Examining Pre-Pregnancy Health and Maternal Outcomes among Women Veterans

背景在美国，每天有两名妇女死于妊娠相关并发症。非 西班牙裔黑人妇女的死亡率是非西班牙裔白色妇女的3至4倍， 低收入地区和妇女也面临更大的风险。每一个与怀孕有关的死亡， 更多的妇女几乎死于严重的孕产妇发病率或妊娠并发症和/或 导致严重持久健康后果的分娩。研究表明，超过60%的死亡 和SMM事件是可以预防的，改善妇女怀孕前的健康（例如，管理 慢性疾病和精神健康状况）可能是预防的关键。人们对女性知之甚少 退伍军人的孕前健康风险和孕产妇结局。试点工作的初步数据表明， 使用VA产妇护理福利的退伍军人中与妊娠相关的死亡率几乎是 全国率。因为女性退伍军人有很高的患病率慢性医疗和心理健康 考虑到18-45岁的女性退伍军人中有一半（48%）被认为是非白人，25%生活在农村， 因此，至关重要的是要研究这些孕前健康风险在不良孕产妇结局中的作用， 探讨来自弱势群体的妇女的共病健康风险因素模式如何变化。 意义/影响。这项研究将填补文献中关于 VA内外的孕产妇死亡率和SMM，并直接与VHA和HSR&D优先事项保持一致 围绕妇女健康和健康公平。创新这项研究是第一次审查的影响， 妊娠健康风险对产妇结局的影响，在全国退伍军人队列中， 研究社会特征是否改变孕前健康与孕产妇 结果。具体目标。目的一是对退伍女兵进行共现分类的定量研究 孕前健康风险，描述风险概况组与不良孕产妇结局之间的关联， 并确定这些关联在不同人群中的差异。目的2是一项定性研究， 女性退伍军人的孕前保健需求，经验和偏好。目标3涉及干预 在关键的VA临床和操作信息提供者的输入下进行开发、改进和试点测试， 女性退伍军人。方法论目标1将使用潜在类别分析和多元回归来检查 2010 -2019财政年度，全国退伍军人怀孕人数超过3万人。目标2将招募和 访谈30名退伍军人，了解她们在孕前保健和健康方面的经验和需求 在VA照顾。目标3将招募约6名退伍军人临床和业务信息员和约3名退伍军人 利益攸关方咨询小组、5-10名退伍军人及其服务提供者就干预措施提供反馈意见 此外，还邀请了10-15名女退伍军人和提供服务者对干预措施的各个组成部分进行试点测试。 执行/后续步骤。调查结果将提交给地方和国家业务伙伴， 直接通知后续研究，以测试一个或多个以患者为中心的孕前健康 多个VA初级保健站点的干预策略。候选人迪尔德丽·奎恩博士是一名博士后 退伍军人管理局健康公平研究和促进中心妇女健康研究员。的目的 该CDA-2是为了促进奎因博士成功地过渡到一个独立的退伍军人管理局卫生服务调查员 重点是实现退伍军人生殖健康的质量和公平。CDA-2的目标是 研究是为了研究女性退伍军人怀孕前的健康风险之间的联系（例如，慢性 条件），社会特征（例如，种族/民族，农村），医疗保健经验，和孕产妇 结果可以为改善女性退伍军人的医疗保健提供机会。这一目标将得以实现 通过专家指导和深入培训：（1）高级定量研究;（2）定性研究; (3)设计及测试改善妇女健康的干预策略;及（4）专业领导。

Background. In the United States, two women die every day from pregnancy-related complications. Non- Hispanic Black women die at 3 to 4 times the rate of non-Hispanic White women, and women living in rural areas and women with low income are also at increased risk. For every pregnancy-related death, about 100 more women nearly die due to severe maternal morbidity (SMM), or complications from pregnancy and/or delivery that result in significant lasting health consequences. Research suggests that >60% of these deaths and SMM events are preventable, and that improving women’s health before pregnancy (e.g., managing chronic medical and mental health conditions) may be one key to prevention. Little is known about women Veterans’ pre-pregnancy health risks and maternal outcomes. Preliminary data from pilot work suggest that the rate of pregnancy-associated deaths among Veterans using VA maternity care benefits is nearly double the national rate. Because women Veterans have a high prevalence of chronic medical and mental health conditions, and given that half (48%) of women Veterans age 18-45 identify as non-White and 25% live in rural areas, it is critical to examine the role of these pre-pregnancy health risks in adverse maternal outcomes and to explore how patterns of comorbid health risk factors vary among women from vulnerable subgroups. Significance / Impact. The proposed research will fill major gaps in the literature about the etiology of maternal mortality and SMM both within and outside of VA, and directly aligns with VHA and HSR&D priorities around women’s health and health equity. Innovation. This study is the first to examine the impact of pre- pregnancy health risks on maternal outcomes among a national cohort of women Veterans and the first to examine whether social characteristics modify associations between pre-pregnancy health and maternal outcomes. Specific Aims. Aim 1 is a quantitative study to classify women Veterans according to co-occurring pre-pregnancy health risks, describe associations between risk profile groups and adverse maternal outcomes, and identify how these associations vary across population subgroups. Aim 2 is a qualitative study to examine women Veterans’ pre-pregnancy healthcare needs, experiences, and preferences. Aim 3 involves intervention development, refinement, and pilot testing with the input of key VA clinical and operational informants and women Veterans. Methodology. Aim 1 will use latent class analysis and multiple regression to examine a national cohort of over 30,000 pregnancies to women Veterans in FY2010-2019. Aim 2 will recruit and interview ~30 women Veterans about their experiences and needs related to pre-pregnancy health and health care in VA. Aim 3 will recruit ~6 VA clinical and operational informants and ~3 women Veterans for a VA stakeholder advisory panel, 5-10 women Veterans and their providers to provide feedback on intervention components, and 10-15 women Veterans and providers to pilot test the intervention components. Implementation / Next Steps. Findings will be presented to local and national operations partners and will directly inform follow-up research to test one or more of a set of patient-centered pre-pregnancy health intervention strategies in multiple VA primary care sites. Candidate. Dr. Deirdre Quinn is a postdoctoral research fellow in women’s health at the VA Center for Health Equity Research and Promotion. The purpose of this CDA-2 is to facilitate Dr. Quinn’s successful transition to an independent VA health services investigator focused on achieving quality and equity in women Veterans’ reproductive health. The objective of this CDA-2 research is to examine how links between women Veterans’ pre-pregnancy health risks (e.g., chronic conditions), social characteristics (e.g., race/ethnicity, rurality), healthcare experiences, and maternal outcomes can inform opportunities to improve women Veterans’ healthcare. This objective will be achieved through expert mentorship and in-depth training in: (1) advanced quantitative research; (2) qualitative research; (3) designing and testing intervention strategies to improve women’s health; and (4) professional leadership.