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Understanding Pregnancy and Maternity Care for Women Veterans

Key Points

  • Over the last decade, the number of pregnant women utilizing VA maternity care benefits has increased exponentially, with VA paying for more than 42,000 deliveries during this period through community-based obstetricians.

  • The HSR&D-funded Center for Maternal and Infant Outcomes Research in Translation (COMFORT) launched in 2014 to better understand women Veterans’ experiences during pregnancy. COMFORT has produced more than 20 papers on topics such as access to prenatal care, perinatal mental health, intimate partner violence, breastfeeding, and abortion.

  • A newly-funded HSR&D pilot study in Durham, North Carolina and New Orleans, Louisiana – both communities with notable disparities in C-section rates among women Veterans of color – will test the feasibility of providing doula care to pregnant Veterans.
  • Nearly 30 years have passed since Congress authorized Public Law 104-262, the Veterans’ Healthcare Eligibility Reform Act of 1996, which allows VA to include pregnancy care as part of the standard benefits package to eligible women Veterans. Over the past decade, the number of pregnant Veterans utilizing VA maternity care benefits for their pregnancies has increased exponentially, with VA paying for more than 42,000 deliveries during that time. However, because VA does not provide obstetric care for Veterans, all obstetric care is delivered by community-based obstetricians enrolled in the VA Community Care Network (CCN) and contracted through Optum or TriWest.

    Although many pregnant Veterans continue to see VA providers for ongoing medical and mental healthcare during pregnancy while also receiving obstetric care from community providers, information regarding pregnant Veterans’ experiences during pregnancy remains largely undocumented in VA medical records. Hence, following pregnancy, VA providers have little information available to understand Veterans’ experiences with prenatal care access and utilization, medical and mental health conditions experienced during pregnancy, and postpartum health concerns. And while Public Law (PL) 111-163 Section 206 of the Caregivers and Veteran Omnibus Health Services Act amended VA’s medical benefits package to include up to seven days of medical care for newborns delivered by women Veterans who are receiving VA maternity care benefits, there is virtually no information available regarding the health of the infant. To better understand women Veterans’ experiences during pregnancy, including medical and mental health conditions, access and utilization of care, the role of social determinants of health in accessing care, postpartum concerns, and newborn care, we launched the HSR&D-funded Center for Maternal and Infant Outcomes Research in Translation (COMFORT) in 2014. Since its launch, the COMFORT study has enrolled more than 1,300 pregnant Veterans from 15 VA facilities nationwide. VA study sites were carefully chosen to include geographically distinct urban and rural settings (e.g., Los Angeles, California and Fargo, North Dakota), and facilities with high proportions of racial and ethnic minority Veterans (e.g., San Juan, Puerto Rico; Little Rock, Arkansas; Durham, North Carolina). The study featured in-depth telephone surveys at two points in time – approximately 20 weeks of pregnancy and 12 weeks postpartum – in order to understand both pregnancy and postpartum health.1 More than 90 percent of COMFORT-enrolled Veterans completed both the pregnancy and postpartum interviews, giving researchers a view into the full range of perinatal health experiences of women Veterans.

    The data generated from the COMFORT study has allowed our study team, along with our co-investigators across the country, to examine many aspects of pregnancy and maternity care. COMFORT has produced more than 20 papers on topics related to maternity care coordination, access to prenatal care, perinatal mental health, intimate partner violence, breastfeeding, abortion, and COVID-19 vaccine hesitancy. Other papers have examined alcohol and tobacco use among pregnant Veterans, sufficiency of information from providers during pregnancy, and pregnancy-related cardiovascular conditions.

    An emerging area of interest for our COMFORT study team is racial/ethnic disparities in maternal health, particularly in cesarean section (C-section) rates.2 According to the Centers for Disease Control (CDC), the national average rate for C-sections is 32 percent, though substantial geographic and racial/ethnic variation exists. In fact, rates vary from 23 percent in Alaska to 38 percent in Mississippi, and national C-section rates are highest for Black women (36 percent) compared to Hispanic (32 percent) and non-Hispanic White women (31 percent). The COMFORT study found similarly disparate rates, with Veterans of color significantly more likely to deliver by C-section compared to White Veterans (44 percent vs. 29 percent). Furthermore, we found that C-section rates reached nearly 67 percent among women Veterans of color delivering in Little Rock and just over 51 percent in Durham. These rates are substantially higher than the U.S. national average C-section rate noted above.

    To better understand why more women Veterans of color are receiving C-sections, the COMFORT study team conducted in-depth interviews with more than 30 women Veterans of color in Durham, Little Rock, and New Orleans who delivered by C-section to understand the circumstances that may have led to the procedure. While many of the Veterans received C-sections due to multiple previous C-sections or conditions that potentially could have endangered their lives or that of their infants, other women were uncertain of why a C-section was ordered. Several Veterans who had previously delivered by C-section requested the opportunity to try a vaginal birth after Cesarean (VBAC), but these requests were denied at their first prenatal care appointment. Other women Veterans of color were told that they were either too small or too large to deliver safely, and in one case, a Veteran was given a C-section because the following day was a holiday, and her obstetrician would be on vacation.

    Our COMFORT study team is also examining issues related to racial/ethnic disparities in maternal outcomes through an in-depth focus on the quality of care provided by hospitals where women Veterans deliver. Funded by a pilot grant from the Community Care Research Evaluation and Knowledge Center (CREEK), in conjunction with HSR&D, Dr. Kroll-Desrosiers has begun to examine the quality of obstetric care provided to pregnant Veterans enrolled in COMFORT, with a focus on racial/ethnic differences in where Veterans receive care. Growing attention is being paid to healthcare quality, as previous studies have demonstrated that hospital quality is associated with obstetric and neonatal outcomes. The National Quality Forum has produced a set of quality measures for perinatal health that have been adopted by the Joint Commission as standards for accreditation of its healthcare facilities.3

    These perinatal care measures focus on achieving integrated, coordinated, and patient-centered care for clinically uncomplicated pregnancies and births.

    Continuing our focus of racial/ethnic disparities in maternal health, our study team was recently awarded an HSR&D pilot grant to test the feasibility of doula care for women Veterans of color. Substantial evidence points to enduring disparities in maternal health and birth outcomes arising from structural and interpersonal racism, pre-existing health conditions, social determinants of health, and healthcare quality. Growing evidence suggests that doulas, nonclinical support paraprofessionals who provide physical, informational, and emotional support to pregnant women, may yield positive results on birth-specific and postpartum-specific outcomes. Doulas care for women in every birth setting – home, birth center, and hospital – and provide services in all phases of childbirth, including pregnancy and postpartum. Studies conducted with low-income Black and Latina women in doula programs that include prenatal, labor, and postpartum support have shown lower rates of cesarean birth, increased breastfeeding initiation, and longer duration of breastfeeding.

    We have chosen to conduct our pilot work in Durham and New Orleans as our previous work in C-section rates shows notable disparities in these communities. Our team has been busy setting up contracts with local doula agencies to provide care to a small number of Veterans in these two cities, with the overall aim to test the feasibility of providing doula care to pregnant Veterans. This work requires extensive conversations with doulas, VA maternity care coordinators, and VA women’s health providers to determine which Veterans would most benefit from doula care in this pilot study, what doula benefits Veterans enrolled in the study will receive, and how community-based doulas will interact with VA maternity care coordinators to ensure that pregnant Veterans receive high-quality, coordinated care.

    1. Mattocks K, Kroll-Desrosiers A, Baldor R, Bastian L. “Factors Impacting Perceived Access to Prenatal Care in Women Veterans Enrolled in Care in the Department of Veterans Affairs,” Women’s Health Issues 2019; 29(1):56-63.
    2. Mattocks KM, et al. “Racial Differences in Cesarean Rates among Women Veterans using VA Community Care,” Medical Care 2021; 59(2):131-8.
    3. The Quality Forum. Perinatal and Reproductive Health 2015-2016. Retrieved from: http://www.qualityforum/org/Publications/2016/12/Perinatal_and_Reproductive_ Health_2015-2016_Final_Report.aspx.

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