Understanding Maternity Care Coordination for Women Veterans Using an Integrated Care Model Approach

Integrated maternity care: A concept analysis

INTRODUCTION

Integrated maternity care is strongly promoted in the Netherlands. However, the term 'integrated' and its practical meaning is understood differently by professionals and policy makers. This lack of clarity is also visible in other countries and hinders implementation. In this study, we will examine how the concept of 'integrated maternity care' and its defining attributes are presented in the international literature.

METHODS

This study aims to provide a definition and deeper understanding of the concept of integrated maternity care by conducting a concept analysis using Morse's method. We performed a systematic search using Embase and Ebscohost (CINAHL, PsychINFO, SocINDEX, MEDLINE) including records that described integrated maternity care from on organizational perspective. Through a qualitative analysis of the selected research and non-research records, we identified defining attributes, boundaries, antecedents, and consequences of the concept. Subsequently, we constructed a definition of the concept based on the findings.

RESULTS

We included 36 records on integrated maternity care in the period from 1978 to 2022. Our search included 21 research and 15 non-research records (e.g. guidelines and policy records). Only half of these had a definition of integrated maternity care. Over time, the definition became more specific. Our concept analysis resulted in three defining attributes of integrated maternity care: collaboration, organizing collaboration and woman-centeredness. We identified role clarity, a culture of collaboration, and clear and timely communication as antecedents of integrated maternity care. A number of consequences were found: continuity of care, improved outcomes, and efficiency. All consequences were described as expected effects of integrated maternity care and not based on evidence.

CONCLUSION

We propose the following definition: 'Integrated maternity care is woman-centred care provided by (maternity) care professionals collaborating together within and across different levels of healthcare with a specific focus on organizing seamless care.' Addressing the antecedents is important for the successful implementation of integrated maternity care.

Experiences and Perceptions of Maternal Autonomy and Racism Among BIPOC Veterans Receiving Cesarean Sections

BACKGROUND

Previous studies of pregnant veterans enrolled in Department of Veterans Affairs (VA) care reveal high rates of cesarean sections among racial/ethnic minoritized groups, particularly in southern states. The purpose of this study was to better understand contributors to and veteran perceptions of maternal autonomy and racism among veterans receiving cesarean sections.

METHODS

We conducted semi-structured interviews to understand perceptions of maternal autonomy and racism among 27 Black, Indigenous, People of Color (BIPOC) veterans who gave birth via cesarean section using VA maternity care benefits.

RESULTS

Our study found that a substantial proportion (67%) of veterans had previous cesarean sections, ultimately placing them at risk for subsequent cesarean sections. More than 60% of veterans with a previous cesarean section requested a labor after cesarean (LAC) but were either refused by their provider or experienced complications that led to another cesarean section. Qualitative findings revealed the following: (1) differences in treatment by veterans' race/ethnicity may reduce maternal agency, (2) many veterans felt unheard and uninformed regarding birthing decisions, (3) access to VA-paid doula care may improve maternal agency for BIPOC veterans during labor and birth, and (4) BIPOC veterans face substantial challenges related to social determinants of health.

CONCLUSION

Further research should examine veterans' perceptions of racism in obstetrical care, and the possibility of VA-financed doula care to provide additional labor support to BIPOC veterans.

Disparate Risk Factors Among Pregnant Veterans Using Veterans Administration Health Benefits for Community-Based Obstetrical Care

INTRODUCTION

Veterans using the Veterans Administration Health Care System (VAHCS) for obstetrical care experience disparate pregnancy-related risks and health outcomes when compared to their pregnant counterparts. This study examined the prevalence of risk factors associated with pregnancy-related comorbidities among U.S. Veterans receiving obstetrical care using VAHCS benefits in Birmingham, Alabama.

MATERIALS AND METHODS

A retrospective chart review was conducted of pregnant Veterans receiving care at a large Veterans Administration facility from 2018 to 2021. Using one-sample t-tests, the data from the study charts were compared to the Alabama overall prevalence of tobacco and alcohol use, pregnancy-related hypertension/preeclampsia, and gestational diabetes and, when the Alabama data were unavailable, the U.S. national average prevalence of overweight, obesity, pre-pregnancy hypertension, posttraumatic stress disorder, depression, and anxiety among patients receiving obstetrical care. The institutional review board at the Birmingham VAHCS approved the study, with an exemption for human subjects research.

RESULTS

The study sample (N = 210) experienced higher levels of obesity (42.3% vs. 24.3%, P < .001), tobacco (21.9% vs. 10.8%, P < .001) and alcohol (19.5% vs. 5.4%, P < .001) use, pre-pregnancy hypertension (10.5% vs. 2.1%, P < .001), posttraumatic stress disorder (33.8% vs. 3.3%, P < .001), anxiety (66.7% vs. 15.2%, P < .001), and depression (66.7% vs. 15.0, P < .001). Fewer patients in the study sample were classified as overweight (16.7% vs. 25.5%, P < .001), developed pregnancy-related hypertension/preeclampsia (7.6% vs. 14.4%, P < .001), or were diagnosed with gestational diabetes (7.1% vs. 10.2%, P < .001). The results did not vary by race or age.

CONCLUSION

The findings highlight the need for further examination of social factors that may be driving disparities among pregnant Veterans, who may benefit from supplemental services to address modifiable comorbidities. Additionally, the implementation of a centralized database to track pregnancy-related outcomes for Veterans would allow these comorbidities to be more closely monitored and addressed. Heightened awareness of a patient's Veteran status and associated increased risks can alert providers to screen for depression and anxiety more frequently and to familiarize themselves with additional services the VAHCS may offer to patients. These steps could improve referrals to counseling and/or targeted exercise interventions.

Incidence and risk factors for postpartum mood and anxiety disorders among women veterans

BACKGROUND

Our aim was to determine rates of postpartum mood and anxiety disorders (PMADs) among U.S. women Veterans and the overlap among PMADs. We further sought to identify PMAD risk factors, including those unique to military service.

METHODS

A national sample of women Veterans completed a computer-assisted telephone interview (N = 1414). Eligible participants were aged 20-45 and had separated from service within the last 10 years. Self-report measures included demographics, general health, reproductive health, military exposures, sexual assault, childhood trauma, and posttraumatic stress disorder (PTSD). The PMADs of interest were postpartum depression (PPD), postpartum anxiety (PPA) and postpartum PTSD (PPPTSD). This analysis included 1039 women Veterans who had ever been pregnant and who answered questions about PPMDs related to their most recent pregnancy.

RESULTS

A third (340/1039, 32.7%) of participants were diagnosed with at least one PMAD and one-fifth (215/1039, 20.7%) with two or more. Risk factors common for developing a PMAD included: a mental health diagnosis prior to pregnancy, a self-report of ever having had a traumatic birth experience, and most recent pregnancy occurring during military service. Additional risk factors were found for PPD and PPPTSD.

CONCLUSION

Women Veterans may be at an increased risk for developing PMADs due to high rates of lifetime sexual assault, mental health disorders, and military-specific factors including giving birth during military service and military combat deployment exposures.

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.

Sufficiency of Health Information During Pregnancy: What's Missing and for Whom? A Cross-Sectional Analysis Among Veterans

Background: Women Veterans often experience trauma and physical and mental health conditions that increase risk of adverse pregnancy outcomes. Information provision during pregnancy may facilitate improved outcomes. However, little evidence exists about information women Veterans receive during pregnancy, and their perceptions of it. Materials and Methods: We recruited pregnant Veterans from 15 Veterans Affairs medical centers. Through telephone surveys, women (N = 851) provided information about sociodemographic characteristics, military service, health, and pregnancy experiences. We asked postpartum women whether, during pregnancy, they received sufficient information about nine health topics. We calculated a composite score (range: 0-9) that reflected sufficiency of information received. Multivariable logistic regression models identified determinants of perceived sufficiency of information. Results: Mean age was 32.1 years. Most reported being White (56.3%), non-Hispanic (80.3%), married/living with a partner (85.1%), and employed (54.4%). Most (54.6%) had been diagnosed with depression (54.6%); one-quarter reported current depressive symptoms. Mean sufficiency of information score was 6.9. Topics that women most reported they did not receive sufficient information on included, what to expect during delivery (32.3%) and how their spouse/partner might support them during labor (40.3%). History of depression (β = -0.35, p = 0.03), current depressive symptoms (β = -0.66, p = 0.001), military sexual trauma (β = 0.37, p = 0.03), and experience of violence (β = 0.66, p = 0.03) were associated with lower sufficiency of information scores. Conclusion: Results indicate need for enhanced and tailored provision of information for Veterans during pregnancy, particularly among those with experience of trauma, past depression diagnoses, and current depressive symptoms. This may include optimizing care coordination and increasing access to childbirth education classes and doula support.

Meeting the complex healthcare needs of veterans

ABSTRACT

More than half of US veterans seek care outside of the Veterans Health Administration. Physical and mental healthcare needs can be complicated by experiences during military service. Community clinicians can deliver more holistic and comprehensive care to veterans through understanding the unique needs of the veteran population.

The impact of military sexual trauma on parent-infant bonding in a sample of perinatal women veterans

BACKGROUND

The experience of sexual assault and harassment during military service (military sexual trauma [MST]) is associated with increased risk for perinatal and reproductive health problems among women veterans. The objective of this study was to examine the associations between mothers' MST exposure and mother-infant bonding, as well as to examine whether there are any salient sociodemographic or military service characteristics among women veterans with greater impairment to mother-infant bonding, including stress during pregnancy and posttraumatic stress disorder (PTSD) diagnosis.

METHODS

This study was a secondary analysis of data collected from prospective, longitudinal study of women veterans using VHA maternity care benefits at 15 VHA medical centers across the US between January 2016 and February 2020. Participants were 697 pregnant veterans using VHA maternity care benefits.

RESULTS

MST was associated with higher maternal depression, and higher maternal depression was associated with poorer mother-infant bonding. The effect of MST on bonding was indirect through depression. PTSD diagnosis and life stressors during pregnancy also had significant indirect pathways with bonding through maternal depression.

CONCLUSIONS

Results underscore the need for access to high quality and trauma-informed perinatal mental health treatment for women veterans, for education on the unique risks conveyed by MST provided to civilian providers treating this population outside VA, and for further research to understand how to ameliorate the harmful effects of MST on perinatal women veterans and their children.

Intimate Partner Violence Among Pregnant Veterans: Prevalence, Associated Mental Health Conditions, and Health Care Utilization

BACKGROUND

Intimate partner violence (IPV) is a prevalent and serious health concern for women veterans, associated with mental and physical health symptoms. The adverse impacts of IPV are exacerbated during pregnancy, with added risks for pregnancy and postpartum outcomes.

OBJECTIVE

Identify the scope of IPV among pregnant veterans and associations with health outcomes.

DESIGN

Data were obtained from a national retrospective cohort study.

PARTICIPANTS

Study participants were 442 pregnant veterans using VHA maternity care benefits.

MAIN MEASURES

Mental health history was assessed via self-report measure and chart review; history of IPV and perinatal depression were assessed via brief validated self-report measures.

KEY RESULTS

Fourteen percent of the sample reported past-year IPV. Report of past-year IPV was associated with higher self-reported rates of lifetime mental health disorders including depression (p = 0.01), posttraumatic stress disorder (p = 0.02), anxiety disorders (p = 0.05), mood disorders (p = 0.01), bipolar disorder (p = 0.001), and eating disorders (p = 0.003); past-year IPV was also associated with the diagnosis of posttraumatic stress disorder during pregnancy (p = 0.002). Additionally, past-year IPV was associated with higher rates of military sexual trauma (MST; p = 0.03), pregnancy health risk behaviors (i.e., smoking, alcohol, and drug use; p = 0.004), greater number of VHA mental health visits during pregnancy (p = 0.04), and a lower likelihood of seeking social support from a spouse or partner (p < 0.0001).

CONCLUSIONS

Results indicate substantial rates of IPV among pregnant veterans, and high rates of mental health conditions which may be exacerbated by MST experience and lower likelihood of seeking social support. Clinicians treating pregnant veterans should screen for and address IPV and mental health treatment needs, and risks should be assessed among pregnant veterans experiencing IPV.

Postpartum Transition of Care: Racial/Ethnic Gaps in Veterans' Re-Engagement in VA Primary Care after Pregnancy

INTRODUCTION

Pregnancy presents an opportunity to engage veterans in health care. Guidelines recommend primary care follow-up in the year postpartum, but loss to follow-up is common, poorly quantified, and especially important for those with gestational diabetes (GDM) and hypertension. Racial maternal inequities are well-documented and might be exacerbated by differential postpartum care. This study explores variation in postpartum re-engagement in U.S. Department of Veteran Affairs health care system (VA) primary care to identify potential racial/ethnic inequities in this care transition.

METHODS

We conducted a complete case analysis of the 2005-2014 national VA birth cohort (n = 18,414), and subcohorts of veterans with GDM (n = 1,253), and hypertensive disorders of pregnancy (HDP; n = 2,052) using VA-reimbursed discharge claims and outpatient data. Outcomes included incidence of any VA primary care visit in the postpartum year; in age-adjusted logistic regression, we explored race/ethnicity as a primary predictor.

RESULTS

In the year after a VA-covered birth, the proportion of veterans with one or more primary care visit was 53.8% overall, and slightly higher in the GDM (56.0%) and HDP (57.4%) subcohorts. In adjusted models, the odds of VA primary care follow-up were significantly lower for Black/African American (odds ratio, 0.87; 95% confidence interval, 0.81-0.93), Asian (odds ratio, 0.76; 95% confidence interval, 0.61-0.95), and Hawaiian/other Pacific Islander (odds ratio, 0.73; 95% confidence interval, 0.55-0.96) veterans, compared with White veterans. Among the subcohorts with GDM or HDP, there were no significant associations between primary care and race/ethnicity.

CONCLUSIONS

One-half of veterans re-engage in VA primary care after childbirth, with significant racial differences in this care transition. Re-engagement for those with the common pregnancy complications of HDP and GDM is only slightly higher, and less than 60%. The potential for innovations like VA maternity care coordinators to address such gaps merits attention.

Being a woman, being a soldier, being a mother: a qualitative analysis of perceptions of pregnancy on working lives of women in the Spanish Armed Forces

INTRODUCTION

Thirty-two years after Spain first allowed women to join the armed forces, 12% of active troops are women, although there are no data on how many of them are mothers. There is a lack of research related to the impact of motherhood on their careers and the challenges they face as well. Previous quantitative research, within North Atlantic Treaty Organization (NATO) forces, has focused on the increased vulnerability and reduced performance of women returning to service after childbirth. However, no study to date has examined the narratives of these women.

METHODS

A qualitative, cross-sectional study was carried out by means of individual interviews which were subsequently analysed employing the interpretative approach of hermeneutic phenomenology. All the interviews were conducted by videoconference, being recorded for subsequent transcription and analysis with MAXQDA v.2018.

RESULTS

Servicewoman reported experiencing fear of informing their command chain of their pregnancy. Many women described feelings of constantly having to prove their worth, and thus perceived the physical restrictions associated with pregnancy and/or postpartum as a threat to their previous achievements. This sometimes led to behaviours that posed a risk to the health of mothers and babies, or eventually resulted in both acute and chronic conditions.

CONCLUSIONS

Some restrictions put in place to protect them during their pregnancies become a source of additional anxiety. Returning to active service, we found that women's desire to fulfil their duties can cause long-term damage to their physical and psychological health. The attitudes servicewomen perceive towards pregnant women and mothers seems to exert a strong influence on the risks they are willing to assume. Understanding and addressing the needs of servicewomen after childbirth, either now, as active members of the Armed Forces, or in the foreseeable future, as veterans, is crucial to both military and civilian healthcare providers.

Development of integration indexes to determine the extent of family planning and child immunization services integration in health facilities in urban areas of Nigeria

Background

Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities.

Methods

This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high).

Results

Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high.

Conclusion

Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.

The Focus They Deserve: Improving Women Veterans' Health Care Access

PURPOSE

Veterans Health Administration (VHA) initiatives aim to provide veterans timely access to quality health care. The focus of this analysis was provider and staff perspectives on women veterans' access in the context of national efforts to improve veterans' access to care.

METHODS

We completed 21 site visits at Veterans Health Administration medical facilities to evaluate the implementation of a national access initiative. Qualitative data collection included semistructured interviews (n = 127), focus groups (n = 81), and observations with local leadership, administrators, providers, and support staff across primary and specialty care services at each facility. Deductive and inductive content analysis was used to identify barriers, facilitators, and contextual factors affecting implementation of initiatives and women veterans' access.

RESULTS

Participants identified barriers to women veterans' access and strategies used to improve access. Barriers included a limited availability of providers trained in women's health and gender-specific care services (e.g., women's specialty care), inefficient referral and coordination with community providers, and psychosocial factors (e.g., childcare). Participants also identified issues related to childcare and perceived harassment in medical facility settings as distinct access issues for women veterans. Strategies focused on increasing internal capacity to provide on-site women's comprehensive care and specialty services by streamlining provider training and credentialing, contracting providers, using telehealth, and improving access to community providers to fill gaps in women's services. Participants also highlighted efforts to improve gender-sensitive care delivery.

CONCLUSIONS

Although some issues affect all veterans, problems with community care referrals may disproportionately affect women veterans' access owing to a necessary reliance on community care for a range of gender-specific services.