Race matters: maternal morbidity in the Military Health System.

BACKGROUND: In the United States, Black women are 3 to 4 times more likely to die from childbirth and have a 2-fold greater risk of maternal morbidity than their White counterparts. This disparity is theorized to be related to differences in access to healthcare or socioeconomic status. Military service members and their dependents are a diverse community and have equal access to healthcare and similar socioeconomic statuses. OBJECTIVE: This study hypothesized that universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of race or ethnic background. STUDY DESIGN: A retrospective cohort study included data from the inaugural National Perinatal Information Center special report comparing indicators of severe maternal morbidity by race. National Perinatal Information Center data from participating military treatment facilities in the Department of Defense performing more than 1000 deliveries annually from April 1, 2018, to March 31, 2019, were included. Using this convenience data set, Chi-square analyses comparing the percentages of cesarean deliveries, adult intensive care unit admissions, and severe maternal morbidity between Black and White patients were performed. RESULTS: Black women were more likely to deliver via cesarean delivery (31.68% vs 23.58%; P<.0001; odds ratio, 1.5; 95% confidence interval, 1.38-1.63), be admitted to an adult intensive care unit (0.49% vs 0.18%; P=.0026; odds ratio, 2.78; 95% confidence interval, 1.46-5.27), and experience overall severe maternal morbidity (2.66% vs 1.66%; P=.0001; odds ratio, 1.67; 95% confidence interval, 1.3-2.15) even when excluding blood transfusion (0.64% vs 0.32%; P=.0139; odds ratio, 1.99; 95% confidence interval, 1.17-3.36) than their White counterparts. There were no substantial differences between races in overall severe maternal morbidity associated with postpartum hemorrhage even when excluding blood transfusion in this subset. CONCLUSION: Equal access to healthcare and similar socioeconomic statuses in the military healthcare system do not explain the healthcare disparities seen regarding maternal morbidity encountered by Black women having children in the United States. This study identifies healthcare disparities in severe maternal morbidity among active duty service members and their families. Further studies to assess causes such as systemic racism (including implicit and explicit medical biases) and physiological factors are warranted.

Depression Screening During Pregnancy: Compliance and Effectiveness in a Military Population.

INTRODUCTION: Perinatal and postpartum depression are common, affecting 13% to 24% of pregnant women through the first year postpartum. Depression screening is recommended by the American College of Obstetrics and Gynecology as an effective and low-cost intervention to improve patient outcomes; however, no nationwide screening rate is reported in the literature. This study was designed to assess the rate and effectiveness of screening in a major military medical center. MATERIALS AND METHODS: Institutional review board (IRB) approval was obtained before beginning the study. The facility where this study was performed has a universal depression screening policy in which all patients should be screened using the Edinburgh Postnatal Depression Scale (EPDS) at the initial obstetric visit, the 28-week visit, and the postpartum visit. The EPDS scores and demographic data were collected by chart review of patients seen between May 2015 and April 2017. RESULTS: Ninety-six percent of patients completed EPDS at their first appointment with a mean score of 3.8. At 28 weeks, 60% of patients were screened with a mean score of 3.8, and at the postpartum appointment, 84% were screened with a mean score of 3.5. Veterans Affairs (VA) patients and dependent daughters had significantly higher EPDS scores than active duty women and dependent wives (mean 7.91, 5.78, 3.19, 3.70, P < .0001). Eight-eight percent of patients with scores of ≥12 were offered the appropriate treatment. CONCLUSIONS: First trimester screening rates are excellent; however, 28-week and postpartum screening rates need improvement. Standardization of clinic screening procedures may be necessary to increase the screening rates. Veterans Affairs patients and dependent daughters have a higher-than-average risk for depression and should be monitored closely. This study demonstrates that a universal postpartum depression screening program is an important part of obstetric care.