Self-reported reproductive outcomes among male and female 1991 Gulf War era US military veterans

Australian Veterans of the Middle East Conflicts 2001–2010: Select Reproductive Health Outcomes Part 2 — Prenatal, Fetal, and Neonatal Outcomes

Background: Following on from Part 1 of these companion articles, which described the maternal and paternal cohort of the Middle East Area of Operations (MEAO) Census Study, this manuscript aims to describe fetal and infant characteristics and outcomes from the self-report data, including live deliveries, stillbirths, all other pregnancy losses, and unknown outcomes.

Methods: A descriptive analysis was performed on the clinical variables where data were reported. Descriptive statistics (means, frequencies, percentiles) were used to describe the occurrence of adverse gestational outcomes. Odds ratios were also calculated for perinatal outcomes. Infant characteristics and outcomes were evaluated using statistical analysis software IBM SPSS v26.

Results: There were 15,417 pregnancies reported by respondents to the MEAO Census Study. Of these, 74% (11,367) resulted in a live delivery, 0.75% in a stillbirth, and 20% in another type of pregnancy loss (ectopic pregnancy, miscarriage, termination). The unadjusted odds of an adverse perinatal outcome were higher in the MEAO Census population than in the general Australian population, notably stillbirth (OR = 3.11, 95% CI 2.56–3.80), perinatal death (OR = 3.80, 95% CI 3.26–4.44), and neonatal death (OR = 5.43, 95% CI 4.27–6.91). There were 499 cases of birth defects reported and 85 cases of childhood cancer in the MEAO population. The unadjusted odds of childhood cancer were slightly higher (OR = 1.7, 95% CI 0.09–3.28) in the MEAO population, and the unadjusted odds of birth defects were lower (OR = 0.52, 95% CI 0.40–0.68). The male:female infant sex ratio of babies born to respondents was 102 (5939 males:5823 females).

Conclusions: The MEAO Census Study presents a generally reassuring picture of reproductive health for women serving in the Australian Defence Force with regards to the risk of pregnancy loss and perinatal outcomes. The increased odds of perinatal and neonatal death and stillbirth are worthy of further study and evaluation, as is the increase in likelihood of childhood cancer in the offspring of MEAO veterans.

Obstetric Outcomes in Military Servicewomen: Emerging Knowledge, Considerations, and Gaps

The number of women in the U.S. military is dramatically increasing. Similarly, the roles of active-duty women are greatly expanding, thus exposing them to new occupational risks. Determining the impact of pregnancy outcomes for women while in the military is difficult due to changing exposures over time, difficulty in utilizing appropriate comparison groups, and the lack of prospective investigations. Despite these limitations, it was concerning that the available data suggest that servicewomen delivering within 6 months of their first deployment have an increased preterm birth risk (adjusted odds ratio [aOR]: 2.1), and those with three prior deployments have an even greater risk (aOR: 3.8). Servicewomen also have an increased risk of hypertensive disorders with a rate of 13% compared with 5% in the general obstetric population. Furthermore, depression is higher for women who deploy after childbirth and are exposed to combat when compared with those who have not deployed since the birth of their child (aOR: 2.01). Due to the importance of this issue, prospective research designs are necessary to better understand and address the unique health care needs of this population.

Impact of Deployment on Reproductive Health in U.S. Active-Duty Servicewomen and Veterans

Reproductive-age women are a fast-growing component of active-duty military personnel who experience deployment and combat more frequently than previous service-era women Veterans. With the expansion of the number of women and their roles, the United States Departments of Defense and Veterans Affairs have prioritized development and integration of reproductive services into their health systems. Thus, understanding associations between deployments or combat exposures and short- or long-term adverse reproductive health outcomes is imperative for policy and programmatic development. Servicewomen and women Veterans may access reproductive services across civilian and military or Veteran systems and providers, increasing the need for awareness and communication regarding deployment experiences with a broad array of providers. An example is the high prevalence of military sexual trauma reported by women Veterans and the associated mental health diagnoses that may lead to a lifetime of high risk-coping behaviors that increase reproductive health risks, such as sexually transmitted infections, unintended pregnancies, and others. Care coordination models that integrate reproductive healthcare needs, especially during vulnerable times such as at the time of military separation and in the immediate postdeployment phase, may identify risk factors for early intervention with the potential to mitigate lifelong risks.

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.

A Review of Epidemiologic Studies of the Health of Gulf War Women Veterans

INTRODUCTION

In the 25 years since the 1990-1991 Gulf War (GW), studies have evaluated Gulf War Illness (GWI), sometimes referred to as medically unexplained multi symptom illness, and other medical and neurological conditions in women GW veterans.

MATERIALS AND METHODS

In this article, we review epidemiologic studies of the health of women who served in the 1990-1991 GW based upon bibliographic searches in PubMed and CINAHL with relevant search terms through September 2015.

RESULTS

A total of 56 articles were identified in the bibliographic searches. By screening abstracts or full-text articles, a total of 21 relevant studies were identified. Results from some studies, but not all, suggest that GWI is more common in women GW veterans than their male counterparts. Few studies of GW veterans focused on women's health. A small number of studies suggested excess rates of woman's health problems, e.g., breast cysts, abnormal Papanicolaou (Pap) smears, yeast infections, and bladder infections. Several studies have identified significantly elevated rates of birth defects and adverse reproductive outcomes among GW veterans. However, findings have varied with different study designs and sample sizes, with some studies showing elevated risks of stillbirths, miscarriages, and/or birth defects and others have not. In some studies, participants reported increased risks of ectopic pregnancies and spontaneous abortions.

CONCLUSION

Further research is needed to provide a comprehensive picture of the health of women GW veterans and to examine a broad range of women's health issues including adverse reproductive outcomes. Some deployment-related health problems only become apparent decades later and other conditions may worsen or improve over time. Assessments are needed of current health status, changes in health symptoms and conditions over time, and possible differences in health outcomes associated with specific experiences and exposures during the war. Future studies would be strengthened by assessing GWI symptom patterns that may be specific to women veterans, examine diagnosed medical conditions among women veterans, and evaluate changes in women's health over time, including changes potentially associated with menopause and age.

Health-related quality of life in haemophilia patients with inhibitors and their caregivers

Data on the health-related quality of life (HRQoL) of congenital haemophilia patients with inhibitors (CHwI) and their caregivers are limited. To understand the association between patient demo-graphics/clinical characteristics with HRQoL among CHwI patients and caregivers, a survey was developed to assess HRQoL with haemophilia-specific QoL questionnaires (HAEMO-QoL/HAEM-A-QoL). In the cross-sectional study, paper-pencil questionnaires were mailed to 261 US CHwI patients/caregivers in July 2010. Descriptive analyses were performed to characterize HRQoL by age and to identify drivers of impairment, from both patient/caregiver perspectives. HRQoL scores were transformed on a scale of 0-100, with higher scores indicating higher impairment in HRQoL. Ninety-seven respondents completed the HRQoL assessment. HRQoL impairment was higher in adult patients. In children ages 8-16 years, mean HAEMO-QoL total score was 33.8 (SD = 15.5), and 35.0 (SD = 16.1) in children ages 4-7 years; for adult patients the mean HAEM-A-QoL total score was 42.2 (SD = 14.8). Adults reported highest impairment in the 'sports/leisure' subscale (Mean = 62.5, SD = 18.7), whereas patients 8-16 years reported highest impairment in the 'physical health' subscale (Mean = 50.8, SD = 30.5).Caregivers of patients ages 4-7 years reported greatest impairment within the 'family' subscale (Mean = 55.6, SD = 19.4). Caregivers were ''considerably/very much'' bothered by their child's inhibitors and reported higher QoL impairment for their child than parents who were not bothered. Within ChwI patients, HRQoL impairments increased with age and existed across a range of physical/psychosocial domains. In addition, caregiver burden also affected the perceived HRQoL of paediatric CHwI patients. Additional research is considered necessary to further understand the support caregivers need while caring for children with CHwI.

Birth defects in infants born in 1998-2004 to men and women serving in the U.S. military during the 1990-1991 Gulf War era

BACKGROUND

Concerns about reproductive health persist among U.S. military members who served in the 1990-1991 Gulf War. This study explores the long-term impact of 1990-1991 Gulf War deployment on the prevalence of birth defects among infants of Gulf War veterans.

METHODS

Health care data from the Department of Defense Birth and Infant Health Registry and demographic and deployment information from the Defense Manpower Data Center were used to identify infants born between 1998 and 2004 to both male and female 1990-1991 Gulf War veterans. Multivariable logistic regression models estimated the adjusted odds of any birth defect and eight specific birth defects among infants of deployers versus non-deployers. In addition, birth defects were evaluated among infants born to 1990-1991 Gulf War veterans with deployment-specific exposures.

RESULTS

Among 178,766 infants identified for these analyses, 3.4% were diagnosed with a birth defect in the first year of life. Compared to infants of non-deployers, infants of deployers were not at increased odds of being diagnosed with a birth defect, or any of eight specific birth defects, in the first year of life. A slightly increased prevalence of birth defects was observed among infants born to men who deployed to the 1990-1991 Gulf War for 153 to 200 days compared to those who deployed for 1 to 92 days. No other deployment-specific exposures were associated with birth defects in these infants.

CONCLUSIONS

The 1990-1991 Gulf War deployers, including those with specific exposures of concern, were not found to be at increased risk for having infants with birth defects 7 to 14 years after deployment.

Health outcomes among infants born to women deployed to United States military operations during pregnancy

BACKGROUND

Military professionals who deploy to combat operations may encounter hazards that could adversely affect reproductive health. Pregnant women are generally exempt from deployment to military operations; however, exposures to such environments may inadvertently occur. We investigated whether maternal deployment during pregnancy was associated with adverse health outcomes in infants.

METHODS

The United States Department of Defense Birth and Infant Health Registry identified infants born to military service women between 2002 and 2005, and defined their health outcomes at birth and in the first year of life. Multivariable modeling was applied to investigate preterm birth and birth defects among infants, based on maternal deployment experience during pregnancy.

RESULTS

Among 63,056 infants born to military women from 2002 to 2005, 22,596 were born to women with deployment experience in support of the current military operations before, during, or after their pregnancy. These included 2941 infants born to women who appeared to have been deployed some time during their first trimester of pregnancy. Compared to infants born to women who deployed at other times, or never deployed, exposed infants were not more likely to be born preterm, diagnosed with a major birth defect, or diagnosed with a malignancy.

CONCLUSIONS

In this exploratory analysis, infants born to women who inadvertently deployed to military operations during their pregnancy were not at increased risk of adverse birth or infant health outcomes. Future analyses should examine outcomes related to specific maternal exposures during deployment, and outcomes among the growing number of infants conceived after deployment.

Evaluation of preterm births and birth defects in liveborn infants of US military women who received smallpox vaccine

BACKGROUND

Women serving in the US military have some unique occupational exposures, including exposure to vaccinations that are rarely required in civilian professions. When vaccinations are inadvertently given during pregnancy, such exposures raise special concerns. These analyses address health outcomes, particularly preterm births and birth defects, among infants who appear to have been exposed to maternal smallpox vaccination in pregnancy.

METHODS

This retrospective cohort study included 31,420 infants born to active-duty military women during 2003-2004. We used Department of Defense databases to define maternal vaccination and infant health outcomes. Multivariable regression models were developed to describe associations between maternal smallpox vaccination and preterm births and birth defects in liveborn infants.

RESULTS

There were 7,735 infants identified as born to women ever vaccinated against smallpox, and 672 infants born to women vaccinated in the first trimester of pregnancy. In multivariable modeling, maternal smallpox vaccination in pregnancy was not associated with preterm or extreme preterm delivery. Maternal smallpox vaccination in the first trimester of pregnancy was not significantly associated with overall birth defects (OR 1.40; 95% CI: 0.94, 2.07), or any of seven specific defects individually modeled.

CONCLUSIONS

Results may be reassuring that smallpox vaccine, when inadvertently administered to pregnant women, is not associated with preterm delivery or birth defects in liveborn infants.

Reproductive health and pregnancy outcomes among French gulf war veterans

Background

Since 1993, many studies on the health of Persian Gulf War veterans (PGWVs) have been undertaken. Some authors have concluded that an association exists between Gulf War service and reported infertility or miscarriage, but that effects on PGWV's children were limited.

The present study's objective was to describe the reproductive outcome and health of offspring of French Gulf War veterans.

Methods

The French Study on the Persian Gulf War (PGW) and its Health Consequences is an exhaustive cross-sectional study on all French PGWVs conducted from 2002 to 2004. Data were collected by postal self-administered questionnaire. A case-control study nested in this cohort was conducted to evaluate the link between PGW-related exposures and fathering a child with a birth defect.

Results

In the present study, 9% of the 5,666 Gulf veterans who participated reported fertility disorders, and 12% of male veterans reported at least one miscarriage among their partners after the PGW. Overall, 4.2% of fathers reported at least one child with a birth defect conceived after the mission. No PGW-related exposure was associated with any birth defect in children fathered after the PGW mission. Concerning the reported health of children born after the PGW, 1.0% of children presented a pre-term delivery and 2.7% a birth defect. The main birth defects reported were musculoskeletal malformations (0.5%) and urinary system malformations (0.3%). Birth defect incidence in PGWV children conceived after the mission was similar to birth defect incidence described by the Paris Registry of Congenital Malformations, except for Down syndrome (PGWV children incidence was lower than Registry incidence).

Conclusion

This study did not highlight a high frequency of fertility disorders or miscarriage among French PGW veterans. We found no evidence for a link between paternal exposure during the Gulf War and increased risk of birth defects among French PGWV children.

Reproductive health of male Australian veterans of the 1991 Gulf War

Background

Since the 1991 Gulf War concerns have been raised about the effects of deployment to the Gulf War on veterans' health. Studies of the reproductive health of Gulf War veterans have reported varied findings.

Methods

We undertook a cross-sectional study of male Australian Gulf War veterans (n = 1,424) and a randomly sampled military comparison group (n = 1,548). The study was conducted from August 2000 to April 2002. A postal questionnaire included questions about difficulties achieving pregnancy, pregnancy outcomes including live births, stillbirths, miscarriages and terminations; and for all live births gestation, birth weight, sex, and any cancers, birth defects, chromosomal abnormalities or serious health problems.

Results

Male Gulf War veterans reported slightly increased risk of fertility difficulties following the Gulf War (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.0–1.8), but were more successful at subsequently fathering a child (OR 1.8; 95% CI 1.3–2.6). The study groups reported similar rates of pregnancies and live births. There was no increased risk in veterans of miscarriage, stillbirth, or terminations. Children of male Gulf War veterans born after the period of the Gulf War were not at greater risk of being born prematurely, having a low birth weight, or having a birth defect or chromosomal abnormality (OR 1.0; 95% CI 0.6–1.6). The numbers of cancers and deaths in children were too small to draw any firm conclusions.

Conclusion

The results of this study do not show an increased risk of adverse reproductive outcome in Australian male Gulf War veterans.