Deployment and Adverse Pregnancy Outcomes: Primary Findings and Methodological Considerations

Development of the Ready to Care Survey for VA Women's Health Primary Care Provider

INTRODUCTION

Women Veterans are at increased risk for poor pregnancy outcomes and are increasingly using Veteran Affairs (VA) for maternity benefits. VA Women's Health Primary Care Providers (WH-PCPs) are well positioned to improve maternal outcomes for women Veterans, yet little is understood about their experience and comfort with perinatal care. The objective of this study was to develop and validate a survey that could be utilized to assess WH-PCPs' experience, comfort, and attitudes towards perinatal care.

METHODS

After a review of the literature, we adapted a previously published survey to address four content areas including clinical experience, comfort level, and attitudes towards perinatal care and knowledge of VA specific maternity services. This survey was piloted with five WH-PCPs before undergoing two rounds of content validation with content experts. Content validity indexes (CVI) were calculated based on the content experts' ratings. Qualitative feedback from the content experts were summarized and reviewed by the research team. The CVI and qualitative responses were utilized to guide the decision to revise, refine, or delete survey questions.

RESULTS

After the first round of content validation, we deleted three questions, revised three questions, and add three questions to the content areas of clinical experience and comfort. In the domain of attitudes towards perinatal care, we deleted one question and revised two questions and three questions were added to the knowledge of VA specific maternity services domain. After the second round of content validation, only one question was deleted from the attitudes domain.

DISCUSSION

We developed and validated the Ready to Care Survey for VA WH-PCP using two rounds of content validation. The final survey had face and content validity. This survey tool can be used to assess VA WH-PCP's knowledge and readiness in caring for Veterans of child-bearing age for operational and research needs.

Ethnoracial Disparities in Perinatal Outcomes among Women Veterans

Objective: Non-Hispanic Black women have increased rates of preterm birth and low infant birth weight. However, we do not know if these disparities replicate in women veterans, a population that may be at further risk for poor perinatal outcomes. This study sought to examine ethnoracial differences in preterm birth and low infant birth weight in veterans. Methods: A national sample of randomly chosen women veterans (i.e., oversampled for residency in high crime neighborhoods) reported information about all pregnancies they have had in their life, demographic characteristics, and history of childhood trauma exposures. The analytic sample was limited to individuals who identified as Hispanic/Latinx, Black, or White (n = 972). Mixed-effects regression models were used to examine ethnoracial differences in gestational age at delivery and infant birth weight, controlling for age at pregnancy, childhood trauma exposure, pregnancy during military service, income, and education. Results: Both Black and Hispanic/Latinx veterans were significantly more likely to have an infant born at lower gestational age (B = -1.04 and B = -1.11, respectively) and lower infant birth weight (B = -195.83 and B = -144.27, respectively) as compared with White veterans in covariate-adjusted models. Black (odds ratio = 3.24, confidence interval = 1.16, 9.09) veterans were more likely to meet the clinical definition of preterm birth as compared with White veterans. Conclusions: Results align with what is seen in the general population regarding ethnoracial disparities in gestational age at delivery and infant birth weight. Findings highlight the critical need for more research on mechanisms and prevention efforts for ethnoracial disparities in perinatal outcomes.

Women of the Gulf War: Understanding Their Military and Health Experiences Over 30 Years

INTRODUCTION

Women Veterans of the Persian Gulf War (GW) expanded the military roles they had filled in previous military eras, with some women engaging in direct combat for the first time. Many GW service members, including women, had unique combat exposures to hazardous agents during deployment, which might have contributed to the development of chronic health problems. This study aims to understand the experiences of women GW Veterans (GWVs) as it is related to their military service and subsequent health in order to better inform and improve their clinical care.

MATERIALS AND METHODS

We conducted in-depth interviews with 10 women GWVs to understand their experiences and perspectives about how their military service in the Gulf has impacted their lives and health. We used an integrated approach of content analysis and inductive thematic analysis to interpret interview data.

RESULTS

Besides having many of the same war-related exposures as men, women faced additional challenges in a military that was inadequately prepared to accommodate them, and they felt disadvantaged as women within the military and local culture. After service, participants had emergent physical and mental health concerns, which they described as developing into chronic and complex conditions, affecting their relationships and careers. While seeking care and service connection at Veterans Health Administration (VA), women voiced frustration over claim denials and feeling dismissed. They provided suggestions of how VA services could be improved for women and GWVs. Participants found some nonpharmacological approaches for symptom management and coping strategies to be helpful.

CONCLUSIONS

Women in the GW encountered challenges in military and healthcare systems that were inadequately prepared to address their needs. Women faced chronic health conditions common to GWV and voiced the desire to be understood as a cohort with unique needs. There is an ongoing need to expand services within the VA for women GWVs, particularly involving psychosocial support and management of chronic illness. While the small sample size can limit generalizability, the nature of these in-depth, minimally guided interviews provides a rich narrative of the women GWVs in this geographically diverse sample.

A systematic review of quantitative bias analysis applied to epidemiological research

BACKGROUND

Quantitative bias analysis (QBA) measures study errors in terms of direction, magnitude and uncertainty. This systematic review aimed to describe how QBA has been applied in epidemiological research in 2006-19.

METHODS

We searched PubMed for English peer-reviewed studies applying QBA to real-data applications. We also included studies citing selected sources or which were identified in a previous QBA review in pharmacoepidemiology. For each study, we extracted the rationale, methodology, bias-adjusted results and interpretation and assessed factors associated with reproducibility.

RESULTS

Of the 238 studies, the majority were embedded within papers whose main inferences were drawn from conventional approaches as secondary (sensitivity) analyses to quantity-specific biases (52%) or to assess the extent of bias required to shift the point estimate to the null (25%); 10% were standalone papers. The most common approach was probabilistic (57%). Misclassification was modelled in 57%, uncontrolled confounder(s) in 40% and selection bias in 17%. Most did not consider multiple biases or correlations between errors. When specified, bias parameters came from the literature (48%) more often than internal validation studies (29%). The majority (60%) of analyses resulted in >10% change from the conventional point estimate; however, most investigators (63%) did not alter their original interpretation. Degree of reproducibility related to inclusion of code, formulas, sensitivity analyses and supplementary materials, as well as the QBA rationale.

CONCLUSIONS

QBA applications were rare though increased over time. Future investigators should reference good practices and include details to promote transparency and to serve as a reference for other researchers.

The Gulf War Women's Health Cohort: Study Design and Protocol

Military service and deployment affect women differently than men, underscoring the need for studies of the health of women veterans and their receipt of health care services. Despite the large numbers of women who served during the 1990-1991 Gulf War, few studies have evaluated Gulf War illness (GWI) and other medical conditions specifically as they affect women veterans of the 1991 Gulf War. The objectives of the Gulf War Women's Health Cohort study are: (1) to establish the Gulf War women's cohort (GWWC), a large sample of women veterans who served in the 1990-1991 Gulf War and a comparison group of women who served in other locations during that period; and (2) to provide current, comprehensive data on the health status of women who served during the 1990-1991 Gulf War, and identify any specific conditions that affect Gulf War women veterans at excess rates. The study will utilize both existing datasets and newly collected data to examine the prevalence and patterns of Gulf War Illness symptoms, diagnosed medical conditions, reproductive health, birth outcomes and other health issues among women who served during the Gulf War. The Gulf War Women's Health Cohort study will address the need for information about the comprehensive health of women veterans who were deployed to the Gulf War, and other wars during the Gulf War era.

Reproductive Health of Women Veterans: A Systematic Review of the Literature from 2008 to 2017

The literature on the reproductive health and healthcare of women Veterans has increased dramatically, though there are important gaps. This article aims to synthesize recent literature on reproductive health and healthcare of women Veterans. We updated a literature search to identify manuscripts published between 2008 and July 1, 2017. We excluded studies that were not original research, only included active-duty women, or had few women Veterans in their sample. Manuscripts were reviewed using a standardized abstraction form. We identified 52 manuscripts. Nearly half (48%) of the new manuscripts addressed contraception and preconception care (n = 15) or pregnancy (n = 10). The pregnancy and family planning literature showed that (1) contraceptive use and unintended pregnancy among women Veterans using VA healthcare is similar to that of the general population; (2) demand for VA maternity care is increasing; and (3) women Veterans using VA maternity care are a high-risk population for adverse pregnancy outcomes. A recurrent finding across topics was that history of lifetime sexual assault and mental health conditions were highly prevalent among women Veterans and associated with a wide variety of adverse reproductive health outcomes across the life course. The literature on women Veterans' reproductive health is rapidly expanding, but remains largely observational. Knowledge gaps persist in the areas of sexually transmitted infections, infertility, and menopause.

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.

Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from Linked Department of Veterans Affairs and California Birth Data

OBJECTIVE

To describe variation in payer and outcomes in Veterans' births.

DATA/SETTING

Secondary data analyses of deliveries in California, 2000-2012.

STUDY DESIGN

We performed a retrospective, population-based study of all live births to Veterans (confirmed via U.S. Department of Veterans Affairs (VA) enrollment records), to identify payer and variations in outcomes among: (1) Veterans using VA coverage and (2) Veteran vs. all other births. We calculated odds ratios (aOR) adjusted for age, race, ethnicity, education, and obstetric demographics.

METHODS

We anonymously linked VA administrative data for all female VA enrollees with California birth records.

PRINCIPAL FINDINGS

From 2000 to 2012, we identified 17,495 births to Veterans. VA covered 8.6 percent (1,508), Medicaid 17.3 percent, and Private insurance 47.6 percent. Veterans who relied on VA health coverage had more preeclampsia (aOR 1.4, CI 1.0-1.8) and more cesarean births (aOR 1.2, CI 1.0-1.3), and, despite similar prematurity, trended toward more neonatal intensive care (NICU) admissions (aOR 1.2, CI 1.0-1.4) compared to Veterans using other (non-Medicaid) coverage. Overall, Veterans' birth outcomes (all-payer) mirrored California's birth outcomes, with the exception of excess NICU care (aOR 1.15, CI 1.1-1.2).

CONCLUSIONS

VA covers a higher risk fraction of Veterans' births, justifying maternal care coordination and attention to the maternal-fetal impacts of Veterans' comorbidities.

Deployment and Preterm Birth Among US Army Soldiers

With increasing integration of women into combat roles in the US military, it is critical to determine whether deployment, which entails unique stressors and exposures, is associated with adverse reproductive outcomes. Few studies have examined whether deployment increases the risk of preterm birth; no studies (to our knowledge) have examined a recent cohort of servicewomen. We therefore used linked medical and administrative data from the Stanford Military Data Repository for all US Army soldiers with deliveries between 2011 and 2014 to estimate the associations of prior deployment, recency of deployment, and posttraumatic stress disorder with spontaneous preterm birth (SPB), adjusting for sociodemographic, military-service, and health-related factors. Of 12,877 deliveries, 6.1% were SPBs. The prevalence was doubled (11.7%) among soldiers who delivered within 6 months of their return from deployment. Multivariable discrete-time logistic regression models indicated that delivering within 6 months of return from deployment was strongly associated with SPB (adjusted odds ratio = 2.1, 95% confidence interval: 1.5, 2.9). Neither multiple past deployments nor posttraumatic stress disorder was significantly associated with SPB. Within this cohort, timing of pregnancy in relation to deployment was identified as a novel risk factor for SPB. Increased focus on servicewomen's pregnancy timing and predeployment access to reproductive counseling and effective contraception is warranted.