive health clinician,
practitioners in the fields of general medicine, family
practice and medical specialties who commonly see
reproductive-aged women should emphasize the importance
of preventing unintended pregnancy, especially for women
with medical disorders. Given the significantly increased
morbidity associated with pregnancy in women with
cardiovascular disorders, there is urgent need for medical
providers who care for them to become more informed
regarding contraceptive options and address this issue during
routine care. Long-acting reversible contraceptives and
sterilization (when childbearing is complete) may be
especially appropriate for such women. Though guidelines
from ACOG [21] and the CDC [22] exist to assist with
contraceptive selection in women with medical problems,
many clinicians may be unaware of them [13,23]. Focus on
publicizing and implementing these guidelines and research
aimed at improving effectiveness of contraceptive counsel-
ing is needed to help decrease unintended pregnancies.
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