comprehensive women s healthcare includes basic reproductive health services , such as hormonal contraception , and specialized services , such as infertility evaluation / treatment and prenatal and obstetric care.1,2 as the number of women veterans enrolling in the veterans health administration ( va ) has increased , so has the demand for basic and specialized reproductive health services.36 while all va sites are required to provide basic women s health services on - site , specialized services may be delivered through referral to another va site or through non - va purchased ( fee basis ) or contract care from community ( non - va ) providers .
specific specialized services , such as prenatal care , are almost exclusively provided through these mechanisms.2,79 on - site availability of reproductive services may be influenced by the practice context , including the site environment and organizational features such as practice structure , size , and resources.2,8,10 previous reports indicate that while the majority of sites serving a large number of women veterans are hospital - based and located in large urban areas,11 approximately 14  % of va sites serving at least 400 women are located in non - metropolitan areas.12 non - metropolitan areas have a documented shortage of reproductive service providers,13 and women veterans may face significant barriers to obtaining reproductive health services in these communities . va community - based outpatient clinics ( cbocs ) provide basic primary care for veterans.14 compared with hospital based clinics , cbocs frequently serve fewer women veterans and are often located in non - metropolitan areas.14,15 site location and type may jointly influence on - site availability of reproductive health services for women veterans,16 and lack of on - site availability of reproductive health care services may delay care for women veterans .
currently , little is known regarding the on - site availability of reproductive health services for women veterans , particularly those served by cbocs or sites in non - metropolitan areas .
therefore , the objectives of this study were to : 1 ) describe the overall on - site availability of hormonal contraceptives , intrauterine device ( iud ) placement , infertility evaluation / treatment , and prenatal care , by site location and type ; 2 ) describe the characteristics of sites providing these reproductive health services ; and 3 ) to examine , within this context , whether site location and type is associated with on - site availability of specialized reproductive services .
we used cross - sectional survey data from the 2007 veterans health administration survey of women veterans health programs and practices ( wvhp ) merged with the area resource file and va administrative records .
the protocol received institutional review board ( irb ) approval from va greater los angeles and an exemption from irb review by va puget sound health care system .
the wvhp survey queried informants at the health care system ( chief of staff , n  =  123 ) , and practice ( senior clinician , n  =  195 ) levels at sites serving at least 300 unique women veterans .
chiefs of staff identified senior women s health clinicians most responsible for or knowledgeable regarding the women s health care delivery .
response rates for chiefs of staff and senior clinicians were 93  % and 86  % respectively .
this analysis included data from 193 sites and utilized the senior clinician portion of the survey , with the exception of the variable regarding a separate budget for the women s health program at a site , which used the chief of staff module when the senior clinician response was missing .
primary outcomes were on - site availability of 1 ) hormonal contraception , 2 ) iud placement , 3 ) infertility evaluation / treatment , and 4 ) prenatal care .
senior clinicians were asked to specify whether a given service was  available at this va site ,   only available at another va site ,   available through contract or fee - basis on - site ,   available through contract or fee - basis off - site ,   not available ,  or available through some  other arrangement . 
a service was considered to be available on - site if a response was either 
 the primary exposure combined site location and type ( metropolitan hospital - based clinic , non - metropolitan hospital - based clinic , metropolitan cboc ) .
location was defined as metropolitan or non - metropolitan using data from the area resource file.17 non - metropolitan cbocs ( n  =  2 ) were excluded from the analysis .
independent variables included elements of practice context and organization.8,10 variables related to practice context were the geographic region ( northeast , midwest , south , and west ) in which each va site was located , as designated by the us census bureau , and va regional networks known as veterans integrated service networks ( visn ) ( n  =  21 ) . variables related to organization of the practice included : practice size , structure for providing care to women veterans , and resource availability .
practice size was defined as the number of unique women veterans with at least one visit to the site in the year preceding the survey ( 2006 ) ( < median ,  median ) .
the structure for providing care to women veterans was characterized by the presence of specialized models for gender - specific care .
specialized models for gender - specific care were not mutually exclusive and included presence of a separate women s clinic for primary care ( yes , no ) or gynecology clinic ( yes , no ) .
resource availability included informant ratings of the sufficiency of resources and personnel ; availability of formal training in women s health ; availability of a separate budget for women s health ; and change in resource availability over the preceding two years .
informants rated the sufficiency of resources for the following items : overall clinical expertise in women s health , availability of same gender - providers , nursing staff , administrative and support staff , clinic space , examination rooms properly equipped for pelvic examinations and pap smears , female attendants to chaperone gender - sensitive examinations , and budget or funding for the women s health program .
responses were dichotomized as  always or usually sufficient  and  sometimes , rarely , or never sufficient  .
informants reported if formal training in women s health was available at their site ( yes , no ) . combining the practice and chief of staff level responses
, we determined whether there was a separate budget for the women s health program at each site .
finally , informants reported whether resources for women veterans care had increased , decreased , or remained unchanged in the past 2  years .
we compared characteristics of sites with and without onsite availability of hormonal contraception , iud placement , infertility evaluation / treatment , or prenatal care .
continuous variables were compared via students t - test ; categorical variables were compared via the  test or if cell sizes were < 5 using the fischer exact test .
random effects models were used to examine association of site type and location with on - site availability of iud placement and infertility evaluation / treatment.18 two levels of independent variables were considered : visn was considered a level two variable since multiple sites are nested within a single visn , while all other variables were considered level one variables .
adjustments for variables regarding structure for providing care to women veterans and resource availability were not made , as these characteristics were potentially consequences of site type and location.19 due to the extremely small number of facilities offering prenatal care ( n  =  11 ) , we did not include availability of prenatal care as a separate outcome .
we used cross - sectional survey data from the 2007 veterans health administration survey of women veterans health programs and practices ( wvhp ) merged with the area resource file and va administrative records .
the protocol received institutional review board ( irb ) approval from va greater los angeles and an exemption from irb review by va puget sound health care system .
the wvhp survey queried informants at the health care system ( chief of staff , n  =  123 ) , and practice ( senior clinician , n  =  195 ) levels at sites serving at least 300 unique women veterans .
chiefs of staff identified senior women s health clinicians most responsible for or knowledgeable regarding the women s health care delivery .
response rates for chiefs of staff and senior clinicians were 93  % and 86  % respectively .
this analysis included data from 193 sites and utilized the senior clinician portion of the survey , with the exception of the variable regarding a separate budget for the women s health program at a site , which used the chief of staff module when the senior clinician response was missing .
primary outcomes were on - site availability of 1 ) hormonal contraception , 2 ) iud placement , 3 ) infertility evaluation / treatment , and 4 ) prenatal care .
senior clinicians were asked to specify whether a given service was  available at this va site ,   only available at another va site ,   available through contract or fee - basis on - site ,   available through contract or fee - basis off - site ,   not available ,  or available through some  other arrangement . 
a service was considered to be available on - site if a response was either 
 the primary exposure combined site location and type ( metropolitan hospital - based clinic , non - metropolitan hospital - based clinic , metropolitan cboc ) .
location was defined as metropolitan or non - metropolitan using data from the area resource file.17 non - metropolitan cbocs ( n  =  2 ) were excluded from the analysis .
independent variables included elements of practice context and organization.8,10 variables related to practice context were the geographic region ( northeast , midwest , south , and west ) in which each va site was located , as designated by the us census bureau , and va regional networks known as veterans integrated service networks ( visn ) ( n  =  21 ) . variables related to organization of the practice included : practice size , structure for providing care to women veterans , and resource availability .
practice size was defined as the number of unique women veterans with at least one visit to the site in the year preceding the survey ( 2006 ) ( < median ,  median ) .
the structure for providing care to women veterans was characterized by the presence of specialized models for gender - specific care .
specialized models for gender - specific care were not mutually exclusive and included presence of a separate women s clinic for primary care ( yes , no ) or gynecology clinic ( yes , no ) .
resource availability included informant ratings of the sufficiency of resources and personnel ; availability of formal training in women s health ; availability of a separate budget for women s health ; and change in resource availability over the preceding two years .
informants rated the sufficiency of resources for the following items : overall clinical expertise in women s health , availability of same gender - providers , nursing staff , administrative and support staff , clinic space , examination rooms properly equipped for pelvic examinations and pap smears , female attendants to chaperone gender - sensitive examinations , and budget or funding for the women s health program .
responses were dichotomized as  always or usually sufficient  and  sometimes , rarely , or never sufficient  .
informants reported if formal training in women s health was available at their site ( yes , no ) . combining the practice and chief of staff level responses
, we determined whether there was a separate budget for the women s health program at each site .
finally , informants reported whether resources for women veterans care had increased , decreased , or remained unchanged in the past 2  years .
we compared characteristics of sites with and without onsite availability of hormonal contraception , iud placement , infertility evaluation / treatment , or prenatal care .
continuous variables were compared via students t - test ; categorical variables were compared via the  test or if cell sizes were < 5 using the fischer exact test .
random effects models were used to examine association of site type and location with on - site availability of iud placement and infertility evaluation / treatment.18 two levels of independent variables were considered : visn was considered a level two variable since multiple sites are nested within a single visn , while all other variables were considered level one variables .
adjustments for variables regarding structure for providing care to women veterans and resource availability were not made , as these characteristics were potentially consequences of site type and location.19 due to the extremely small number of facilities offering prenatal care ( n  =  11 ) , we did not include availability of prenatal care as a separate outcome .
table  1 shows the characteristics of the surveyed sites , including practice context and organization . of the 193 sites included in the analysis , 106 ( 55  % ) were metropolitan hospital - based clinics , 23 were non - metropolitan hospital - based clinics ( 12  % ) , and 64 were metropolitan cbocs ( 33  % ) .
the median practice size at geographically distinct sites was 1,209 ( interquartile range : 6052,212 ) . compared with metropolitan hospital - based clinics , non - metropolitan hospital - based clinics and metropolitan cbocs served fewer women veterans , were less likely to have a separate primary care women s health or gynecology clinic , and were less likely to have a separate budget for the women s health program.table 1characteristics of va sites serving 300 unique women veterans in 2006 by site location and type ( n  =  193)totalmetropolitan hospitalnon - metropolitan hospitalmetropolitan cbocn1931062364practice contextregion n ( % ) northeast30 ( 16)23 ( 22)2 ( 9)5 ( 8)midwest44 ( 23)25 ( 24)8 ( 35)11 ( 17)south73 ( 38)38 ( 36)7 ( 30)28 ( 43)west46 ( 24)20 ( 19)6 ( 26)20 ( 31)organization of the practice 1,209 women veterans in 200697 ( 51)77 ( 73)7 ( 30)13 ( 21)women s health clinic for primary care n ( % ) 130 ( 67)84 ( 79)16 ( 70)30 ( 47)gynecology clinic n ( % ) 85 ( 44)59 ( 56)8 ( 35)18 ( 28)women s health resources : always or usually sufficient n ( % ) clinical expertise160 ( 84)88 ( 85)20 ( 87)52 ( 83)same gender providers154 ( 82)90 ( 86)17 ( 77)47 ( 76)nursing staff142 ( 74)78 ( 74)17 ( 74)47 ( 75)administrative and support staff108 ( 57)60 ( 57)10 ( 44)38 ( 60)clinic space125 ( 66)68 ( 65)18 ( 78)39 ( 63)properly equipped examination rooms183 ( 96)101 ( 97)22 ( 96)60 ( 95)female attendants163 ( 86)91 ( 88)22 ( 96)50 ( 79)budget or funding73 ( 46)42 ( 47)8 ( 42)23 ( 46)formal women s health training n ( % ) 16 ( 8)12 ( 12)04 ( 6)separate budget or control point n ( % ) 32 ( 17)25 ( 24)3 ( 13)4 ( 7)change in women s health resources over the last 2  years n ( % ) increased62 ( 33)10 ( 39)7 ( 31)15 ( 24)unchanged102 ( 54)47 ( 45)12 ( 52)43 ( 68)decreased26 ( 13)17 ( 16)4 ( 17)5 ( 8)missing data :  1,209 women veterans in 2006 , one missing ; clinical expertise , three missing ; same gender providers , four missing ; nursing staff , two missing ; administrative and support staff , two missing ; clinic space , four missing ; properly equipped examination rooms , three missing ; female attendants , three missing ; budget or funding , 35 missing ; formal women s health training , two missing ; separate budget or control point , five missing ; change in resources over the last 2  years , three missing characteristics of va sites serving 300 unique women veterans in 2006 by site location and type (
n  =  193 ) missing data :  1,209 women veterans in 2006 , one missing ; clinical expertise , three missing ; same gender providers , four missing ; nursing staff , two missing ; administrative and support staff , two missing ; clinic space , four missing ; properly equipped examination rooms , three missing ; female attendants , three missing ; budget or funding , 35 missing ; formal women s health training , two missing ; separate budget or control point , five missing ; change in resources over the last 2  years , three missing table  2 indicates the on - site availability of the four reproductive health services .
overall , 94  % of sites offered on - site hormonal contraception , 50  % offered on - site iud placement , 30  % offered on - site infertility evaluation / treatment , and 6  % offered on - site prenatal care .
of the 11 sites not offering hormonal contraception on - site , five provided this service at another va site and six offered it through fee - basis or contract providers ( data not shown ) . compared with metropolitan hospitals , a smaller percentage of non - metropolitan hospital - based clinics and metropolitan cbocs offered on - site iud placement .
metropolitan cbocs were the least likely to offer infertility evaluation / treatment , but non - metropolitan hospital - based clinics were the most likely to offer on - site infertility evaluation only.table 2on - site availability of individual reproductive health care services and combinations of services by site location and typetotalmetropolitan hospitalnon - metropolitan hospitalmetropolitan cbocn1931062364individual services n ( % ) hormonal contraception182 ( 94)102 ( 96)22 ( 96)58 ( 91)iud placement97 ( 50)70 ( 66)9 ( 39)18 ( 28)infertility evaluation or treatment57 ( 30)39 ( 37)8 ( 35)10 ( 16)infertility evaluation only29 ( 15)19 ( 18)5 ( 22)5 ( 8)infertility treatment only6 ( 3)6 ( 6)00infertility evaluation or treatment22 ( 11)14 ( 13)3 ( 13)5 ( 8)prenatal care11 ( 6)7 ( 7)04 ( 6)number of services out of four n ( % ) none10 ( 5)3 ( 3)1 ( 4)6 ( 9)one74 ( 38)29 ( 27)11 ( 48)34 ( 53)two56 ( 29)35 ( 33)5 ( 22)16 ( 25)three51 ( 26)37 ( 35)6 ( 26)8 ( 13)four2 ( 1)2 ( 2)00combinations of servicesone service ( n  =  74)hormonal contraception73 ( 99)28 ( 97)11 ( 100)34 ( 100)iud placement1 ( 1)1 ( 3)00infertility evaluation or treatment0000prenatal care0000two services ( n  =  56)hormonal contraception and iud placement47 ( 84)31 ( 89)3 ( 60)13 ( 81)hormonal contraception and prenatal care1 ( 2)1 ( 3)00hormonal contraception and infertility evaluation or treatment8 ( 14)3 ( 8)2 ( 40)3 ( 19)iud placement and prenatal care0000iud placement and infertility evaluation or treatment0000prenatal care and infertility evaluation or treatment0000three services ( n  =  51)hormonal contraception , iud placement , and infertility evaluation or treatment43 ( 84)29 ( 88)5 ( 100)4 ( 50)hormonal contraception , iud placement , and prenatal care4 ( 8)3 ( 8)01 ( 12)hormonal contraception , prenatal care , and infertility evaluation or treatment4 ( 8)1 ( 3)03 ( 38)iud placement , infertility evaluation or treatment , and prenatal care0000 on - site availability of individual reproductive health care services and combinations of services by site location and type compared with sites not offering hormonal contraception , those offering this service were more likely to have a separate women s health clinic for primary care , and to report sufficient clinical expertise , availability of same gender providers , and properly equipped exam rooms ( table  3 ) . compared with sites not offering on - site iud placement , those offering this service were more likely to serve more women veterans , have a separate women s health clinic for primary care or gynecology clinic , report sufficient women s health clinical expertise , and have a separate women s health program budget ( table  3 ) . compared with sites not offering on - site infertility evaluation / treatment , those offering these services served more women veterans , were more likely to include a separate gynecology clinic , report sufficient women s health clinical expertise , and to have increased funding for women s health in the prior 2  years ( table  4 ) . compared with sites not offering prenatal care , those offering this service were more likely to have a formal women s health training program ( table  4).table 3characteristics of sites by on - site availability of hormonal contraception and iud placement , ( n  =  193)hormonal contraceptioniud placementavailability : noyespnoyespn111829697practice contextregion n ( % ) northeast1 ( 9)29 ( 16)0.3116 ( 17)14 ( 14)0.65midwest1 ( 9)43 ( 24)25 ( 26)19 ( 20)south4 ( 36)69 ( 38)34 ( 35)39 ( 40)west5 ( 46)41 ( 23)21 ( 22)25 ( 26)organization of the practice 1,209 women veterans in 20065 ( 46)92 ( 51)0.7329 ( 30)68 ( 71 ) < 0.001women s health clinic for primary care n ( % ) 2 ( 18)128 ( 70)0.00152 ( 54)78 ( 80 ) < 0.001gynecology clinic n ( % ) 2 ( 18)83 ( 46)0.1219 ( 20)66 ( 68 ) < 0.001resources : always or usually sufficient n ( % ) clinical expertise6 ( 55)154 ( 86)0.0177 ( 81)83 ( 87)0.02same gender providers6 ( 55)145 ( 83)0.0276 ( 80)78 ( 83)0.60nursing staff6 ( 55)136 ( 76)0.1268 ( 72)74 ( 77)0.38administrative and support staff5 ( 46)103 ( 57)0.4556 ( 59)52 ( 54)0.51clinic space7 ( 64)118 ( 66)1.0066 ( 70)59 ( 62)0.24properly equipped examination rooms7 ( 78)176 ( 97)0.0489 ( 95)94 ( 97)0.72female attendants7 ( 70)156 ( 87)0.1677 ( 83)86 ( 87)0.25budget or funding3 ( 38)70 ( 47)0.7336 ( 49)37 ( 44)0.56formal women s health training n ( % ) 1 ( 9)15 ( 8)1.004 ( 4)12 ( 13)0.07separate budget or control point n ( % ) 1 ( 9)31 ( 18)0.6910 ( 11)22 ( 23)0.03change in resources over the last 2  years n ( % ) increased1 ( 9)61 ( 34)0.2026 ( 27)36 ( 38)0.35decreased2 ( 18)21 ( 13)14 ( 15)12 ( 13)unchanged8 ( 73)94 ( 53)54 ( 58)48 ( 50)table 4characteristics of sites by on - site availability of infertility evaluation / treatment and prenatal care , ( n  =  193)infertility evaluation / treatmentprenatal careavailability : noyespnoyespn1365718211practice contextregion n ( % ) northeast22 ( 16)8 ( 14)0.9326 ( 14)4 ( 36)n / amidwest32 ( 24)12 ( 21)44 ( 24)0south51 ( 38)22 ( 39)73 ( 40)0west31 ( 23)15 ( 26)39 ( 21)7 ( 64)organization of the practice1,209 women veterans in 200658 ( 43)39 ( 68)0.00188 ( 49)9 ( 82)0.06women s health clinic for primary care n ( % ) 86 ( 63)44 ( 77)0.06123 ( 68)7 ( 64)0.75gynecology clinic n ( % ) 51 ( 38)34 ( 60)0.0180 ( 44)5 ( 46)0.92resources : always or usually sufficient n ( % ) clinical expertise106 ( 80)54 ( 95)0.01151 ( 84)9 ( 82)0.69same gender providers104 ( 78)50 ( 89)0.08146 ( 82)8 ( 73)0.43nursing staff99 ( 74)43 ( 75)0.82137 ( 76)5 ( 46)0.03administrative and support staff83 ( 62)25 ( 44)0.02101 ( 56)7 ( 64)0.76clinic space86 ( 65)39 ( 68)0.66117 ( 66)8 ( 73)0.75properly equipped examination rooms130 ( 98)53 ( 93)0.20173 ( 97)10 ( 91)0.35female attendants116 ( 87)47 ( 83)0.39158 ( 88)5 ( 46)0.001budget or funding49 ( 45)24 ( 48)0.7669 ( 47)4 ( 36)0.55formal women s health training n ( % ) 12 ( 9)4 ( 7)0.7813 ( 7)3 ( 30)0.04separate budget or control point
n ( % ) 18 ( 14)14 ( 25)0.0732 ( 18)0n / achange in resources over the last 2  years n ( % ) 38 ( 28)24 ( 44)0.01increased15 ( 11)11 ( 20)59 ( 33)3 ( 30)n / adecreased82 ( 61)20 ( 36)26 ( 14)0unchanged38 ( 28)24 ( 44)0.0195 ( 52)7 ( 70)n / a not applicable due to cell size of zero characteristics of sites by on - site availability of hormonal contraception and iud placement , ( n  =  193 ) characteristics of sites by on - site availability of infertility evaluation / treatment and prenatal care , ( n  =  193 ) n / a not applicable due to cell size of zero after adjusting for visn and practice size , compared with metropolitan hospital - based clinics , non - metropolitan hospital - based clinics had lower odds of offering on - site iud placement ( or 0.57 ; 95  % ci 0.20 , 1.62 ) , but higher odds of offering on - site infertility evaluation / treatment ( or 1.42 ; 95  % ci 0.48 , 4.22 ) , although these associations did not reach statistical significance . after adjustment , compared with metropolitan hospital - based clinics , metropolitan cbocs had 67  % lower odds of offering on - site iud placement ( or 0.33 ; 95  % ci 0.14 , 0.74 ) .
similar , although not statistically significant , associations were observed comparing metropolitan cbocs with metropolitan hospital - based clinics with respect to on - site infertility evaluation / treatment ( or 0.43 ; 95  % ci 0.17 , 1.11 ) .
table  1 shows the characteristics of the surveyed sites , including practice context and organization . of the 193 sites included in the analysis , 106 ( 55  % ) were metropolitan hospital - based clinics , 23 were non - metropolitan hospital - based clinics ( 12  % ) , and 64 were metropolitan cbocs ( 33  % ) .
the median practice size at geographically distinct sites was 1,209 ( interquartile range : 6052,212 ) . compared with metropolitan hospital - based clinics , non - metropolitan hospital - based clinics and metropolitan cbocs served fewer women veterans , were less likely to have a separate primary care women s health or gynecology clinic , and were less likely to have a separate budget for the women s health program.table 1characteristics of va sites serving 300 unique women veterans in 2006 by site location and type ( n  =  193)totalmetropolitan hospitalnon - metropolitan hospitalmetropolitan cbocn1931062364practice contextregion n ( % ) northeast30 ( 16)23 ( 22)2 ( 9)5 ( 8)midwest44 ( 23)25 ( 24)8 ( 35)11 ( 17)south73 ( 38)38 ( 36)7 ( 30)28 ( 43)west46 ( 24)20 ( 19)6 ( 26)20 ( 31)organization of the practice 1,209 women veterans in 200697 ( 51)77 ( 73)7 ( 30)13 ( 21)women s health clinic for primary care n ( % ) 130 ( 67)84 ( 79)16 ( 70)30 ( 47)gynecology clinic n ( % ) 85 ( 44)59 ( 56)8 ( 35)18 ( 28)women s health resources : always or usually sufficient n ( % ) clinical expertise160 ( 84)88 ( 85)20 ( 87)52 ( 83)same gender providers154 ( 82)90 ( 86)17 ( 77)47 ( 76)nursing staff142 ( 74)78 ( 74)17 ( 74)47 ( 75)administrative and support staff108 ( 57)60 ( 57)10 ( 44)38 ( 60)clinic space125 ( 66)68 ( 65)18 ( 78)39 ( 63)properly equipped examination rooms183 ( 96)101 ( 97)22 ( 96)60 ( 95)female attendants163 ( 86)91 ( 88)22 ( 96)50 ( 79)budget or funding73 ( 46)42 ( 47)8 ( 42)23 ( 46)formal women s health training n ( % ) 16 ( 8)12 ( 12)04 ( 6)separate budget or control point n ( % ) 32 ( 17)25 ( 24)3 ( 13)4 ( 7)change in women s health resources over the last 2  years n ( % ) increased62 ( 33)10 ( 39)7 ( 31)15 ( 24)unchanged102 ( 54)47 ( 45)12 ( 52)43 ( 68)decreased26 ( 13)17 ( 16)4 ( 17)5 ( 8)missing data :  1,209 women veterans in 2006 , one missing ; clinical expertise , three missing ; same gender providers , four missing ; nursing staff , two missing ; administrative and support staff , two missing ; clinic space , four missing ; properly equipped examination rooms , three missing ; female attendants , three missing ; budget or funding , 35 missing ; formal women s health training , two missing ; separate budget or control point , five missing ; change in resources over the last 2  years , three missing characteristics of va sites serving 300 unique women veterans in 2006 by site location and type ( n  =  193 ) missing data :  1,209 women veterans in 2006 , one missing ; clinical expertise , three missing ; same gender providers , four missing ; nursing staff , two missing ; administrative and support staff , two missing ; clinic space , four missing ; properly equipped examination rooms , three missing ; female attendants , three missing ; budget or funding , 35 missing ; formal women s health training , two missing ; separate budget or control point , five missing ; change in resources over the last 2  years , three missing
table  2 indicates the on - site availability of the four reproductive health services .
overall , 94  % of sites offered on - site hormonal contraception , 50  % offered on - site iud placement , 30  % offered on - site infertility evaluation / treatment , and 6  % offered on - site prenatal care .
of the 11 sites not offering hormonal contraception on - site , five provided this service at another va site and six offered it through fee - basis or contract providers ( data not shown ) . compared with metropolitan hospitals , a smaller percentage of non - metropolitan hospital - based clinics and metropolitan cbocs offered on - site iud placement .
metropolitan cbocs were the least likely to offer infertility evaluation / treatment , but non - metropolitan hospital - based clinics were the most likely to offer on - site infertility evaluation only.table 2on - site availability of individual reproductive health care services and combinations of services by site location and typetotalmetropolitan hospitalnon - metropolitan hospitalmetropolitan cbocn1931062364individual services n ( % ) hormonal contraception182 ( 94)102 ( 96)22 ( 96)58 ( 91)iud placement97 ( 50)70 ( 66)9 ( 39)18 ( 28)infertility evaluation or treatment57 ( 30)39 ( 37)8 ( 35)10 ( 16)infertility evaluation only29 ( 15)19 ( 18)5 ( 22)5 ( 8)infertility treatment only6 ( 3)6 ( 6)00infertility evaluation or treatment22 ( 11)14 ( 13)3 ( 13)5 ( 8)prenatal care11 ( 6)7 ( 7)04 ( 6)number of services out of four n ( % ) none10 ( 5)3 ( 3)1 ( 4)6 ( 9)one74 ( 38)29 ( 27)11 ( 48)34 ( 53)two56 ( 29)35 ( 33)5 ( 22)16 ( 25)three51 ( 26)37 ( 35)6 ( 26)8 ( 13)four2 ( 1)2 ( 2)00combinations of servicesone service ( n  =  74)hormonal contraception73 ( 99)28 ( 97)11 ( 100)34 ( 100)iud placement1 ( 1)1 ( 3)00infertility evaluation or treatment0000prenatal care0000two services ( n  =  56)hormonal contraception and iud placement47 ( 84)31 ( 89)3 ( 60)13 ( 81)hormonal contraception and prenatal care1 ( 2)1 ( 3)00hormonal contraception and infertility evaluation or treatment8 ( 14)3 ( 8)2 ( 40)3 ( 19)iud placement and prenatal care0000iud placement and infertility evaluation or treatment0000prenatal care and infertility evaluation or treatment0000three services ( n  =  51)hormonal contraception , iud placement , and infertility evaluation or treatment43 ( 84)29 ( 88)5 ( 100)4 ( 50)hormonal contraception , iud placement , and prenatal care4 ( 8)3 ( 8)01 ( 12)hormonal contraception , prenatal care , and infertility evaluation or treatment4 ( 8)1 ( 3)03 ( 38)iud placement , infertility evaluation or treatment , and prenatal care0000 on - site availability of individual reproductive health care services and combinations of services by site location and type compared with sites not offering hormonal contraception , those offering this service were more likely to have a separate women s health clinic for primary care , and to report sufficient clinical expertise , availability of same gender providers , and properly equipped exam rooms ( table  3 ) . compared with sites not offering on - site iud placement , those offering this service were more likely to serve more women veterans , have a separate women s health clinic for primary care or gynecology clinic , report sufficient women s health clinical expertise , and have a separate women s health program budget ( table  3 ) . compared with sites not offering on - site infertility evaluation / treatment , those offering these services served more women veterans , were more likely to include a separate gynecology clinic , report sufficient women s health clinical expertise , and to have increased funding for women s health in the prior 2  years ( table  4 ) . compared with sites not offering prenatal care , those offering this service were more likely to have a formal women s health training program ( table  4).table 3characteristics of sites by on - site availability of hormonal contraception and iud placement , ( n  =  193)hormonal contraceptioniud placementavailability : noyespnoyespn111829697practice contextregion n ( % ) northeast1 ( 9)29 ( 16)0.3116 ( 17)14 ( 14)0.65midwest1 ( 9)43 ( 24)25 ( 26)19 ( 20)south4 ( 36)69 ( 38)34 ( 35)39 ( 40)west5 ( 46)41 ( 23)21 ( 22)25 ( 26)organization of the practice 1,209 women veterans in 20065 ( 46)92 ( 51)0.7329 ( 30)68 ( 71 ) < 0.001women s health clinic for primary care n ( % ) 2 ( 18)128 ( 70)0.00152 ( 54)78 ( 80 ) < 0.001gynecology clinic n ( % ) 2 ( 18)83 ( 46)0.1219 ( 20)66 ( 68 ) < 0.001resources : always or usually sufficient n ( % ) clinical expertise6 ( 55)154 ( 86)0.0177 ( 81)83 ( 87)0.02same gender providers6 ( 55)145 ( 83)0.0276 ( 80)78 ( 83)0.60nursing staff6 ( 55)136 ( 76)0.1268 ( 72)74 ( 77)0.38administrative and support staff5 ( 46)103 ( 57)0.4556 ( 59)52 ( 54)0.51clinic space7 ( 64)118 ( 66)1.0066 ( 70)59 ( 62)0.24properly equipped examination rooms7 ( 78)176 ( 97)0.0489 ( 95)94 ( 97)0.72female attendants7 ( 70)156 ( 87)0.1677 ( 83)86 ( 87)0.25budget or funding3 ( 38)70 ( 47)0.7336 ( 49)37 ( 44)0.56formal women s health training n ( % ) 1 ( 9)15 ( 8)1.004 ( 4)12 ( 13)0.07separate budget or control point n ( % ) 1 ( 9)31 ( 18)0.6910 ( 11)22 ( 23)0.03change in resources over the last 2  years n ( % ) increased1 ( 9)61 ( 34)0.2026 ( 27)36 ( 38)0.35decreased2 ( 18)21 ( 13)14 ( 15)12 ( 13)unchanged8 ( 73)94 ( 53)54 ( 58)48 ( 50)table 4characteristics of sites by on - site availability of infertility evaluation / treatment and prenatal care , ( n  =  193)infertility evaluation / treatmentprenatal careavailability : noyespnoyespn1365718211practice contextregion n ( % ) northeast22 ( 16)8 ( 14)0.9326 ( 14)4 ( 36)n / amidwest32 ( 24)12 ( 21)44 ( 24)0south51 ( 38)22 ( 39)73 ( 40)0west31 ( 23)15 ( 26)39 ( 21)7 ( 64)organization of the practice1,209 women veterans in 200658 ( 43)39
( 68)0.00188 ( 49)9 ( 82)0.06women s health clinic for primary care n ( % ) 86 ( 63)44 ( 77)0.06123 ( 68)7 ( 64)0.75gynecology clinic n ( % ) 51 ( 38)34 ( 60)0.0180 ( 44)5 ( 46)0.92resources : always or usually sufficient n ( % ) clinical expertise106 ( 80)54 ( 95)0.01151 ( 84)9 ( 82)0.69same gender providers104 ( 78)50 ( 89)0.08146 ( 82)8 ( 73)0.43nursing staff99 ( 74)43 ( 75)0.82137 ( 76)5 ( 46)0.03administrative and support staff83 ( 62)25 ( 44)0.02101 ( 56)7 ( 64)0.76clinic space86 ( 65)39 ( 68)0.66117 ( 66)8 ( 73)0.75properly equipped examination rooms130 ( 98)53 ( 93)0.20173 ( 97)10 ( 91)0.35female attendants116 ( 87)47 ( 83)0.39158 ( 88)5 ( 46)0.001budget or funding49 ( 45)24 ( 48)0.7669 ( 47)4 ( 36)0.55formal women s health training n ( % ) 12 ( 9)4 ( 7)0.7813 ( 7)3 ( 30)0.04separate budget or control point n ( % ) 18 ( 14)14 ( 25)0.0732 ( 18)0n / achange in resources over the last 2  years n ( % ) 38 ( 28)24 ( 44)0.01increased15 ( 11)11 ( 20)59 ( 33)3 ( 30)n / adecreased82 ( 61)20 ( 36)26 ( 14)0unchanged38 ( 28)24 ( 44)0.0195 ( 52)7 ( 70)n / a not applicable due to cell size of zero characteristics of sites by on - site availability of hormonal contraception and iud placement , ( n  =  193 ) characteristics of sites by on - site availability of infertility evaluation / treatment and prenatal care , ( n  =  193 ) n / a not applicable due to cell size of zero after adjusting for visn and practice size , compared with metropolitan hospital - based clinics , non - metropolitan hospital - based clinics had lower odds of offering on - site iud placement ( or 0.57 ; 95  % ci 0.20 , 1.62 ) , but higher odds of offering on - site infertility evaluation / treatment ( or 1.42 ; 95  % ci 0.48 , 4.22 ) , although these associations did not reach statistical significance . after adjustment , compared with metropolitan hospital - based clinics , metropolitan cbocs had 67  % lower odds of offering on - site iud placement ( or 0.33 ; 95  % ci 0.14 , 0.74 ) .
similar , although not statistically significant , associations were observed comparing metropolitan cbocs with metropolitan hospital - based clinics with respect to on - site infertility evaluation / treatment ( or 0.43 ; 95  % ci 0.17 , 1.11 ) .
while almost all surveyed va sites offered hormonal contraception on - site , the on - site availability of specialized reproductive health services , including iud placement , infertility evaluation / treatment , and prenatal care , varied considerably . however , 11 of the surveyed sites , including metropolitan and non - metropolitan hospitals and metropolitan cbocs , did not offer hormonal contraception on - site , which is a basic reproductive health service .
lack of on - site provision of effective contraception may delay care and lead to increased risk of unplanned pregnancy.20 compared with metropolitan hospital - based clinics , metropolitan cbocs were less likely to offer specialized reproductive health services . in seeking to provide comprehensive reproductive health care for women veterans
, va must consider the cost of providing these services on - site and the optimal means of ensuring the highest quality of care .
although the number of women veterans in va is increasing , they remain a numerical minority in va , and , particularly at cbocs , it may not be feasible to offer all specialized reproductive health services on - site .
metropolitan cbocs were least likely to have organizational features that facilitated on - site provision of specialized reproductive care , such as separate women s health clinics for primary care or women s gynecology clinics.12 women receiving care at cbocs may have to travel long distances to obtain reproductive health services if they are referred to another va site.14 while use of non - va ( fee basis ) or contract care may minimize travel distances , the efficiency and quality of these services is not well understood .
introduction of innovative modalities , such as telegynecology or telematernity care , may improve access to certain reproductive health services . incorporating specialized models for gender - specific care within metropolitan cbocs may increase availability and access to specialized reproductive health services for women veterans .
given the low volume of women patients , it may never be feasible to offer certain specialized reproductive health services ( i.e. prenatal care ) on - site .
compared with metropolitan hospital - based clinics , non - metropolitan hospital - based clinics may be more likely to offer on - site infertility evaluation / treatment .
non - metropolitan hospital - based clinics were almost as likely as their metropolitan counterparts to contain a separate women s clinic for primary care , but much less likely to have a gynecology clinic .
infertility treatments are typically delivered by obstetrician gynecologist specialists ; however , infertility evaluation may have been facilitated at non - metropolitan hospitals by the presence of providers at women s clinics .
alternatively , large metropolitan hospital - based clinics may opt to purchase such services in the community , while non - metropolitan hospital - based clinics may order laboratory tests for infertility evaluation on - site and only refer patients out once a need for infertility treatment is established .
strengths of this study included the high response rate and large number of healthcare organizations .
first , although rural setting was not an exclusion criterion , the survey was intentionally designed to query facilities with 300 or more women veterans , which likely differentially excluded rural sites .
this is particularly important , given earlier findings indicating that facilities with smaller women veteran caseloads receive lower ratings for gender - related satisfaction and appropriateness compared with larger sites that incorporated tailored women s primary care models.11 second , it is possible that respondents may have been more likely to report availability of certain services due to social desirability bias or ambiguity of definitions of multi - faceted services , such as infertility evaluation or treatment .
third , we were unable to determine distances between sites , which may impact on - site availability of specialized reproductive health services .
metropolitan cbocs are less likely than their similarly located hospital counterparts to offer specialized reproductive services on - site .
future studies should evaluate delivery of specialized reproductive health care services for women veterans in cbocs and clinics in non - metropolitan areas .
 abstractintroductionwith the increasing number of women veterans enrolling in the veterans health administration ( va ) , there is growing demand for reproductive health services . 
 little is known regarding the on - site availability of reproductive health services at va and how this varies by site location and type.objectiveto describe the on - site availability of hormonal contraception , intrauterine device ( iud ) placement , infertility evaluation or treatment , and prenatal care by site location and type ; the characteristics of sites providing these services ; and to determine whether , within this context , site location and type is associated with on - site availability of these reproductive health services.methodswe used data from the 2007 veterans health administration survey of women veterans health programs and practices , a national census of va sites serving 300 or more women veterans assessing practice structure and provision of care for women . 
 hierarchical models were used to test whether site location and type ( metropolitan hospital - based clinic , non - metropolitan hospital - based clinic , metropolitan community - based outpatient clinic [ cboc ] ) were associated with availability of iud placement and infertility evaluation / treatment . 
 non - metropolitan cbocs were excluded from this analysis ( n  =  2).resultsof 193 sites , 182 ( 94  % ) offered on - site hormonal contraception , 97 ( 50  % ) offered on - site iud placement , 57 ( 30  % ) offered on - site infertility evaluation / treatment , and 11 ( 6  % ) offered on - site prenatal care . after adjustment , compared with metropolitan hospital based - clinics , 
 metropolitan cbocs were less likely to offer on - site iud placement ( or 0.33 ; 95  % ci 0.14 , 0.74).conclusioncompared with metropolitan hospital - based clinics , metropolitan cbocs offer fewer specialized reproductive health services on - site . 
 additional research is needed regarding delivery of specialized reproductive health care services for women veterans in cbocs and clinics in non - metropolitan areas . 
INTRODUCTION
METHODS
Study Design
Data Source
Study Variables
Statistical Analysis
RESULTS
Site Characteristics
On-Site Availability of Reproductive Health Services
DISCUSSION
CONCLUSION
Conflict of Interest