June 2018

In This Issue: Care Coordination
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Patterns and Experiences of VA Maternity Care Coordination for Women Veterans

Feature Article

Over the past decade, the number of women Veterans using VA care has more than doubled, growing from 159,630 to 440,000 between FY2000 and FY2015. A substantial proportion of these women Veterans are of reproductive age. As a result, VA has substantially increased its attention to reproductive healthcare, including pregnancy-related care. Recent evidence suggests the number of women Veterans using VA maternity benefits has nearly doubled in the past five years, and yet beyond a small handful of studies describing demographic and clinical characteristics of pregnant Veterans, little information exists regarding how these women access and use maternity care. Focused research on understanding pregnancy and maternity care for women Veterans has been recently identified as a critical next step in VA's mission to provide high-quality care for women Veterans. Further, because nearly all maternity care is provided by community obstetrical providers through VA Community Care, virtually nothing is known about how women Veterans access and use maternity care services, how their maternity care is coordinated, or how ongoing VA care (e.g., primary care, specialty care, mental healthcare) is managed during and after pregnancy.

This ongoing HSR&D study is the first VA study of women’s maternal healthcare issues and needs. The Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study will inform ongoing efforts to improve prenatal, maternity, and post-partum care coordination and follow-up for women enrolled in VA healthcare. Women Veterans were surveyed at approximately 20 weeks of pregnancy and again at 12 weeks post-partum. Investigators collected information regarding perceptions of maternity care coordination, as well as pregnancy experiences, co-existing physical and mental health conditions during pregnancy, social support, and post-partum health of both mother and baby. In addition, interviews with VA primary care, gynecologic, and mental health providers will investigate prevailing approaches for care coordination during pregnancy, including an understanding of how mental health is coordinated with community-based obstetrical care.

Findings:

To date, 547 pregnant Veterans have completed the baseline pregnancy interview, and 418 of these women have delivered babies and completed the post-partum interview. The mean age of pregnant women was 32 years, and 77% reported having a service connected disability. Overall, 77% of women Veterans reported receiving VA maternity care coordination services at the time of the pregnancy interview. A sizeable proportion of pregnant women also reported a history of mental health conditions, including depression (57%), anxiety disorder (46%) and PTSD (41%).  More than 50% of women had experienced sexual harassment during their military service, while 29% of these women experienced unwanted sexual contact during their military service. More than one-third of women were seeing a mental health provider at the time of pregnancy diagnosis, though only 21% of women continued to receive mental healthcare during their pregnancies. Reasons for discontinuation included the belief that they no longer needed mental healthcare, or that they weren’t eligible for mental health treatment during pregnancy.

Prenatal care

Fifteen percent of women in the study did not receive prenatal care until after the first trimester, and nearly 30% of women in the study did not receive prenatal care as soon as they would have liked. Reasons for not seeing a prenatal care provider in a timely manner included difficulties getting VA paperwork to get prenatal care, and the inability to find a provider in the community who was affiliated with either HealthNet or TriWest. 

Deliveries

Overall, 431 babies have been born to women enrolled in COMFORT. Thirteen percent of deliveries occurred prior to 37 weeks gestation, which is slightly higher than the national average of 12%. Similarly, 9% of infants were born with a low birthweight (<5.8 pounds), which is slightly higher than the national average of 7.9%. A majority (90%) of infants had health insurance at birth; among those that didn't, the major reason was an inability to secure Medicaid coverage prior to birth.

Impact:
Pregnant Veterans may struggle with ongoing mental health problems during pregnancy, and it is important to understand how these Veterans continue to access mental healthcare during pregnancy. This study also sheds light on challenges pregnant Veterans experience while trying to access prenatal care. Future research should address specific components of VA care coordination and how these components directly impact access to prenatal care. 

Principal Investigator:  Kristin Mattocks, PhD, MPH, Research Chief of Staff at the VA Central Western Massachusetts Healthcare System.

Publications:

None at this time.

Patterns and Experiences of VA Maternity Care Coordination for Women Veterans project abstract