A comprehensive assessment of maternal health and pregnancy outcomes among women veterans

背景：女性在退伍军人中所占的比例越来越大，尤其是在年轻退伍军人中。到目前为止 还没有对女性退伍军人的怀孕结果进行全面评估，这是 需要，特别是考虑到退伍军人的怀孕风险比普通人群更高。 意义：鉴于女性退伍军人的比例不断增长，她们怀孕的风险增加，以及众所周知的美国。 种族和地理上的孕产妇健康差异，退伍军人管理局需要更好地了解提供和结果 妊娠保健部执行政策，优化退伍军人的妊娠结局。调查结果将有助于 退伍军人事务部妇女健康服务办公室(WHS)努力改善妊娠护理和结局。 创新和影响：将创新地应用现有最先进的方法来检查国家VA 与州医疗补助记录并行，以全面评估退伍军人事务部的产妇保健。这个项目是第一个 在全国范围内，严格将退伍军人管理局的妊娠结局与普通人群进行比较。 具体目标：目标1.这个目标有两个部分，其中第一个纯粹是描述性的：我们将描述一个广泛的 关键孕产妇结果的范围，审查随时间变化的趋势和变化(关于关键的退伍军人政策 对于退伍军人管理局提供孕期护理(购买)的所有妊娠。关键的产妇结局将是 包括剖腹产、妊娠并发症和严重的孕产妇发病率(SMM)，CDC定义 一系列严重危及生命的产妇并发症。我们还将描述广泛的母体风险 因素(个人健康因素以及种族和地理的系统性因素)和进程结果包括 使用产前护理、退伍军人精神保健和产后重返退伍军人护理。我们还将检查是否 具有已知风险因素的退伍军人在适合其风险水平的环境下分娩，结果是 显然，当高风险的交付发生在次优环境中时，情况会更糟。同时，我们将评估关键 婴儿结局(例如，死亡率、早产儿和意外进入NICU--即非早产儿)。 目标1的最后部分将使用回归分析来检查退伍军人政策变化对关键 在分析成果方面种族/族裔和城乡差距的程度的同时，还对结果进行了分析。 目标2：同时重复目标1的描述性分析，向退伍军人登记的退伍军人提供 不要使用退伍军人事务部的产假福利，而是使用医疗补助。我们将评估这些退伍军人在 特征和母体结局。既然他们选择不让退伍军人管理局为他们的交货买单，我们将 还要评估他们在分娩前和分娩后几年对VA护理的使用情况，以确定是否选择非VA 妊娠护理是一种暂时或持久的医疗保健转变，远离退伍军人管理局。 目标3：比较退伍军人保险分娩和退伍军人保险分娩的关键结局(例如并发症发生率和SMM) 医疗补助覆盖了退伍军人与普通人群的分娩。检查是否存在已知差异 在退伍军人或医疗补助覆盖的退伍军人中，种族/民族和城市/农村的出生结果更明显/更不明显。 方法：将使用已建立的疾控中心方法来搜索退伍军人管理局的行政记录，包括 购买护理，以识别所有接受过怀孕护理的登记女退伍军人，可追溯到 2000年，退伍军人管理局第一次涵盖怀孕，一直到2021年。这些数据将由所有年份的 可用的医疗补助数据。除了描述性分析外，还将使用回归分析进行调整 对于已知的危险因素和调节因素，以检查广泛的妊娠结局。因果推论 将使用技术来分析退伍军人管理局和其他政策对关键成果的影响。学习小组是由 由国际公认的围产期护理评估专家，他们拥有所有需要的 进行适当的分析并有效地传播调查结果的专业知识。 下一步/实施：我们与WHS密切合作，共享结果并根据他们的信息进行分析 需要。世界卫生组织可以通过向所有退伍军人管理局的产妇保健协调员发出指令，直接实施变革。

Background: Women are a growing share of the VA population, especially among younger Veterans. To date there hasn’t been a comprehensive assessment of pregnancy outcomes among women Veterans, which is needed, especially given that Veterans have higher pregnancy risk profiles than the general population. Significance: Given the growing share of women Veterans, their increased pregnancy risk, and known U.S. racial and geographic maternal health disparities, VA needs to better understand the provision and outcomes of pregnancy care to implement policies to optimize pregnancy outcomes for Veterans. Findings will facilitate the VA Office of Women’s Health Services (WHS) efforts to improve pregnancy care and outcomes. Innovation and Impact: Existing state of the art methods will be innovatively applied to examine national VA and state Medicaid records in parallel to comprehensively assess VA maternity care. This project is the first to rigorously compare VA pregnancy outcomes with those in the general population at a national level. Specific Aims: Aim 1. This aim has two parts, of which the first is purely descriptive: We will describe a wide range of key maternal outcomes, examining trends and changes over time (with respect to key VA policy changes) for all pregnancies where the VA provided pregnancy care (purchased). Key maternal outcomes will include cesarean deliveries, pregnancy complications and severe maternal morbidity (SMM), a CDC defined set of serious life-threatening maternal complications. We will also describe a broad range of maternal risk factors (individual health factors, and systemic factors of race and geography) and process outcomes including use of prenatal care, VA mental healthcare, and post-partum reintegration to VA care. We will also examine if Veterans with known risk-factors deliver at settings appropriate for their risk levels, as outcomes are demonstrably worse when high-risk deliveries occur in sub-optimal settings. Concurrently we will assess key infant outcomes (e.g., mortality, prematurity, and unexpected NICU admission—i.e. in non-preterm infants). The final part of Aim 1 will use regression analyses to examine the impacts of VA policy changes on key outcomes, while also analyzing the extent of racial/ethnic and urban/rural disparities in outcomes. Aim 2: Repeat, in parallel, the Aim 1 descriptive analyses, for deliveries to VA-enrolled Veterans who do NOT use VA maternity benefits, but instead use Medicaid. We will assess how these Veterans differ in characteristics and maternal outcomes. Since they have chosen not to have VA cover their delivery, we will also assess their use of VA care in the years prior to and after delivery to determine if opting for non-VA pregnancy care was a temporary or lasting healthcare shift away from VA. Aim 3: Compare key outcomes (e.g., complication rates and SMM) of VA-covered deliveries and of Medicaid-covered Veterans’ deliveries with those in the general population. Examine if known disparities racial/ethnic and urban/rural in birth outcomes are more/less pronounced in VA or Medicaid covered Veterans. Methodology: Established CDC methods will be used to search VA administrative records, including purchased care, to identify all enrolled women Veterans who received pregnancy care, extending back to 2000, when VA first covered pregnancy, through 2021. These data will be supplemented by all years of Medicaid data that are available. In addition to descriptive analysis, regression analyses will be used to adjust for known risk factors and moderators to examine a wide range of pregnancy outcomes. Causal inference techniques will be used to analyze the effect of VA and other policies on key outcomes. The study team is led by internationally recognized experts in the evaluation of perinatal care and they have all of the needed expertise to conduct appropriate analyses and effectively disseminate the findings. Next Steps/Implementation: We work closely WHS to share results and tailor analyses to their information needs. WHS can directly implement change via directives to maternity care coordinators at all VA facilities.