Journal of Women's Health Care
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Newborn Outcomes among Veterans Utilizing VHA Maternity Benefits, 2016-2020

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Introduction

In 2010, the Veterans Health Administration (VHA) enacted Public Law (PL) 111-163, Section 206 of the Caregivers and Veterans Omnibus Health Services Act, expanding the VHA medical benefits package for pregnant Veterans to include up to 7 days of health care for their newborns. In addition to providing Veterans with prenatal care throughout pregnancy, the VHA expansion coverage helps to ensure a healthy start for newborns that may not have insurance coverage otherwise. This expansion of VHA coverage to the first 7 days of the newborn’s life could potentially be one step in reducing disparities in chronic comorbidities across a lifetime.

In the United States, 1 in 10 babies are born prematurely, or at less than 37 week’s gestation, annually [1,2]. One repercussion of preterm deliveries is low-birthweight neonates weighing less than 5 pounds, 8 ounces at birth [3]. In the United State 8% of deliveries are low birthweight newborns [1,4]. Premature delivery and low birthweight contribute to infant mortality and are leading causes of complex comorbidities throughout infancy and into adulthood. The costs associated with caring for infants with morbidity due to preterm delivery or low birthweight in the United States is estimated around $6 million more than for normal birthweight babies [5,6]. Despite efforts to reduce the prevalence of preterm deliveries and low birthweight, little progress has been made over the past two decades [7]. Early access to routine health care provides an important opportunity for improving newborn outcomes.

Several risk factors for preterm birth and low birthweight have been identified as prevalent in Veterans [8-10]. Compared to the general population, women Veterans have a higher prevalence of complex clinical (diabetes, hypertension) and mental health (depression, posttraumatic stress disorder [PTSD], anxiety) comorbidities [9, 11-13]. Previous studies of the general population have concluded that increased maternal clinical comorbidities and advanced age are associated with preterm birth [6, 14]. Maternal mental health symptoms also have been related to preterm delivery and low birthweight [15-17].

Furthermore, a substantial number of women Veterans have sociodemographic characteristics that may impact newborn outcomes. Maternal economic and health care instability are significant challenges to accessing quality prenatal care and attaining positive outcomes for both the mother and the newborn. It is not unusual for women to experience a gap in coverage within six months of giving birth, making health care for the mother and infant a challenge. Previous literature has underscored the role of continuous maternal health insurance coverage on newborn outcomes among the Medicaid population [18]. Insurance gaps may be even more common among Veterans and their newborns. Women Veterans are more likely to be uninsured or be utilizing the VHA as their sole source of health care compared to their male counterparts [19]. Over half of women Veterans who use VHA health care also have a service-connected disability rating, indicating an injury or illness incurred or aggravated during military service, rated on a severity scale from 0 (lowest disability rating) to 100 (highest disability rating) percent. Women are more likely to be at the higher disability ratings, which are also associated with unemployment and may explain why women are more likely to have no personal income and to be living below the poverty line compared to their male Veteran counterparts [19].

Adverse maternal and newborn outcomes are amenable to prevention but unaddressed can result in hospitalizations, emergency room visits, and higher overall costs over a lifetime [20]. The cost implications of infant morbidity make newborn outcomes an important VHA policy issue. Yet, relatively little is known about the babies born to Veterans utilizing the VHA maternity care benefit (8). In recent years, the VHA has also offered Maternity Care Coordinators (MCC) for all eligible Veterans in an effort to reduce the risk for adverse maternal and newborn outcomes [21]. VHA MCCs help women coordinate and navigate their health care between the VHA and community-based obstetrics settings. It is unclear whether the VHA’s enhanced services, such as MCC and the newborn expansion policy, are enough support to ensure good maternal and newborn health. Our goal was to examine the newborn outcomes of Veterans, with a focus on the overall infant health and healthcare. Of interest, are the relationships between maternal risk factors and newborn outcomes, specifically gestation and birthweight?

Methods

Study Design

This study utilized data collected in the ongoing COMFORT (Center for Maternal & Infant Outcomes Research in Translation) study to analyze characteristics of infants born to women Veterans [22]. To be eligible for the COMFORT study, participants were English-speaking women Veterans, 18 years of age or older with a confirmed pregnancy and enrolled in VHA care at one of the 15 COMFORT study sites throughout the United States.

Potential participants were mailed a study invitation letter which included a phone number to opt out of the study. Two weeks after the invitation letter was mailed, the research team made follow-up phone calls to see if the Veteran was interested in participating. Veterans who consented to participate completed two telephone surveys: the first around 20 weeks of pregnancy and the second around 10 weeks postpartum. All phone surveys were conducted by a trained research coordinator. Participants received a $25 gift card for the completion of each interview. The COMFORT study was approved by the Veterans Administration Central Institutional Review Board, along with the Research & Development Committee at each site.

Survey data was collected and managed in Research Electronic Data Capture (REDCap) and included maternal sociodemographic characteristics, mental health symptoms, clinical comorbidities, social support, military service, and pregnancy-related factors [8]. For this analysis, Veterans had to have completed both the prenatal and postpartum interviews. Additionally, all Veterans in this cohort had to be matched in the VHA Electronic Medical Record (EMR) database so that maternal clinical characteristics could be confirmed. For women with more than one delivery during the study period, only the first delivery was included.

Study Outcomes

Dependent variables included newborn preterm birth (PTB), defined as an infant born prior to 37 weeks gestational age and contrasted with full-term birth (FTB), and low birthweight (LBW) [23]. Due to the constraints of the data collection instrument, LBW was defined as a newborn weight equal to or less than 5.8 pounds. We defined the comparison group as newborn weight greater than 5.8 pounds (normal birthweight; NBW); high birthweight was not assessed [24]. We also analyzed self-reported newborn insurance coverage at two months after delivery as a dependent variable

Independent Variables

Sociodemographic variables were chosen based on previous literature [1,7,25] and include maternal age dichotomized as greater or less than 35 years, minority race or ethnicity defined as not white in race and/or Hispanic or Latino ethnicity (yes/ no), marital status (married/not married), and maternal health insurance (VHA insurance vs private vs both VHA and private/ other). Military characteristics included ever deployed (yes/no) and history of military sexual trauma (MST). MST included both harassment and rape, and was assessed using the VHA’s universal MST screening questions [26,27] and combined into a single indicator for multivariable models.

Clinical factors included self-reported first prenatal care appointment as early enough (within the first 13 weeks of pregnancy, yes/no), first pregnancy (yes/no), self-reported receipt of VHA MCC, self-reported gestational diabetes or gestational hypertension (combined into a single indicator, yes/no), provider visit(s) for a newborn complication or illness after hospital discharge (yes/no), newborn health status at two months rated as excellent or very good (yes/no), maternal satisfaction with newborn health care rated as very satisfied or satisfied (yes/no) and newborn hospital stay after delivery as 8 or more days (yes/no). Additional maternal clinical comorbidities were abstracted from the EMR and included mental health conditions (depression or anxiety; PTSD) diagnosed within three timeframes of interest: 9 months prior to conception, pregnancy, 9 months after delivery. Also abstracted from the EMR was service-connected disability status as determined by the Veterans Benefits Administration (28) and Veteran service period during OEF/OIF/OND (yes/no).

Statistical Analysis

Associations between sociodemographic and outcome measures (PTB, LBW, newborn insurance at 2 months) were assessed using X² statistics for nominal data and Student t-tests for continuous measures. Multivariable logistic regression examined the factors associated with each outcome. These models adjusted for covariates previously shown to be associated with newborn outcomes: maternal age, race, ethnicity, comorbidity (PTSD, MST, and gestational hypertension/diabetes), use of VHA MCC and use of the VHA maternity benefit. All tests were two-sided; p-values <0.05 indicated statistical significance. Adjusted odds ratios (OR) were presented with their 95% confidence intervals (CI95); CI95 excluding 1.0 denoted significant associations. Analyses were conducted using STATA 14 (StataCorp LLC., 2017. College Station, TX).

Results

Comfort Women Veterans

Overall, 1,223 pregnant Veterans were enrolled in the COMFORT study from January 2016-December 2020. Of these women, 26% had yet to complete the post-delivery interview, 2% had miscarriages, and 6% were missing EMR data resulting in a sample of 811 Veterans eligible for this analysis.

The average age of the mothers was 32.2 years (SD: 4.6; range: 20-49); 51% were non-Hispanic white in race and ethnicity, and 67% were married. Sixty percent of women were deployed during their military service; 98% of Veterans served in OEF/OIF/OND. The majority of Veterans (96%) were utilizing the VHA maternity care benefit for their pregnancy and 84% reported receiving VHA MCC. Fifty-five percent reported a history of MST. As documented by the EMR, Veterans had a high prevalence of mental health comorbidities in the months prior to, during, and following pregnancy including depression/anxiety (63%) and PTSD (39%). Eight percent of the mothers reported being diagnosed with gestational diabetes or hypertension during their pregnancy.

Infant Outcomes

Our infant cohort included 829 infants (18 twin births), of which 34% percent were delivered by cesarean section. On average, newborns were delivered at 37.6 weeks gestation; 11% were PTBs. Nine percent of newborns were of LBW. After discharge from the hospital, 42% of newborns experienced complications, primarily jaundice, tongue tied, or lack of weight gain. Eleven percent of newborns had hospital stays of 8 or more days after their deliveries. Eleven percent of newborns did not have health insurance two months following birth. In addition, 95% of Veterans rated their newborn’s health as ‘excellent’ or ‘very good’; 91% were ‘very satisfied’ or ‘satisfied’ with their newborn’s health care.

Table 1 presents the bivariate associations with PTB, affecting 11% of our newborns. Infants born before 37 weeks gestation were more likely to be delivered to older mothers (X=33.6 +/- 4.7 years) in comparison to their younger counterparts (X=32.0 +/- 4.6 years). Veterans with a history depression/anxiety accounted for a higher percentage (65%) of PTB compared to their counterparts without a mental history (35%), but the difference was not statistically significant. PTB infants were more likely to be born at a lower birthweight than their counterparts (p<0.001). Veterans with a gestational diagnosis of hypertension and/or diabetes were significantly more likely to deliver preterm infants compared to those mothers without a comorbidity (p<0.001). Veterans were delivered preterm infants were also less likely to rate their newborn’s health status as excellent/very in compared to mothers who delivered newborns to full term (p=0.006). There were no significant differences in gestational age at birth by the remainder of the maternal sociodemographic factors, including newborn insurance at two months post-delivery.

Table 1: Maternal characteristics by newborn gestation (N=811).

Table 2 presents the bivariate associations with newborn birthweight. Sixty-eight percent of LBW babies were born to minority mothers. Veterans of LBW newborns were less likely to be married (60%) compared to their counterparts (71%) who had NBW deliveries. PTSD was more common among mothers who delivered LBW babies (55%) versus NBW babies (37%; p=0.003), as was a diagnosis of depression or anxiety (72% LBW vs. 62% NBW; p=0.12). Among LBW deliveries, 18% of Veterans had a comorbidity of gestational hypertension or diabetes in comparison to 7% of mothers with NBW deliveries (p=0.004).

Table 2: Maternal characteristics by newborn birthweight (N=811).

There were no significant findings between maternal characteristics and newborn health insurance coverage at two months post-delivery.

Multivariable Regression Models

Table 3 presents the results of the multivariable models. After adjusting for selected characteristics, PTB was associated with a maternal age: Veterans who were 35 years or older during their pregnancies were twice as likely to have PTB newborn (OR: 1.1; 95% CI: 1.0, 1.1). Veterans diagnosed with a gestational comorbidity (hypertension and/or diabetes) were more than three times more likely to have a preterm delivery than their counterparts (OR: 3.5; CI: 1.8-6.5; p<0.001). Maternal minority race, PTSD diagnosis, and newborn complications after discharge were not associated with PTB.

Table 3: Predictors of Newborn outcomes among 811 Newborns of Women Veterans.

A LBW delivery was significantly more likely among mothers who self-reported their race and/or ethnicity as non-white and/or Hispanic (OR: 2.3; 95% CI: 1.3, 4.0; p=0.003), and among Veterans with a diagnosis of PTSD (OR: 2.2; 95% CI: 1.3, 3.6; p=0.003). The remainder of the maternal sociodemographic and clinical characteristics were not associated with newborn birthweight in the final model. Neither PTB nor LBW were associated with VHA maternity care coordination or utilization of the VHA maternity benefit for prenatal and newborn care.

Discussion

This is the first study to examine newborn outcomes among women Veterans since the expansion of the VHA maternity benefit. Overall, the majority of Veterans’ newborns were fullterm and normal birthweight, and most newborns did not require extended hospital stays of more than 7 days. The prevalence of PTB was slightly higher in our cohort (11% vs 10%), as was LBW (9%) deliveries, compared to the general population (8.28%) [2]. In our study, infants who did experience problems at birth were more likely to have mothers who were older, self-identified as being non-white and/or Hispanic, and who were diagnosed with pregnancy-related health conditions. Among women aged 35 years or older, gestational hypertension and diabetes as maternal risk factors for adverse newborn outcomes is a well-known finding [25,29]. Risk factors for gestational diabetes and hypertension often coincidence with other medical and socioeconomic vulnerabilities, underscoring the essential need for VHA MCC and for having a patient advocate and co-navigator during this time.

Previous literature has demonstrated the association between the timing and frequency of prenatal care on newborn outcomes [29]. Our study findings highlight the need to further understand how these risk-specific factors and community-engaging models of prenatal care could be implemented in different profiles of Veterans to reduce PTB and LBW, most specifically among older and minority mothers, along with those diagnosed with PTSD. Increasing the amount of VHA MCC could be one way in which to further coordinate cares between VHA providers and community-based prenatal providers for Veterans at highrisk. The benefits of MCC have already been described in the Veteran population, [21] however, limited time and personnel make it very challenging to coordinate comprehensive care for all pregnant Veterans.

Advanced maternal age is a risk factor for negative pregnancy outcomes, including LBW and PTB, among both primiparas and multiparas [30,31]. Among our cohort, Veterans who were 35 years or older were at a higher risk of having a PTB. Previous work has described the impact of premature birth and its associated costs [32] along with the need for novel interventions that seek to delay premature labor, specifically in older Veterans. Delaying premature labor may lead to shorter stays, cost savings, and better neonatal outcomes.

Minority infants die of complications associated with low birthweight at almost three times the rate of their white counterparts [33]. Our study findings suggest that among newborns, those of non-white, minority race or ethnicity are more than two times more likely to be born at a low birthweight, even after adjusting for VHA benefit and MCC. Previous literature has underscored the role of maternal health care coverage on minority newborn outcomes. The expansion of Medicaid coverage for underserved women has resulted in the improved continuity and access to prenatal care, as well as better newborn outcomes [34,35]. Specifically, literature has reported greater reductions in rates of low birthweight and preterm birth outcomes among black infants relative to white infants in expansion Medicaid states [33].

Other potential, yet more complex explanations for the increased risk for low birthweight among non-white, minority race or ethnicity newborns, include maternal distrust in the healthcare system, social disparities such as income and neighborhood factors, stress, or physical health (including pre-pregnancy weight); yet, these factors were beyond the scope of this study [36]. Understanding these complex relationships is especially relevant in VHA mothers because many identify as non-white, minority race or ethnicity minority, and providing the best care possible, including averting adverse outcomes for Veterans’ newborns, is an important part of the VHA mission.

Our study found that women with a PTSD diagnosis had twice the odds of delivering a LBW newborn. Previous literature has assessed the relationship between PTSD and adverse newborn outcomes, yet these studies were often limited by small sample size or not exclusive to Veterans [37]. One study that did examine a large Veteran cohort found that women with a diagnosis of PTSD during pregnancy had a 35% increase in their odds for adverse newborn outcomes [7]. The early identification of Veterans of childbearing age with PTSD is imperative to preventing adverse pregnancy outcomes. It is important that Veterans with a PTSD diagnosis have adequate mental health care coordinated with their prenatal care in effort to reduce stress before, during, and after pregnancy.

Coordinated care is particularly important among Veterans who have a dual diagnosis of PTSD and depressive disorder which elevates the risk of PTB almost four-fold [38]. Forty-six percent of our cohort had a dual diagnosis of PTSD and depression resulting in women and newborns being particularly vulnerable. The VHA maternity care coordinator may be an effective resource in helping reduce adverse newborn outcomes among Veterans given that the first step towards better outcomes is to encourage prenatal care at an earlier date. This care should include the opportunity for the Veteran to discuss her PTSD with her prenatal care team/provider, ongoing VHA mental health care, and an active collaboration with a maternity care coordinator to address concerns about labor, breastfeeding, and prenatal visits that may further increase stress. The early identification of women with PTSD (and depression/ anxiety) may help reduce adverse pregnancy repercussions and morbidity; future research is needed on how to best intervene with mental health conditions to produce positive outcomes.

At two months post-delivery, 89% of our newborns had health insurance coverage. Although younger Veterans were less likely to have babies who were insured at two months, we did not find any significant associations between any of the maternal characteristics and newborn coverage. Our finding suggests opportunity to incorporate counseling on newborn insurance coverage into VHA MCC activities [39]. Alternative explanations, such as residing in a state where insurance options are more costly or less available, should also be explored.

Limitations of the study included lack of information on women Veterans who decided not to participate or were at VHA sites outside our sampling frame, however, sites were chosen to ensure racial and geographic diversity. Sociodemographic characteristics and clinical diagnoses made during pregnancy were self-reported as obstetrical and neonatal providers’ data were unavailable. Although most of the COMFORT sample was matched with their VHA EMR, some did not provide sufficient data to be matched. The measure of low birthweight (<5.8 pounds) is a relatively unrefined measure. Still, the COMFORT cohort provides a large and diverse dataset in which to explore correlates of newborn outcomes among women Veterans.

Implications for Practice and Policy

As the number of women Veterans utilizing the VHA Maternity benefit for pregnancy and delivery continues to increase, so does the need to provide targeted, collaborative prenatal care to Veterans who are older in age, of minority populations, who are at risk for gestational comorbidities, and who have been diagnosed with PTSD in effort to produce the best maternal and newborn outcomes.

Conclusion

The majority of our Veterans delivered full-term, normal birthweight babies, and 89% of newborns had health insurance coverage at two months after delivery. Yet Veterans have excess risk of adverse newborn outcomes including preterm birth and low birthweight. PTB and LBW deliveries increase the risk of complex medical comorbidities throughout childhood and adulthood. It is important that maternal risk factors are addressed early in pregnancy to facilitate full-term gestation and healthy newborns. VHA Public Law (PL) 111-163, Section 206 aids in providing a healthy start for Veterans’ newborns by providing health insurance for the first 7 days of life, which is particularly important in caring for PTB and LBW infants.

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