Background. In the United States, two women die every day from pregnancy-related complications. Non- Hispanic Black women die at 3 to 4 times the rate of non-Hispanic White women, and women living in rural areas and women with low income are also at increased risk. For every pregnancy-related death, about 100 more women nearly die due to severe maternal morbidity (SMM), or complications from pregnancy and/or delivery that result in significant lasting health consequences. Research suggests that >60% of these deaths and SMM events are preventable, and that improving women’s health before pregnancy (e.g., managing chronic medical and mental health conditions) may be one key to prevention. Little is known about women Veterans’ pre-pregnancy health risks and maternal outcomes. Preliminary data from pilot work suggest that the rate of pregnancy-associated deaths among Veterans using VA maternity care benefits is nearly double the national rate. Because women Veterans have a high prevalence of chronic medical and mental health conditions, and given that half (48%) of women Veterans age 18-45 identify as non-White and 25% live in rural areas, it is critical to examine the role of these pre-pregnancy health risks in adverse maternal outcomes and to explore how patterns of comorbid health risk factors vary among women from vulnerable subgroups. Significance / Impact. The proposed research will fill major gaps in the literature about the etiology of maternal mortality and SMM both within and outside of VA, and directly aligns with VHA and HSR&D priorities around women’s health and health equity. Innovation. This study is the first to examine the impact of pre- pregnancy health risks on maternal outcomes among a national cohort of women Veterans and the first to examine whether social characteristics modify associations between pre-pregnancy health and maternal outcomes. Specific Aims. Aim 1 is a quantitative study to classify women Veterans according to co-occurring pre-pregnancy health risks, describe associations between risk profile groups and adverse maternal outcomes, and identify how these associations vary across population subgroups. Aim 2 is a qualitative study to examine women Veterans’ pre-pregnancy healthcare needs, experiences, and preferences. Aim 3 involves intervention development, refinement, and pilot testing with the input of key VA clinical and operational informants and women Veterans. Methodology. Aim 1 will use latent class analysis and multiple regression to examine a national cohort of over 30,000 pregnancies to women Veterans in FY2010-2019. Aim 2 will recruit and interview ~30 women Veterans about their experiences and needs related to pre-pregnancy health and health care in VA. Aim 3 will recruit ~6 VA clinical and operational informants and ~3 women Veterans for a VA stakeholder advisory panel, 5-10 women Veterans and their providers to provide feedback on intervention components, and 10-15 women Veterans and providers to pilot test the intervention components. Implementation / Next Steps. Findings will be presented to local and national operations partners and will directly inform follow-up research to test one or more of a set of patient-centered pre-pregnancy health intervention strategies in multiple VA primary care sites. Candidate. Dr. Deirdre Quinn is a postdoctoral research fellow in women’s health at the VA Center for Health Equity Research and Promotion. The purpose of this CDA-2 is to facilitate Dr. Quinn’s successful transition to an independent VA health services investigator focused on achieving quality and equity in women Veterans’ reproductive health. The objective of this CDA-2 research is to examine how links between women Veterans’ pre-pregnancy health risks (e.g., chronic conditions), social characteristics (e.g., race/ethnicity, rurality), healthcare experiences, and maternal outcomes can inform opportunities to improve women Veterans’ healthcare. This objective will be achieved through expert mentorship and in-depth training in: (1) advanced quantitative research; (2) qualitative research; (3) designing and testing intervention strategies to improve women’s health; and (4) professional leadership.

The number of women in the United States dying during or around pregnancy has been increasing for the past thirty years. Women from racial and ethnic minorities, women who live in rural areas, and women with low- income have a higher risk than other women of dying during or around pregnancy. Many of these deaths are related to pre-existing chronic health conditions and may be preventable by improving women’s health before they become pregnant. Women Veterans have a high prevalence of chronic medical and mental health conditions; little is known about their maternal outcomes. This project will use quantitative and qualitative research methods to understand how women Veterans’ pre-pregnancy health conditions, social characteristics, healthcare experiences, and maternal outcomes are linked. This critical new information will be used to design interventions that improve women’s pre-pregnancy health and reduce the incidence of adverse maternal outcomes, including maternal death.