Background: Women are a growing share of the VA population, especially among younger Veterans. To date there hasn’t been a comprehensive assessment of pregnancy outcomes among women Veterans, which is needed, especially given that Veterans have higher pregnancy risk profiles than the general population. Significance: Given the growing share of women Veterans, their increased pregnancy risk, and known U.S. racial and geographic maternal health disparities, VA needs to better understand the provision and outcomes of pregnancy care to implement policies to optimize pregnancy outcomes for Veterans. Findings will facilitate the VA Office of Women’s Health Services (WHS) efforts to improve pregnancy care and outcomes. Innovation and Impact: Existing state of the art methods will be innovatively applied to examine national VA and state Medicaid records in parallel to comprehensively assess VA maternity care. This project is the first to rigorously compare VA pregnancy outcomes with those in the general population at a national level. Specific Aims: Aim 1. This aim has two parts, of which the first is purely descriptive: We will describe a wide range of key maternal outcomes, examining trends and changes over time (with respect to key VA policy changes) for all pregnancies where the VA provided pregnancy care (purchased). Key maternal outcomes will include cesarean deliveries, pregnancy complications and severe maternal morbidity (SMM), a CDC defined set of serious life-threatening maternal complications. We will also describe a broad range of maternal risk factors (individual health factors, and systemic factors of race and geography) and process outcomes including use of prenatal care, VA mental healthcare, and post-partum reintegration to VA care. We will also examine if Veterans with known risk-factors deliver at settings appropriate for their risk levels, as outcomes are demonstrably worse when high-risk deliveries occur in sub-optimal settings. Concurrently we will assess key infant outcomes (e.g., mortality, prematurity, and unexpected NICU admission—i.e. in non-preterm infants). The final part of Aim 1 will use regression analyses to examine the impacts of VA policy changes on key outcomes, while also analyzing the extent of racial/ethnic and urban/rural disparities in outcomes. Aim 2: Repeat, in parallel, the Aim 1 descriptive analyses, for deliveries to VA-enrolled Veterans who do NOT use VA maternity benefits, but instead use Medicaid. We will assess how these Veterans differ in characteristics and maternal outcomes. Since they have chosen not to have VA cover their delivery, we will also assess their use of VA care in the years prior to and after delivery to determine if opting for non-VA pregnancy care was a temporary or lasting healthcare shift away from VA. Aim 3: Compare key outcomes (e.g., complication rates and SMM) of VA-covered deliveries and of Medicaid-covered Veterans’ deliveries with those in the general population. Examine if known disparities racial/ethnic and urban/rural in birth outcomes are more/less pronounced in VA or Medicaid covered Veterans. Methodology: Established CDC methods will be used to search VA administrative records, including purchased care, to identify all enrolled women Veterans who received pregnancy care, extending back to 2000, when VA first covered pregnancy, through 2021. These data will be supplemented by all years of Medicaid data that are available. In addition to descriptive analysis, regression analyses will be used to adjust for known risk factors and moderators to examine a wide range of pregnancy outcomes. Causal inference techniques will be used to analyze the effect of VA and other policies on key outcomes. The study team is led by internationally recognized experts in the evaluation of perinatal care and they have all of the needed expertise to conduct appropriate analyses and effectively disseminate the findings. Next Steps/Implementation: We work closely WHS to share results and tailor analyses to their information needs. WHS can directly implement change via directives to maternity care coordinators at all VA facilities.

Women are a growing share of the VA population, especially among younger veterans. While there have been some limited evaluations of maternal health/pregnancy care and outcomes among women veterans, to date there hasn’t been a comprehensive assessment of this care. The VA provision of this care is complicated by the fact that VA purchases virtually all pregnancy-related care, which effects the coordination of care in both directions (VA sending information to obstetrics providers and receiving back information about the pregnancy). VA has made significant efforts to address care coordination for pregnant veterans. A comprehensive assessment is needed to inform VA of possible gaps and guide continued improvement of this care, especially around factors that veterans are at elevated risk for, such as post-traumatic stress disorder (PTSD). The study team is closely linked with Women’s Health Services (WHS) and will feed results to WHS to allow rapid diffusion of policy relevant findings.