Pregnancy, Fetal, and Neonatal Outcomes Among Women With Traumatic Brain Injury.

OBJECTIVE: There have been no systematic studies of pregnancy outcomes among women with traumatic brain injury (TBI), potentially limiting informed clinical care for women with such injuries. The purpose of this exploratory study was to evaluate pregnancy and fetal/neonatal outcomes among women with a TBI diagnosis recorded during their delivery hospitalization compared with women without TBI. SETTING: In this cross-sectional study, we identified women with delivery hospitalizations using 2004-2014 data from the Nationwide Inpatient Sample of the Health Care and Cost Utilization Project. PARTICIPANTS: We identified deliveries to women with a TBI diagnosis on hospital discharge records, which included all diagnoses recorded during the delivery, and compared them with deliveries of women without a TBI diagnosis. MAIN MEASURES: Pregnancy outcomes included gestational diabetes; preeclampsia/eclampsia; placental abruption; cesarean delivery; and others. Fetal/neonatal outcomes included preterm birth; stillbirth; and small or large gestational age. DESIGN: We modeled risk for each outcome among deliveries to women with TBI compared with women without TBI, using multivariate Poisson regression. Models included sociodemographic and hospital characteristics; secondary models added clinical characteristics (eg, psychiatric disorders) that may be influenced by TBI. RESULTS: We identified 3 597 deliveries to women with a TBI diagnosis and 9 106 312 deliveries to women without TBI. Women with TBI were at an increased risk for placental abruption (relative risk [RR] = 2.73; 95% CI, 2.26-3.30) and associated sequelae (ie, antepartum hemorrhage, cesarean delivery). Women with TBI were at an increased risk for stillbirth (RR = 2.55; 95% CI, 1.97-3.29) and having a baby large for gestational age (RR = 1.30; 95% CI, 1.09-1.56). Findings persisted after controlling for clinical characteristics. CONCLUSIONS: Risk for adverse pregnancy outcomes, including placental abruption and stillbirth, were increased among women with TBI. Future research is needed to examine the association between TBI and pregnancy outcomes using longitudinal and prospective data and to investigate potential mechanisms that may heighten risk for adverse outcomes.

How Did Veterans' Reliance on Veterans Health Administration Outpatient Care Change After Expansion of the Veterans Community Care Program?

BACKGROUND: The Veterans Community Care Program (VCCP) aims to address access constraints in the Veterans Health Administration (VA) by reimbursing care from non-VA community providers. Little existing research explores how veterans' choice of VA versus VCCP providers has evolved as a significant VCCP expansion in 2014 as part of the Veterans Access, Choice, and Accountability Act. OBJECTIVES: We examined changes in reliance on VA for primary care (PC), mental health (MH), and specialty care (SC) among VCCP-eligible veterans. RESEARCH DESIGN: We linked VA administrative data with VCCP claims to retrospectively examine utilization during calendar years 2016-2018. SUBJECTS: 1.78 million veterans enrolled in VA before 2013 and VCCP-eligible in 2016 due to limited VA capacity or travel hardship. MEASURES: We measured reliance as the proportion of total annual outpatient (VA+VCCP) visits occurring in VA for PC, MH, and SC. RESULTS: Of the 26.1 million total outpatient visits identified, 45.6% were for MH, 29.9% for PC, and 24.4% for SC. Over the 3 years, 83.2% of veterans used any VA services, 23.8% used any VCCP services, and 20.0% were dual VA-VCCP users. Modest but statistically significant declines in reliance were observed from 2016-2018 for PC (94.5%-92.2%), and MH (97.8%-96.9%), and a more significant decline was observed for SC (88.5%-79.8%). CONCLUSIONS: Veterans who have the option of selecting between VA or VCCP providers continued using VA for most of their outpatient care in the initial years after the 2014 VCCP expansion.

A systematic review of screening for perinatal depression and anxiety in community-based settings.

Screening for perinatal depression and anxiety in community-based maternal and child health settings may help close the detection and treatment gap among women at higher risk for these conditions. We aim to review perinatal depression and anxiety screening tools, timing, and follow-up processes for positive screens in community-based settings. We conducted a systematic review of the literature to identify papers describing screening and interventions for perinatal depression and anxiety in community-based settings. We identified 49 papers describing 47 studies of perinatal depression or anxiety screening in community-based settings. The Edinburgh Postnatal Depression Scale (EPDS) was the most frequently used screening tool. Referral and referral tracking for those who screened positive for symptoms were inadequately described. Types of training and technical assistance provided for screening varied widely. It is feasible and acceptable to screen for perinatal depression in community settings, but there is a need for systematic research examining which screening tools to use, the ideal frequency of screening, and referral completion rates. There is a lack of information regarding perinatal anxiety screening and a lack of uniformity in training regarding screening in community-based settings. Future studies should compare the efficacy of screening in community-based settings to screening in healthcare settings.

Experiences of racism and postpartum depression symptoms, care-seeking, and diagnosis.

Postpartum depression (PPD) is common and disproportionately affects people of color. Experiences of emotional upset due to racism (EUR) may be an important predictor of PPD outcomes. Therefore, we aimed to determine if EUR during the 12 months before delivery was associated with PPD symptomology, asking for help for depression, and depression diagnosis among postpartum people of color (PPOC). We conducted a cross-sectional secondary data analysis among PPOC from 11 states and New York City using PRAMS data, 1/1/2015-12/31/2017. We assessed symptomology using an unvalidated PHQ-2. Logistic regression was performed without and with stratification by ethnicity (non-Hispanic PPOC vs Hispanic PPOC) to estimate whether EUR during 12 months before delivery was associated with (1) PPD symptoms, (2) asking for help for depression, and (3) depression diagnosis. Models adjusted for age, educational attainment, timely prenatal care, payment method, stress during pregnancy, and pre-pregnancy depression. Seventy-four thousand nine hundred nine (11.8%) PPOC reported EUR in the 12 months before delivery. After adjustment, EUR was associated with a 10.3 percentage point (%pt; 95% CI: 6.8, 13.8), 13.6%pt (95% CI: 8.8, 18.5), and 4.1%pt (95% CI: 1.4, 8.0) higher probability of positive PPD screening among all PPOC, non-Hispanic PPOC, and Hispanic PPOC, respectively. EUR was not associated with asking for help for depression but was associated with a higher prevalence of depression diagnosis among all PPOC (4.6%pt; 95% CI: 1.0, 8.4) and non-Hispanic PPOC (6.0%pt; 95% CI: 0.8, 11.2).Experiences of EUR are associated with an increased prevalence of PPD symptoms. Additional prospective research spanning the pre-pregnancy through postpartum periods is needed to examine the dynamic relationship between racism, symptomology, help-seeking, and diagnosis of depression.

Recruitment of women veterans into suicide prevention research: Improving response rates with enhanced recruitment materials and multiple survey modalities.

Women veterans (WV) are the fastest growing veteran subpopulation and recognized to be at increased risk for suicide compared with civilians. Improving engagement (e.g., response rates) of WV in survey research is critical to ensuring valid and generalizable findings, which can inform suicide prevention programs tailored for this population. Many factors are known to influence response rates, yet little is known about ways to optimize survey response rates among WV. Three recruitment cohorts (Waves 1 [W1], 2a [W2a], and 2b [W2b]) of WV were invited to participate in an online survey for a national, mixed-methods study examining suicide risk among WV using reproductive health care services paid for or provided by the Veterans Health Administration. To examine the effects of enhanced recruitment efforts, standard recruitment materials were mailed to all three cohorts, with the additions of: a study flyer aiming to build trust between participants and researchers (W2a, W2b) and a paper survey (W2b). Characteristics of responders and non-responders were compared by wave and across survey modalities. Response rates were significantly higher for groups receiving enhanced (W2a = 17.1%; W2b = 24.6%) versus standard (W1 = 12.2%) recruitment materials. WV residing in rural areas were significantly more likely to respond by paper (37.1%) than online (19.8%). Non-respondents were disproportionately racial and ethnic minorities. Disclosure of sensitive information (e.g., military sexual trauma) did not differ by survey modality. Findings suggest that enhanced recruitment materials improve survey response rates among WV, an important consideration for future research with this population.

Contributors to Racial Disparities in Minimally Invasive Hysterectomy in the US Department of Veterans Affairs.

BACKGROUND: Minimally invasive hysterectomy for fibroids decreases recovery time and risk of postoperative complications compared with abdominal hysterectomy. Within Veterans Affair (VA), black women with uterine fibroids are less likely to receive a minimally invasive hysterectomy than white women. OBJECTIVE: To quantify the contributions of patient, facility, temporal and geographic factors to VA black-white disparity in minimally invasive hysterectomy. RESEARCH DESIGN: A cross-sectional study. SUBJECTS: Veterans with fibroids and hysterectomy performed in VA between October 1, 2012 and September 30, 2015. MEASURES: Hysterectomy mode was defined using ICD-9 codes as minimally invasive (laparoscopic, vaginal, or robotic-assisted) versus abdominal. The authors estimated a logistic regression model with minimally invasive hysterectomy modeled as a function of 4 sets of factors: sociodemographic characteristics other than race, health risk factors, facility, and temporal and geographic factors. Using decomposition techniques, systematically substituting each white woman's characteristics for each black woman's characteristics, then recalculating the predicted probability of minimally invasive hysterectomy for black women for each possible combination of factors, we quantified the contribution of each set of factors to observed disparities in minimally invasive hysterectomy. RESULTS: Among 1255 veterans with fibroids who had a hysterectomy at a VA, 61% of black women and 39% of white women had an abdominal hysterectomy. Our models indicated there were 99 excess abdominal hysterectomies among black women. The majority (n=77) of excess abdominal hysterectomies were unexplained by measured sociodemographic factors beyond race, health risk factors, facility, and temporal or geographic trends. CONCLUSION: Closer examination of the equity of VA gynecology care and ways in which the VA can work to ensure equitable care for all women veterans is necessary.

Do trauma type, stressful life events, and social support explain women veterans' high prevalence of PTSD?

OBJECTIVES: To examine factors that account for women veterans' higher prevalence of past-year DSM-5 posttraumatic stress disorder (PTSD) compared to women civilians and men veterans. METHODS: Cross-sectional analyses of the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). Face-to-face interviews with 379 women veterans, 20,007 women civilians, and 2740 men veterans were conducted. Trauma type (child abuse, interpersonal violence, combat or war zone, and other), number of trauma types, past-year stressful life events, current social support, and DSM-5 PTSD were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-5. Generalized linear models were used that accounted for the complex survey design. RESULTS: Women veterans had a higher unadjusted prevalence of past-year PTSD (11.40%) compared to their civilian (5.96%) and male (5.19%) counterparts. Individual predictor models indicated that the difference between women veterans' and civilians' prevalence of PTSD was attenuated when adjusting for number of trauma types, whereas the difference between men and women veterans was attenuated when adjusting for child abuse, interpersonal violence, and stressful life events. Nonetheless, while full adjustment in a multiple predictor model accounted for the difference in PTSD between women veterans and civilians, gender differences between men and women veterans remained. CONCLUSIONS: Number of trauma types, type of trauma, and social factors may together help explain women veterans' higher PTSD prevalence compared to women civilians, but do not fully account for differences between men and women veterans. Results highlight a need to explore additional explanatory factors and evaluate associations with longitudinal data.

Transgender Veterans' Satisfaction With Care and Unmet Health Needs.

BACKGROUND: Transgender individuals are overrepresented among Veterans. However, little is known regarding their satisfaction with Veterans Administration (VA) care and unmet health needs. OBJECTIVES: This study examined transgender Veterans' satisfaction with VA medical and mental health care, prevalence of delaying care, and correlates of these outcomes. RESEARCH DESIGN: We used data from transgender Veterans collected in 2014 through an online, national survey. SUBJECTS: In total, 298 transgender Veterans living in the United States. MEASURES: We assessed patient satisfaction with VA medical and mental health care and self-reported delays in seeking medical and mental health care in the past year. Potential correlates associated with these 4 outcomes included demographic, health, and health care variables. RESULTS: Over half of the sample used VA (56%) since their military discharge. Among transgender Veterans who had used VA, 79% were satisfied with medical care and 69% with mental health care. Lower income was associated with dissatisfaction with VA medical care, and being a transgender man was associated with dissatisfaction with VA mental health care. A substantial proportion reported delays in seeking medical (46%) or mental (38%) health care in the past year (not specific to VA). Screening positive for depression and/or posttraumatic stress disorder was associated with delays in seeking both types of care. CONCLUSIONS: Although the majority of transgender Veterans are satisfied with VA health care, certain subgroups are less likely to be satisfied with care. Further, many report delaying accessing care, particularly those with depression and/or posttraumatic stress disorder symptoms. Adapting health care settings to better engage these vulnerable Veterans may be necessary.

Assessing the potential impact of extending antenatal steroids to the late preterm period.

BACKGROUND: In 2016, guidance statements were issued by the Society for Maternal-Fetal Medicine and the American Congress of Obstetricians and Gynecologists about extending antenatal steroid use to selected late preterm singleton pregnancies. OBJECTIVE: We sought to review antenatal steroid use prior to the 2016 guidance statements and assess the potential impact of these. STUDY DESIGN: This cohort study used chart-abstracted data from singleton deliveries from Jan. 1, 2012, through March 31, 2016, at 12 centers participating in the Obstetrics Clinical Outcomes Assessment Program, a quality initiative in Washington State. Pregnancies with missing gestation at delivery, fetal anomalies, or antepartum demise were excluded. Antenatal steroid use prior to the 2016 guidance was evaluated based on the percentage of early preterm deliveries (23+0-33+6 weeks) and the percentage of all pregnancies that received antenatal steroids. Newborn complication rates were calculated for late preterm deliveries (34+0+0-36+6 weeks), grouped by whether they would be potentially eligible or ineligible for antenatal steroids based on the 2016 guidance statements. RESULTS: The opportunity for antenatal steroids was missed in 21.8% (226/1034) of early preterm deliveries and of all those who received antenatal steroids, 32.2% (614/1908) delivered at term. Of preterm deliveries, 74% (n = 2942) were in the late preterm period. In all, 80% (n = 2363) of late preterm deliveries were potentially eligible for antenatal steroids and 60% of these (n = 1411) delivered at 36 weeks. The rate of respiratory complications in newborns delivering at 34 and 35 weeks was higher in the group potentially eligible for late preterm antenatal steroids compared to those in the ineligible group. Of those delivering at 36 weeks, no differences were detected in prevalence of respiratory complications by potential eligibility for antenatal steroids; however, compared with the ineligible group, those potentially eligible had a lower risk of neonatal intensive care unit admission (P < .001). More than two thirds (69%; 171/248) of newborn respiratory complications among late preterm deliveries potentially eligible for antenatal steroids occurred in those delivering at 34-35 weeks. The highest rate of respiratory complications was in those ineligible for antenatal steroids due to prepregnancy diabetes or chorioamnionitis, regardless of gestational age at delivery. CONCLUSION: Careful consideration of which pregnancies should receive late preterm antenatal steroids and how to identify these pregnancies is important to optimize benefits and mitigate potential risks of this intervention.

Trends in hysterectomy rates among women veterans in the US Department of Veterans Affairs.

BACKGROUND: Prior studies demonstrate a higher prevalence of hysterectomy among veterans compared with nonveterans. While studies identify overall decreasing hysterectomy rates in the United States, none report rates of hysterectomy among women veterans. Given the increasing numbers of women veterans using Veterans Affairs health care, there is an ongoing need to ensure high-quality gynecology care. Therefore, it is important to examine current hysterectomy trends, including proportion of minimally invasive surgeries, among veterans using Veterans Affairs health care. OBJECTIVE: Our objective was to describe hysterectomy trends and utilization of minimally invasive hysterectomy in the Veterans Affairs healthcare system. STUDY DESIGN: This longitudinal study used Veterans Affairs clinical and administrative data from fiscal year 2008 to 2014 to identify hysterectomies provided or paid for by Veterans Affairs. Crude and age-adjusted hysterectomy rates were calculated by indication (benign or malignant), mode (abdominal, laparoscopic, vaginal, robotic assisted, unspecified), and source of care (provided vs paid for by Veterans Affairs). Mode and indication for hysterectomy were classified using International Classification of Diseases, ninth revision, codes. The distribution of hysterectomy mode in each year was calculated by indication and source of care. RESULTS: Between fiscal year 2008 and fiscal year 2014, the total hysterectomy rate decreased from 4.0 per 1000 to 2.6 per 1000 unique women veteran Veterans Affairs users. Age-adjusted rates of abdominal hysterectomy for benign indications decreased over the study period from 1.54 per 1000 (95% confidence interval, 1.40-1.69) to 0.77 per 1000 (95% confidence interval, 0.69-0.85) for procedures provided by Veterans Affairs and 0.77 per 1,000 (95% confidence interval, 0.69-0.85) to 0.29 per 1,000 (95% confidence interval, 0.23-0.34) for those paid for by Veterans Affairs. Among hysterectomies for benign indications provided by (n = 5296) or paid for (n = 2610) by Veterans Affairs, the percentage of hysterectomies performed abdominally decreased from 67.2% to 46.8% and from 68.9% to 57.6%, respectively. CONCLUSION: These findings suggest that gynecology care provided within Veterans Affairs has kept pace with national trends in reducing hysterectomy rates and increasing utilization of minimally invasive surgical techniques.

Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia.

BACKGROUND: Prior work shows that Post-traumatic Stress Disorder (PTSD) predicts an increased risk of preterm birth, but the causal pathway(s) are uncertain. We evaluate the associations between PTSD and antepartum complications to explore how PTSD's pathophysiology impacts pregnancy. METHODS: This retrospective cohort analysis of all Veterans Health Administration (VA)-covered deliveries from 2000-12 used the data of VA clinical and administration. Mothers with current PTSD were identified using the ICD-9 diagnostic codes (i.e. code present during the antepartum year), as were those with historical PTSD. Medical and administrative data were used to identify the relevant obstetric diagnoses, demographics and health, and military deployment history. We used Poisson regression with robust error variance to derive the adjusted relative risk estimates (RR) for the association of PTSD with five clinically relevant antepartum complications [gestational diabetes (GDM), preeclampsia, gestational hypertension, growth restriction, and abruption]. Secondary outcomes included proxies for obstetric complexity (repeat hospitalisation, prolonged delivery hospitalisation, and caesarean delivery). RESULTS: Of the 15 986 singleton deliveries, 2977 (19%) were in mothers with PTSD diagnoses (1880 (12%) current PTSD). Mothers with the complication GDM were 4.9% and those with preeclampsia were 4.6% of all births. After adjustment, a current PTSD diagnosis (reference = no PTSD) was associated with an increased risk of GDM (RR 1.4, 95% confidence interval (CI) 1.2, 1.7) and preeclampsia (RR 1.3, 95% CI 1.1, 1.6). PTSD also predicted prolonged (>4 day) delivery hospitalisation (RR 1.2, 95% CI 1.01, 1.4), and repeat hospitalisations (RR 1.4, 95% CI 1.2, 1.6), but not caesarean delivery. CONCLUSIONS: The observed association of PTSD with GDM and preeclampsia is consistent with our nascent understanding of PTSD as a disruptor of neuroendocrine and cardiovascular health.

Improving Perinatal Mental Health Care for Women Veterans: Description of a Quality Improvement Program.

Purpose We describe results from a quality improvement project undertaken to address perinatal mental healthcare for women veterans. Description This quality improvement project was conducted in a single VA healthcare system between 2012 and 2015 and included screening for depressive symptoms with the Edinburgh Postnatal Depression Scale (EPDS) three times during the perinatal period, a dedicated maternity care coordinator (MCC), an on-site clinical social worker, and an on-site obstetrician/gynecologist (Ob/gyn). Information on prior mental health diagnosis was collected by the MCC or Ob/gyn. The prevalence of perinatal depressive symptoms and receipt of mental healthcare among those with such symptoms are reported by presence of a pre-pregnancy mental health diagnosis. Assessment Of the 199 women who used VA maternity benefits between 2012 and 2015, 56% (n = 111) had at least one pre-pregnancy mental health diagnosis. Compared to those without a pre-pregnancy mental health diagnosis, those with such a diagnosis were more likely to be screened for perinatal depressive symptoms at least once (61.5% vs. 46.8%, p = 0.04). Prevalence of depressive symptoms was 46.7% among those with a pre-pregnancy mental health diagnosis and 19.2% among those without. Among those with a pre-pregnancy mental health diagnosis and depressive symptoms (n = 35), 88% received outpatient mental healthcare and 77% met with the clinical social worker. Among those without a pre-pregnancy mental health diagnosis and depressive symptoms (n = 8), none received outpatient mental healthcare, but 77.8% met with the clinical social worker. Conclusion Improving perinatal mental healthcare for women veterans requires a multidisciplinary approach, including on-site integrated mental healthcare.

Deployment and Adverse Pregnancy Outcomes: Primary Findings and Methodological Considerations.

Objective To characterize the pregnancy outcomes of women Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans including prevalence of preterm delivery, low birth weight, and macrosomia, and to highlight methodological limitations that can impact findings. Methods A retrospective cohort study was conducted starting in 2014 analyzing data from the 2009 to 2011 National Health Study for a New Generation of US Veterans, which sampled Veterans deployed and not deployed to OIF/OEF. All pregnancies resulting in a live birth were included, and categorized as occurring among non-deployers, before deployment, during deployment, or after deployment. Outcomes included preterm birth, low birth weight, and macrosomia. The association of deployment with selected outcomes was estimated using separate general estimating equations to account for lack of outcome independence among women contributing multiple pregnancies. Adjustment variables included maternal age at outcome, and race/ethnicity. Results There were 2276 live births (191 preterm births, 153 low birth weight infants, and 272 macrosomic infants). Compared with pregnancies before deployment, pregnancies among non-deployers and those after deployment appeared to have greater risk of preterm birth [non-deployers: odds ratio (OR) = 2.16, 95 % confidence interval (CI) 1.25, 3.72; after deployment: OR = 1.90, 95 % CI 0.90, 4.02]. A similar pattern was observed for low birth weight. No association of deployment with macrosomia was detected. Discussion Compared with non-deployers, those who eventually deploy appear to have better pregnancy outcomes prior to deployment, but this advantage is no longer apparent after deployment. Non-deployers may not be an appropriate reference group to study the putative health impacts of deployment on pregnancy outcomes.

Gynecologists in the VA: do they enhance availability of sex-specific services and policies in the emergency department?

OBJECTIVES: To examine the association between on-site gynecology and availability of sex-specific services and policies in Department of Veterans Affairs (VA) emergency departments (EDs). RESEARCH DESIGN: Cross-sectional analysis using data from a VA national inventory of emergency services for women and gynecologist staffing information from the VA Office of Productivity, Efficiency, and Staffing. SUBJECTS: ED directors from all VA medical centers (N=120). MEASURES: We used logistic regression to evaluate the association between on-site gynecologist full-time equivalents (FTEs, <0.5 and ≥0.5), and availability of sex-specific ED services, such as consult and follow-up within VA by a gynecologist, emergency contraception, rho (D) immunoglobulin, pelvic ultrasound, and transfer policies for obstetric and gynecologic emergencies. All analyses were adjusted for number of ED encounters by women. RESULTS: Greater gynecologist FTE (≥0.5 vs. <0.5) was associated with increased odds of on-site availability of a gynecology consultation in the ED [odds ratio (OR)=10.9; 95% confidence interval (CI): 3.2, 36.6] and gynecologist follow-up within VA after an ED encounter (OR=2.5; 95% CI: 1.0, 6.2). A positive trend was seen in availability of rho (D) immunoglobulin (OR=1.4; 95% CI: 0.6, 3.5) and presence of transfer policies for obstetric (OR=1.7; 95% CI: 0.7, 4.5) and gynecologic emergencies (OR=1.6; 95% CI: 0.6, 4.2). Half of the facilities with <0.5 FTE did not have transfer policies in place or under development. CONCLUSIONS: On-site gynecologist FTE is associated with improved availability of sex-specific care in EDs. Development of transfer processes for obstetric and gynecologic emergencies in settings with limited on-site gynecology is needed.

Infertility care among OEF/OIF/OND women Veterans in the Department of Veterans Affairs.

BACKGROUND: An increasing number of young women Veterans seek reproductive health care through the VA, yet little is known regarding the provision of infertility care for this population. The VA provides a range of infertility services for Veterans including artificial insemination, but does not provide in vitro fertilization. This study will be the first to characterize infertility care among OEF/OIF/OND women Veterans using VA care. METHODS: We analyzed data from the OEF/OIF/OND roster file from the Defense Manpower Data Center (DMDC)-Contingency Tracking System Deployment file of military discharges from October 1, 2001-December 30, 2010, which includes 68,442 women Veterans between the ages of 18 and 45 who utilized VA health care after separating from military service. We examined the receipt of infertility diagnoses and care using ICD-9 and CPT codes. RESULTS: Less than 2% (n=1323) of OEF/OIF/OND women Veterans received an infertility diagnosis during the study period. Compared with women VA users without infertility diagnosis, those with infertility diagnosis were younger, obese, black, or Hispanic, have a service-connected disability rating, a positive screen for military sexual trauma, and a mental health diagnosis. Overall, 22% of women with an infertility diagnosis received an infertility assessment or treatment. Thirty-nine percent of women Veterans receiving infertility assessment or treatment received this care from non-VA providers. CONCLUSIONS: Overall, a small proportion of OEF/OIF/OND women Veterans received infertility diagnoses from the VA during the study period, and an even smaller proportion received infertility treatment. Nearly 40% of those who received infertility treatments received these treatments from non-VA providers, indicating that the VA may need to examine the training and resources needed to provide this care within the VA. Understanding women's use of VA infertility services is an important component of understanding VA's commitment to comprehensive medical care for women Veterans.

Reproductive health diagnoses of women veterans using department of Veterans Affairs health care.

BACKGROUND: Little is known regarding the reproductive health needs of women Veterans using Department of Veterans Affairs (VA) health care. OBJECTIVE: To describe the reproductive health diagnoses of women Veterans using VA health care, how these diagnoses differ across age groups, and variations in sociodemographic and clinical characteristics by presence of reproductive health diagnoses. RESEARCH DESIGN: This study is a cross-sectional analysis of VA administrative and clinical data. SUBJECTS: The study included women Veterans using VA health care in FY10. MEASURES: Reproductive health diagnoses were identified through presence of International Classification of Disease, 9th Revision (ICD-9) codes in VA clinical and administrative records. The prevalence of specific diagnosis categories were examined by age group (18-44, 45-64, ≥65 y) and the most frequent diagnoses for each age group were identified. Sociodemographic and clinical characteristics were compared by presence of at least 1 reproductive health diagnosis. RESULTS: The most frequent reproductive health diagnoses were menstrual disorders and endometriosis among those aged 18-44 years (n=16,658, 13%), menopausal disorders among those aged 45-64 years (n=20,707, 15%), and osteoporosis among those aged ≥65 years (n=8365, 22%). Compared with women without reproductive health diagnoses, those with such diagnoses were more likely to have concomitant mental health (46% vs. 37%, P<0.001) and medical conditions (75% vs. 63%, P<0.001). CONCLUSIONS: Women Veterans using VA health care have diverse reproductive health diagnoses. The high prevalence of comorbid medical and mental health conditions among women Veterans with reproductive health diagnoses highlights the importance of integrating reproductive health expertise into all areas of VA health care, including primary, mental health, and specialty care.

Strategies for transforming reproductive healthcare delivery in an integrated healthcare system: a national model with system-wide implications.

PURPOSE OF REVIEW: As the number of women serving in the US military has grown, so too has the number of women using the US Department of Veterans Affairs Healthcare System (VA). This poses tremendous opportunity to integrate reproductive health services across a national healthcare system. This review summarizes the approaches used to assess, rapidly design, and integrate VA's first National Reproductive Health Program. RECENT FINDINGS: Compared with the civilian population, women Veterans have poorer health status including increased likelihood of medical comorbidities and mental health conditions. Given these complex health needs, a health systems approach that integrates reproductive health with other needs is essential in this vulnerable population. SUMMARY: Delivery of high-quality reproductive healthcare must incorporate a systems perspective. Promoting major organizational and cultural change in a national system has required use of an evidence-based strategic framework, which has relied on several key tenets including the following: understanding the population of women Veterans served, developing research-clinical partnerships, building interdisciplinary initiatives for system-wide integration of reproductive healthcare, and developing innovative tools for enhancing care delivery. This approach can serve as a model for other healthcare systems committed to developing an integrated system of reproductive healthcare and addressing reproductive health conditions in women with complex needs.

"You want people to listen to you": Patient experiences of women's healthcare within the Veterans Health Administration.

OBJECTIVE: To identify constructs that are critical in shaping Veterans' experiences with Veterans Health Administration (VA) women's healthcare, including any which have been underexplored or are not included in current VA surveys of patient experience. DATA SOURCES AND STUDY SETTING: From June 2022 to January 2023, we conducted 28 semi-structured interviews with a diverse, national sample of Veterans who use VA women's healthcare. STUDY DESIGN: Using VA data, we divided Veteran VA-users identified as female into four groups stratified by age (dichotomized at age 45) and race/ethnicity (non-Hispanic White vs. all other). We enrolled Veterans continuously from each recruitment strata until thematic saturation was reached. DATA COLLECTION/EXTRACTION METHODS: For this qualitative study, we asked Veterans about past VA healthcare experiences. Interview questions were guided by a priori domains identified from review of the literature, including trust, safety, respect, privacy, communication and discrimination. Analysis occurred concurrently with interviews, using inductive and deductive content analysis. PRINCIPAL FINDINGS: We identified five themes influencing Veterans' experiences of VA women's healthcare: feeling valued and supported, bodily autonomy, discrimination, past military experiences and trauma, and accessible care. Each emergent theme was associated with multiple of the a priori domains we asked about in the interview guide. CONCLUSIONS: Our findings underscore the need for a measure of patient experience tailored to VA women's healthcare. Existing patient experience measures used within VA fail to address several aspects of experience highlighted by our study, including bodily autonomy, the influence of past military experiences and trauma on healthcare, and discrimination. Understanding distinct factors that influence women and gender-diverse Veterans' experiences with VA care is critical to advance efforts by VA to measure and improve the quality and equity of care for all Veterans.

Suicidal Ideation and Suicide Attempts Among Women Veterans Using VA Reproductive Health Care: Prevalence and Associations With Fertility-, Pregnancy- and Parenting-related Factors.

INTRODUCTION: Women veterans are at increased risk for suicide and experience a high prevalence of suicidal ideation (SI) and suicide attempt (SA) history. Knowledge regarding SI/SA correlates among women veterans who use reproductive health care services is limited, inhibiting development of evidence-based, gender-sensitive suicide prevention programming tailored to meet women veterans' needs and preferences. This study aimed to 1) describe the prevalence and characteristics of SI and SA among women veterans using Veterans Health Administration (VHA) reproductive health care services and 2) provide an initial exploration of associations between fertility-, pregnancy-, and parenting-related factors with SI and SA to guide future research. METHODS: Post-9/11 women veterans (n = 352) who used VHA reproductive health care in fiscal year 2018 completed a cross-sectional survey on reproductive health, mental health, and parenting. RESULTS: Approximately 30% and 12% experienced SI and SA(s), respectively, after military service; 10% reported past-month SI. Infertility, pregnancy loss, age at first pregnancy, and parental status were not significantly associated with SI or SA history, although notable effect sizes were observed for infertility and age at first pregnancy; further research is warranted. Among parents, parental functioning was not associated with SI/SA, but lower parental satisfaction was significantly associated with past-month SI (prevalence ratio, 3.36; 95% confidence interval, 1.19-9.46; adjusting for demographics, military characteristics, mental health symptoms). CONCLUSIONS: Postmilitary SI and SA(s) are common among women veterans accessing VHA reproductive health care services. Those with low parental satisfaction may be at particularly high risk. Findings can guide future research and inform clinical care to facilitate suicide prevention.

VA location and structural factors associated with on-site availability of reproductive health services.

INTRODUCTION: With 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. OBJECTIVE: To 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. METHODS: We 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). RESULTS: Of 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). CONCLUSION: Compared 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.