The Veterans Health Administration Reproductive Mental Health Consultation Program: an Innovation to Improve Access to Specialty Care

Perinatal mental health and pregnancy-associated mortality: opportunities for change

Perinatal mental health conditions have been associated with adverse pregnancy outcomes, including maternal death. This quality improvement project analyzed pregnancy-associated death among veterans with mental health conditions in order to identify opportunities to improve healthcare and reduce maternal deaths. Pregnancy-associated deaths among veterans using Veterans Health Administration (VHA) maternity care benefits between fiscal year 2011 and 2020 were identified from national VHA databases. Deaths among individuals with active mental health conditions underwent individual chart review using a standardized abstraction template adapted from the Centers for Disease Control and Prevention (CDC). Thirty-two pregnancy-associated deaths were identified among 39,720 paid deliveries with 81% (n = 26) occurring among individuals with an active perinatal mental health condition. In the perinatal mental health cohort, most deaths (n = 16, 62%) occurred in the late postpartum period and 42% (n = 11) were due to suicide, homicide, or overdose. Opportunities to improve care included addressing (1) racial disparities, (2) mental health effects of perinatal loss, (3) late postpartum vulnerability, (4) lack of psychotropic medication continuity, (5) mental health conditions in intimate partners, (6) child custody loss, (7) lack of patient education or stigmatizing patient education, and (8) missed opportunities for addressing reproductive health concerns in mental health contexts. Pregnancy-associated deaths related to active perinatal mental health conditions can be reduced. Mental healthcare clinicians, clinical teams, and healthcare systems have opportunities to improve care for individuals with perinatal mental health conditions.

Assessing Racial Disparities in Access, Use, and Outcomes for Pregnant and Postpartum Veterans and Their Infants in Veterans Health Administration

Objective: Limited population-based data examines racial disparities among pregnant and postpartum Veterans. Our objective was to determine whether Black/white racial disparities in health care access, use, and Veteran and infant outcomes are present among pregnant and postpartum Veterans and their infants using Veterans Health Administration (VA) care. Methods: The VA National Veteran Pregnancy and Maternity Care Survey included all Veterans with a VA paid live birth between June 2018 and December 2019. Participants could complete the survey online or by telephone. The independent variable was self-reported race. Outcomes included timely initiation of prenatal care, perceived access to timely prenatal care, attendance at a postpartum check-up, receipt of needed mental health care, cesarean section, postpartum rehospitalization, low birthweight, preterm birth, admission to a neonatal intensive care unit, and breastfeeding. Nonresponse weighted general linear models with a log-link were used to examine associations of race with outcomes. Cox regression was used to examine the association of race with duration of breastfeeding. Models adjusted for age, ethnicity, urban versus rural residence, and parity. Results: The analytic sample consisted of 1,220 Veterans (Black n = 916; white n = 304) representing 3,439 weighted responses (Black n = 1,027; white n = 2,412). No racial disparities were detected for health care access or use. Black Veterans were more likely than white Veterans to have a postpartum rehospitalization (RR 1.67, 95% CI: 1.04-2.68) and a low-birthweight infant (RR 1.67, 95% CI: 1.20-2.33). Conclusion: While no racial disparities were detected for health care access and use, we identified disparities in postpartum rehospitalization and low birthweight, underscoring that access is not sufficient for ensuring health equity.