The Impact of Military Trauma Exposures on Servicewomen's Pregnancy Outcomes: A Scoping Review

INTRODUCTION

Active-duty servicewomen and veterans make up nearly 20% of the United States military and may experience trauma specific to military service. Military-specific trauma includes combat deployment and military sexual trauma, exposure to which may result in posttraumatic stress disorder (PTSD). The purpose of this scoping review is to examine the extent to which military trauma exposures impact the pregnancy outcomes of active-duty servicewomen and women veterans.

METHODS

A systematic search of OVID MEDLINE, OVID Embase, and OVID PsycINFO from inception to September 25, 2023, identified studies examining associations between military trauma exposures and perinatal outcomes. Of the 614 studies identified, 464 were reviewed for relevance, with 16 meeting inclusion criteria.

RESULTS

Of the 16 included studies, 14 found associations between military trauma exposure and adverse pregnancy outcomes including preterm birth, gestational diabetes, hypertensive disorders of pregnancy, low birth weight, and perinatal mood and anxiety disorders. The risks of adverse pregnancy outcomes increased with the severity of PTSD, the recency of combat deployment, and repetitive deployment.

DISCUSSION

This scoping review strengthens the link between trauma exposures and adverse pregnancy outcomes for current and former military servicewomen. A gap in the literature persists regarding trauma exposure among active-duty servicewomen, which differs significantly from women veterans. As mental health conditions are the leading underlying cause of maternal mortality, standardized screening during the perinatal period for military-specific trauma exposures and PTSD is recommended for this population. Black servicewomen of junior enlisted rank carry disproportionate burdens of PTSD diagnosis and adverse pregnancy outcomes. Comprehensive prenatal and postpartum management may improve perinatal and neonatal outcomes for military servicewomen and provide an innovative approach to reducing existing racial disparities.

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.

Improving the Maternity Care Safety Net: Establishing Maternal Mortality Surveillance for Non-Obstetric Providers and Institutions

The siloed nature of maternity care has been noted as a system-level factor negatively impacting maternal outcomes. Veterans Health Administration (VA) provides multi-specialty healthcare before, during, and after pregnancy but purchases obstetric care from community providers. VA providers may be unaware of perinatal complications, while community-based maternity care providers may be unaware of upstream factors affecting the pregnancy. To optimize maternal outcomes, the VA has initiated a system-level surveillance and review process designed to improve non-obstetric care for veterans experiencing a pregnancy. This quality improvement project aimed to describe the VA-based maternal mortality review process and to report maternal mortality (pregnancy-related death up to 42 days postpartum) and pregnancy-associated mortality (death from any cause up to 1 year postpartum) among veterans who use VA maternity care benefits. Pregnancies and pregnancy-associated deaths between fiscal year (FY) 2011-2020 were identified from national VA databases. All deaths underwent individual chart review and abstraction that focused on multi-specialty care received at the VA in the year prior to pregnancy until the time of death. Thirty-two pregnancy-associated deaths were confirmed among 39,720 pregnancies (PAMR = 80.6 per 100,000 live births). Fifty percent of deaths occurred among individuals who had experienced adverse social determinants of health. Mental health conditions affected 81%. Half (n = 16, 50%) of all deaths occurred in the late postpartum period (43-365 days postpartum) after maternity care had ended. More than half of these late postpartum deaths (n = 9, 56.2%) were related to suicide, homicide, or overdose. Integration of care delivered during the perinatal period (pregnancy through postpartum) from primary, mental health, emergency, and specialty care providers may be enhanced through a system-based approach to pregnancy-associated death surveillance and review. This quality improvement project has implications for all healthcare settings where coordination between obstetric and non-obstetric providers is needed.

Midwifery care during labor and birth in the United States

The intrapartum period is a crucial time in the continuum of pregnancy and parenting. Events during this time are shaped by individuals' unique sociocultural and health characteristics and by their healthcare providers, practice protocols, and the physical environment in which care is delivered. Childbearing people in the United States have less opportunity for midwifery care than in other high-income countries. In the United States, there are 4 midwives for every 1000 live births, whereas, in most other high-income countries, there are between 30 and 70 midwives. Furthermore, these countries have lower maternal and neonatal mortality rates and have consistently lower costs of care. National and international evidences consistently report that births attended by midwives have fewer interventions, cesarean deliveries, preterm births, inductions of labor, and more vaginal births after cesarean delivery. In addition, midwifery care is consistently associated with respectful care and high patient satisfaction. Midwife-physician collaboration exists along a continuum, including births attended independently by midwives, births managed in consultation with a physician, and births attended primarily by a physician with a midwife acting as consultant on the normal aspects of care. This expert review defined midwifery care and provided an overview of midwifery in the United States with an emphasis on the intrapartum setting. Health outcomes associated with midwifery care, specific models of intrapartum care, and workforce issues have been presented within national and international contexts. Recommendations that align with the integration of midwifery have been suggested to improve national outcomes and reduce pregnancy-related disparities.

Midwifery Care of Pregnant Individuals Experiencing Opioid use Disorder: Changing Regulations, Complexities, and Call to Action

Opioid use disorder (OUD), overdose, and death have exploded in the United States in the past 2 decades. The number of pregnant and birthing people reporting opioid use and misuse is also rising. Co-occurring mental illness, multisubstance use, and associated medical comorbidities often complicate care for pregnant individuals with OUD. Neonates who are exposed to opioids in utero are at risk for neonatal opioid withdrawal syndrome and other short- and long-term sequelae. Recent changes to the Department of Health and Human Services Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder have now provided a pathway for midwives to prescribe buprenorphine for opioid use disorder (OUD) for up to 30 individuals at one time without further training or certification of ancillary services. Midwives have a key role to play in expanding the availability and quality of interprofessional care provided to individuals with OUD. The Substance Abuse and Mental Health Services Administration and American Society of Addiction Medicine, along with other professional organizations, provide toolkits and guidelines for the provision of MOUD for pregnant people. Midwives who care for individuals with OUD should be familiar with the unique needs of this population and resources to guide their care. This case study highlights midwives' essential role in treating OUD and co-occurring mental disorders.

Birth during the Covid-19 pandemic: What childbearing people in the United States needed to achieve a positive birth experience

BACKGROUND

The COVID pandemic exposed many inadequacies in the maternity care system in the United States. Maternity care protocols put in place during this crisis often did not include input from childbearing people or follow prepandemic guidelines for high-quality care. Departure from standard maternity care practices led to unfavorable and traumatic experiences for childbearing people. This study aimed to identify what childbearing people needed to achieve a positive birth experience during the pandemic.

METHODS

This mixed-methods, cross-sectional study was conducted among individuals who gave birth during the COVID pandemic from 3/1/2020 to 11/1/2020. Participants were sampled via a Web-based questionnaire that was distributed nationally. Descriptive and bivariate statistics were analyzed. Thematic and content analyses of qualitative data were based on narrative information provided by participants. Qualitative and convergent quantitative data were reported.

RESULTS

Participants (n = 707) from 46 states and the District of Columbia completed the questionnaire with 394 contributing qualitative data about their experiences. Qualitative findings reflected women's priorities for (a) the option of community birth, (b) access to midwives, (c) the right to an advocate at birth, and (d) the need for transparent and affirming communication. Quantitative data reinforced these findings. Participants with a midwife provider felt significantly better informed. Those who gave birth in a community setting (at home or in a freestanding birth center) also reported significantly higher satisfaction and felt better informed. Participants of color (BIPOC) were significantly less satisfied and more stressed while pregnant and giving birth during the pandemic.

CONCLUSIONS

High-quality maternity care places childbearing people at the center of care. Prioritizing the needs of childbearing people, in COVID times or otherwise, is critical for improving their experiences and delivering efficacious and safe care.

Sex Differences in Military Sexual Trauma and Severe Self-Directed Violence

INTRODUCTION

Previous research has demonstrated an association between military sexual trauma and risk for suicide; however, risk for self-directed violence such as suicide attempt or nonsuicidal self-injury following military sexual trauma is understudied. This study examines the relationship between military sexual trauma and serious self-directed violence resulting in hospitalization, as well as whether this relationship differs by sex.

METHODS

Participants were 750,176 Operations Enduring Freedom/Iraqi Freedom/New Dawn veterans who were enrolled in Veterans Health Administration care during the period of October 1, 2001-September 30, 2014 and who were screened for military sexual trauma. Data were analyzed in 2019. Bivariate analyses and Cox proportional hazards regression models were employed.

RESULTS

Women veterans were more likely to screen positive for military sexual trauma (21.33% vs 1.63%), and women and men were equally likely to experience serious self-directed violence (1.19% women vs 1.18% men). Controlling for demographic variables and psychiatric morbidity, military sexual trauma predicted serious self-directed violence for both men and women. Further, men with military sexual trauma were 15% less likely to experience self-directed violence compared with women with military sexual trauma (hazard ratio=0.85, 95% CI=0.74, 0.98).

CONCLUSIONS

Military sexual trauma is associated with risk for serious self-directed violence for both men and women veterans, and the relationship may be pronounced among women. Results underscore the importance of incorporating military sexual trauma into treatment and preventative efforts for self-directed violence.

Severe Maternal Morbidity Among a Cohort of Post-9/11 Women Veterans

Background: Maternal morbidity and mortality are key indicators of women's health status and quality of care. Maternal morbidity and mortality are high and rising in the United States. There has been no evaluation of severe maternal morbidity and mortality among veteran women, although population characteristics suggest that they may be at risk. This study aimed to evaluate a surveillance methodology at the U.S. Department of Veterans Affairs (VA) and describe the characteristics of women veterans who experienced severe maternal morbidity events. Materials and Methods: The study sample derived from a national sample of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans who were enrolled for care at the VA. The surveillance methodology followed a recommended process of case identification and chart review following a standardized guide. Centers for Disease Control and Prevention (CDC) International Classification of Diseases codes for maternal morbidity were applied to billing, inpatient, and outpatient data for 9,829 pregnancies among 91,061 veteran women between January 1, 2014 and December 31, 2016. Descriptive statistics is reported. Results: One hundred twenty-seven pregnancies with severe maternal morbidity events were identified, 66 of which were confirmed after chart review. The positive predictive value of CDC indicators to identify cases was 0.52. High rates of mental health problems, obesity, rurality, maternal conditions, and racial discrepancies were noted among veterans who experienced severe maternal morbidity events. Conclusions: Severe maternal morbidity affects a significant number of veteran women. Systematic reporting of pregnancy outcomes and a multidisciplinary review committee would improve surveillance and case management at the VA. The VA is uniquely positioned to develop innovative comanagement strategies, especially in the area of perinatal mental health.

Trauma and Sexual Risk: Do Men and Women Veterans Differ?

PURPOSE

Trauma has been associated with risky sexual behavior in diverse populations. However, little is known about this association among men and women veterans. This study hypothesized that 1) a history of trauma would be associated with risky sexual behavior among men and women veterans, 2) interpersonal trauma would predict risky sexual behavior among women, whereas noninterpersonal trauma would predict risky sexual behavior among men, and 3) military-related trauma would constitute additional risk. Using data from 567 women and 524 men veterans enrolled at the Veterans Health Administration, this study investigated the association between trauma-related experiences and risky sexual behavior in the last 12 months. Risk and protective factors that have been frequently associated with sexual behavior in previous research were also included in the model.

METHODS

This study was drawn from the Women Veterans Cohort Study, a national survey of veterans. Bivariate and multivariate analyses were performed after multiple imputation for missing data.

RESULTS

Predictive factors associated with risky sexual behavior differed between men and women veterans. Among women, childhood sexual victimization and intimate partner violence were associated with risky sexual behavior. Among men, binge drinking was the single significant risk factor. Military exposures were not significantly associated with risky sexual behavior in either men or women.

CONCLUSIONS

This study lays the groundwork for theory-generating research into the psychological underpinnings of noted associations and underscores the importance of integrated health services to address the range of issues affecting sexual behavior and related health outcomes.

Differences in the fecal microbiota of neonates born at home or in the hospital

Research on the neonatal microbiome has been performed mostly on hospital-born infants, who often undergo multiple birth-related interventions. Both the hospital environment and interventions around the time of birth may affect the neonate microbiome. In this study, we determine the structure of the microbiota in feces from babies born in the hospital or at home, and from vaginal samples of their mothers. We included 35 vaginally-born, breast-fed neonates, 14 of whom delivered at home (4 in water), and 21 who delivered in the hospital. Feces from babies and mothers and maternal vaginal swab samples were collected at enrollment, the day of birth, followed by days 1, 2, 7, 14, 21, and 28. At the time of birth, the diversity of the vaginal microbiota of mothers delivering in the hospital was lower than in mothers delivering at home, and showed higher proportion of Lactobacillus. Among 20 infants not exposed to perinatal maternal antibiotics or water birth, fecal beta diversity differed significantly by birth site, with hospital-born infants having lower Bacteroides, Bifidobacterium, Streptococcus, and Lactobacillus, and higher Clostridium and Enterobacteriaceae family (LDA > 3.0), than babies born at home. At 1 month of age, feces from infants born in the hospital also induced greater pro-inflammatory gene expression (TLR4, IL-8, occludin and TGFβ) in human colon epithelial HT-29 cells. The results of this work suggest that hospitalization (perinatal interventions or the hospital environment) may affect the microbiota of the vaginal source and the initial colonization during labor and birth, with effects that could persist in the intestinal microbiota of infants 1 month after birth. More research is needed to determine specific factors that alter bacterial transmission between mother and baby and the long-term health implications of these differences for the developing infant.