Women's Health Issues 25-4 (2015) 377–381
www.whijournal.com
Original article
Prenatal Care for Women Veterans Who Use Department of Veterans Affairs Health Care Jodie G. Katon, PhD a,b,c,*, Donna L. Washington, MD, MPH d,e, Kristina M. Cordasco, MD, MPH, MSHS d,e, Gayle E. Reiber, PhD a,c,f, Elizabeth M. Yano, PhD, MSPH d,g, Laurie C. Zephyrin, MD, MPH, MBA, FACOG b,h a Health Services Research and Development (HSR&D), Department of Veterans Affairs (VA) Puget Sound Health Care System, VA Medical Center, Seattle, Washington b Women’s Veterans Health Services, Office of Patient Services, VA Central Office, Washington, DC c Department of Health Services, University of Washington School of Public Health, Seattle, Washington d VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California e Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California f Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington g Department of Health Policy and Management, University of California Los Angeles Jonathan and Karin Fielding School of Public Health, Los Angeles, California h Department of Obstetrics and Gynecology, New York University Langone School of Medicine, New York, New York
Article history: Received 22 September 2014; Received in revised form 9 March 2015; Accepted 10 March 2015
a b s t r a c t Objective: The number of women Veterans of childbearing age enrolling in Department of Veterans Affairs (VA) health care is increasing. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits. Study design: We used data from the National Survey of Women Veterans, a population-based survey. VA-eligible women veterans with at least one live birth who had ever used VA and were younger than 45 years when VA prenatal benefits became available were categorized based on self-reported receipt of VA prenatal benefits. Characteristics of by use of VA prenatal benefits were compared using c2 tests with Rao–Scott adjustment. All analyses used sampling weights. Results: In our analytic sample, of those who potentially had the opportunity to use VA prenatal benefits, 25% used these benefits and 75% did not. Compared with women veterans not using VA prenatal benefits, those who did were more likely to be 18 to 24 years old (39.9% vs. 3.7%; p ¼ .03), and more likely to have self-reported diagnosed depression (62.5% vs. 24.5%; p ¼ .02) and current depression or posttraumatic stress disorder (PTSD) symptoms (depression, 46.1% vs. 8% [p ¼ .02]; PTSD, 52.5% vs. 14.8% [p ¼ .02]). Compared with women veterans not using VA prenatal benefits, those who did were more likely to resume VA use after delivery (p < .001). Conclusion: Pregnant women veterans who use VA prenatal benefits are a high-risk group. Among those who opt not to use these benefits, pregnancy is an important point of attrition from VA health care, raising concerns regarding retention of women veterans within VA and continuity of care. Published by Elsevier Inc.
These findings were presented at a poster session at the AcademyHealth Gender and Health Interest Group, Baltimore, MD. June 22, 2013 Disclosure Statement: The authors report no conflicts of interest. * Correspondence to: Jodie G. Katon, PhD, VA Medical Center, 1660 S Columbian Way S-152, Seattle, WA 98108, USA. Phone: 011-1-206-277-1843; fax: 206764-2935. E-mail address: [email protected] (J.G. Katon). 1049-3867/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2015.03.004
The U.S. Census defines a veteran as any individual who has previously served in the United States Armed Forces (Washington, Sun, & Canning, 2010). Currently, there are 2.3 million women veterans in the United States (National Center for Veterans Analysis and Statistics, 2014). Women veterans are enrolling in Department of Veterans Affairs (VA) health care in record numbers, and women veterans of childbearing age
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J.G. Katon et al. / Women's Health Issues 25-4 (2015) 377–381
(18–45 years old) are the fastest group of new VA users (Friedman et al., 2011). Eligibility for VA benefits, including a vast range of health services, is based on multiple criteria, including service in a theatre of combat operations after November 11, 1998. Thus, the majority of new women veterans are eligible for VA health care benefits. VA maternity care, which was added to the VA benefits package in 1996, includes prenatal care, labor and delivery, and postpartum care (U.S. Department of Veterans Affairs, 2010, 2012). Demand for VA maternity care increased by 44% between 2008 and 2012 (Mattocks et al., 2014). No VA medical centers have the volume and capacity to support on-site provision of maternity care. Therefore, this care is outsourced to non-VA community providers, although a few sites provide on-site prenatal care (Katon et al., 2013; Washington, Caffrey, Goldzweig, Simon, & Yano, 2003; Yano, Washington, Goldzweig, Caffrey, & Turner, 2003). Some eligible pregnant women veterans do not avail themselves of this VA arranged care, and instead independently seek additional health care outside of the VA, through private insurance or state or federal programs such as Medicaid (Mengeling, Sadler, Torner, & Booth, 2011). Women veterans, particularly those using VA health care, have complex medical and mental health needs (Lehavot, Hoerster, Nelson, Jakupcak, & Simpson, 2012; Washington, Yano, Simon, & Sun, 2006). However, less is known regarding women veterans who use VA prenatal benefits. Among women veterans deployed to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) who use VA health care and have a delivery paid for by VA, 9% have a prepregnancy diagnosis of depression and 17% have a prepregnancy diagnosis of posttraumatic stress disorder (PTSD) documented in the VA medical records (Katon et al., 2014). Therefore, receiving continued VA services for their non–pregnancy-related conditions during and after pregnancy may be beneficial to overall health outcomes for pregnant women veterans. It is unclear whether these findings are generalizable to all women veterans using VA prenatal benefits. Understanding the characteristics of women veterans who use and do not use VA prenatal benefits is essential for VA providers, and non-VA providers paid to provide prenatal care to women veterans, to address the unique needs of this population and ensure continuity of care during pregnancy and after delivery. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits. Materials and Methods Data Source and Study Population We used data from the National Survey of Women Veterans (NSWV). The sampling frame and weights for this survey have been described previously (Washington et al., 2010). In brief, this was a national telephone survey, conducted from 2008 to 2009, that used a population-based stratified random sample of women veterans including VA users and nonusers. Stratifications were based on VA use/nonuse and military service period. Inclusion criteria were being a woman veteran of the regular armed forces or a member of the National Guard or Reserves who completed a tour of active duty. Exclusion criteria were current active military duty, VA employment, hospitalization, or residence in a long-term care facility. Eighty-six percent of screened and eligible women veterans consented to survey participation.
The NSWV collected data on VA and non-VA health care utilization, demographic characteristics, veteran-specific characteristics, history of medical and mental health diagnoses, and women veterans’ perceptions of VA. In this analysis, we sought to identify a subsample of women veterans who potentially had the opportunity to use VA prenatal benefits; therefore, we included only eligible women veterans who were current or former VA users, had ever had a pregnancy with a live birth, whose last use of VA occurred in 1996 or later, and who were no more than 45 years old (of childbearing age) in 1996 (when VA initiated maternity benefits; Figure 1). We excluded women who reported that they left VA before pregnancy or delivery because, owing to the way the survey questions were constructed, we could not separate those who left before pregnancy from those who left while they were pregnant. The NSWV received Institutional Review Board approval from VA Greater Los Angeles, and the survey was also approved by the U.S. Office of Management and Budget. This study was granted an exemption from full review by the VA Puget Sound Institutional Review Board. Analysis Variables Use of prenatal care purchased or provided by VA, collectively referred to as “VA prenatal benefits,” and resumption of VA health care use after delivery were defined based on responses to survey questions. Figure 1 illustrates the survey questions and our categorizations regarding use of VA prenatal benefits and resumption of VA health care use after delivery. Women were first asked whether their prenatal care was purchased or provided by VA. Those who answered affirmatively were then asked where this care was received. Women whose prenatal care was provided on-site at the VA or who received prenatal care at a “facility outside of the VA, but paid for by the VA” were considered users of VA prenatal benefits. Women were next asked, “After your delivery, how soon, if at all, did you go back to using VA health care?” Women who reported using VA on-site prenatal care exclusively were not asked about resuming VA health care use after delivery as, unlike other groups, they continued to receive on-site VA care during pregnancy and were therefore presumed not to have left VA. Demographic variables included current age group (18–24, 25–34, 35 years old), currently married (yes, no), education (4-year college graduate or not), employed (yes, no), uninsured (lack of any public or private insurance, yes, no), and race/ ethnicity (White, non-Hispanic; Black, non-Hispanic; Hispanic; and other). Responses for variables that change over time (e.g., age) reflect respondents’ status at the time of the survey. Veteran-specific characteristics included service connected disability rating (none, 0–40%, 50–100%). Respondents were asked if they had ever been diagnosed with depression or PTSD. Additionally, respondents completed a two-item screen for current depression symptoms and a screen for current PTSD symptoms (Washington, Davis, Der-Martirosian, & Yano, 2013). Statistical Analysis Demographic characteristics, veteran-specific characteristics, mental health, and resumption of VA use after delivery were compared by use of VA prenatal benefits, using c2 tests. All analyses used appropriate sampling weights and the STATA ‘subpop’ command to obtain weighted percentages accounting for the survey design and frequencies of the subpopulation of
J.G. Katon et al. / Women's Health Issues 25-4 (2015) 377–381
379
Figure 1. Findings related to Department of Veterans Affairs (VA) prenatal benefits in the National Survey of Women Veterans.
interest; statistical tests used the Rao–Scott adjustment (Rao & Scott, 1981; StataCorp, 2015; Washington et al., 2010). All statistical tests were two-sided with an alpha level of 0.05. When observed cell counts were less than 10, the Pearson exact test statistic was used. Analyses were carried out using STATA version 12 (StataCorp, 2013). Results The original survey included 3,611 respondents. After sequentially removing those who did not meet our eligibility criteria (Figure 1), our analytic sample included 334 women veterans: 97 who used VA prenatal benefits and 237 who did not use VA prenatal benefits. For the analysis of resumption of VA health care use after delivery, after excluding those who received prenatal care exclusively at VA (n ¼ 28) and those missing a response regarding resumption of VA health care (n ¼ 9), the analytic sample included 297 women veterans: 170 who resumed VA care after delivery and 127 who did not (Figure 1). At the time of the survey, the 45% of women veterans in our analytic sample were 35 years or younger and married (Table 1). Just over one-half were of White, non-Hispanic ethnicity, and nearly one-quarter had a disability acquired during military service (service-connected disability) of 50% to 100%. Mental health disorders included self-reported previously diagnosed depression in 34%, self-reported previously diagnosed PTSD in 10%, positive current screening for depression symptoms in 17.5%, and positive current screening for PTSD symptoms in 24.2%. Compared with those who did not use VA prenatal
benefits, those who did were younger, less likely to be currently employed, and more likely to be uninsured, although owing to the small sample size these differences were not all significant. Finally, compared with those who did not use VA prenatal benefits, those who did were more likely to have a service connected disability rating of 50% to 100%, more likely to have self-reported previously diagnosed depression, and more likely to screen positive for current symptoms of depression or PTSD. Overall, 60% of women veterans resumed VA health care use after delivery (Table 2). Compared with those who did not use VA prenatal benefits, those who did were more likely to resume VA health care use (90.9% vs. 52.8%; p < .001), with the greatest resumption of VA health use occurring in the initial three months. Discussion Our results indicate that, among pregnant women veterans, those use VA prenatal benefits are, on average, higher risk than those who do not use these benefits. Compared with those who choose not use VA prenatal benefits, Women veterans who use these benefits have lower levels of employment and education and greater mental health morbidity. Although nearly all women who use VA prenatal benefits return to VA care within 1 year of delivery, women who do not use these benefits are less likely to do so. The high rates of mental health morbidity are concerning because depression and PTSD are associated with an increased risk of adverse outcomes for both the mother and child (Grote et al., 2010; Morland et al., 2007; Seng, Low, Sperlich, Ronis, & Liberzon, 2011; Shaw et al., 2014; Yonkers et al., 2014). In the
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J.G. Katon et al. / Women's Health Issues 25-4 (2015) 377–381
Table 1 Characteristics of Women Veterans with Pregnancies in the National Survey of Women Veterans 2008–2009, by Use of Department of Veterans Affairs (VA) Prenatal Benefits (n ¼ 334) Characteristic
Demographic characteristics, %y Age group (y) 18–24 25–34 35 Currently married 4-Year college degree Employed Uninsured Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic All others Veteran specific (%)y Service connected disability None 0–40% 50–100% Mental health (%)y History of diagnosed depression History of diagnosed PTSD Depression symptoms PTSD symptoms
Total
Used VA Prenatal Benefits*
p Value
Yes
No
12.8 42.0 45.2 74.1 31.4 54.6 16.1
39.9 30.4 29.7 65.8 16.4 29.7 25.8
3.7 45.8 50.5 76.9 36.4 62.9 12.9
54.5 24.1 14.4 7.0
72.4 18.0 5.7 3.9
48.5 26.2 17.3 8.0
45.9 31.6 22.5
30.1 18.2 51.7
51.2 36.1 12.7
34.0 10.0 17.5 24.2
62.5 9.8 46.1 52.5
24.5 10.0 8.0 14.8
.002
.45 .15 .06 .19 .30
.02
.02 .98 .01 .02
Abbreviation: PTSD, posttraumatic stress disorder. * Includes prenatal care provided at VA (on-site prenatal care) and prenatal care provided at a facility outside VA, but paid for by VA (non-VA purchased prenatal care). y Weighted percent calculated using sampling weights and the ‘subpop’ command in STATA.
general population of pregnant women, the prevalence of PTSD is 8%, and prevalence of depression is estimated to be between 8% and 12% (Grote et al., 2010; Yonkers et al., 2014), whereas approximately 5% of pregnant women have a confirmed history of medically diagnosed depression (Bowers et al., 2013). In contrast, among women using VA prenatal benefits, rates of selfreported previous diagnosis of PTSD and depression were 9.8% and 62.5%, respectively, and approximately one-half screened positive for current PTSD or depression symptoms. Even among women veterans who did not use VA prenatal benefits, 24% had a self-reported history of previously diagnosed depression, although rates of self-reported history of diagnosed PTSD and current symptoms of PTSD and depression were similar to those in the general population. Thus, pregnant women veterans seem Table 2 Resumption of Department of Veterans Affairs (VA) Health Care Use after Delivery in the National Survey of Women Veterans 2008–2009, by Use of VA Prenatal Benefits (n ¼ 297)* p Value
Group
Total
Used VA Prenatal Benefits Yes
No
Returned to VA after delivery (%)y Quit VA (%)y
60.1 39.9
90.9 9.1
52.8 47.2
www.whijournal.com
Original article
Prenatal Care for Women Veterans Who Use Department of Veterans Affairs Health Care Jodie G. Katon, PhD a,b,c,*, Donna L. Washington, MD, MPH d,e, Kristina M. Cordasco, MD, MPH, MSHS d,e, Gayle E. Reiber, PhD a,c,f, Elizabeth M. Yano, PhD, MSPH d,g, Laurie C. Zephyrin, MD, MPH, MBA, FACOG b,h a Health Services Research and Development (HSR&D), Department of Veterans Affairs (VA) Puget Sound Health Care System, VA Medical Center, Seattle, Washington b Women’s Veterans Health Services, Office of Patient Services, VA Central Office, Washington, DC c Department of Health Services, University of Washington School of Public Health, Seattle, Washington d VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, North Hills, California e Department of Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California f Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington g Department of Health Policy and Management, University of California Los Angeles Jonathan and Karin Fielding School of Public Health, Los Angeles, California h Department of Obstetrics and Gynecology, New York University Langone School of Medicine, New York, New York
Article history: Received 22 September 2014; Received in revised form 9 March 2015; Accepted 10 March 2015
a b s t r a c t Objective: The number of women Veterans of childbearing age enrolling in Department of Veterans Affairs (VA) health care is increasing. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits. Study design: We used data from the National Survey of Women Veterans, a population-based survey. VA-eligible women veterans with at least one live birth who had ever used VA and were younger than 45 years when VA prenatal benefits became available were categorized based on self-reported receipt of VA prenatal benefits. Characteristics of by use of VA prenatal benefits were compared using c2 tests with Rao–Scott adjustment. All analyses used sampling weights. Results: In our analytic sample, of those who potentially had the opportunity to use VA prenatal benefits, 25% used these benefits and 75% did not. Compared with women veterans not using VA prenatal benefits, those who did were more likely to be 18 to 24 years old (39.9% vs. 3.7%; p ¼ .03), and more likely to have self-reported diagnosed depression (62.5% vs. 24.5%; p ¼ .02) and current depression or posttraumatic stress disorder (PTSD) symptoms (depression, 46.1% vs. 8% [p ¼ .02]; PTSD, 52.5% vs. 14.8% [p ¼ .02]). Compared with women veterans not using VA prenatal benefits, those who did were more likely to resume VA use after delivery (p < .001). Conclusion: Pregnant women veterans who use VA prenatal benefits are a high-risk group. Among those who opt not to use these benefits, pregnancy is an important point of attrition from VA health care, raising concerns regarding retention of women veterans within VA and continuity of care. Published by Elsevier Inc.
These findings were presented at a poster session at the AcademyHealth Gender and Health Interest Group, Baltimore, MD. June 22, 2013 Disclosure Statement: The authors report no conflicts of interest. * Correspondence to: Jodie G. Katon, PhD, VA Medical Center, 1660 S Columbian Way S-152, Seattle, WA 98108, USA. Phone: 011-1-206-277-1843; fax: 206764-2935. E-mail address: [email protected] (J.G. Katon). 1049-3867/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2015.03.004
The U.S. Census defines a veteran as any individual who has previously served in the United States Armed Forces (Washington, Sun, & Canning, 2010). Currently, there are 2.3 million women veterans in the United States (National Center for Veterans Analysis and Statistics, 2014). Women veterans are enrolling in Department of Veterans Affairs (VA) health care in record numbers, and women veterans of childbearing age
378
J.G. Katon et al. / Women's Health Issues 25-4 (2015) 377–381
(18–45 years old) are the fastest group of new VA users (Friedman et al., 2011). Eligibility for VA benefits, including a vast range of health services, is based on multiple criteria, including service in a theatre of combat operations after November 11, 1998. Thus, the majority of new women veterans are eligible for VA health care benefits. VA maternity care, which was added to the VA benefits package in 1996, includes prenatal care, labor and delivery, and postpartum care (U.S. Department of Veterans Affairs, 2010, 2012). Demand for VA maternity care increased by 44% between 2008 and 2012 (Mattocks et al., 2014). No VA medical centers have the volume and capacity to support on-site provision of maternity care. Therefore, this care is outsourced to non-VA community providers, although a few sites provide on-site prenatal care (Katon et al., 2013; Washington, Caffrey, Goldzweig, Simon, & Yano, 2003; Yano, Washington, Goldzweig, Caffrey, & Turner, 2003). Some eligible pregnant women veterans do not avail themselves of this VA arranged care, and instead independently seek additional health care outside of the VA, through private insurance or state or federal programs such as Medicaid (Mengeling, Sadler, Torner, & Booth, 2011). Women veterans, particularly those using VA health care, have complex medical and mental health needs (Lehavot, Hoerster, Nelson, Jakupcak, & Simpson, 2012; Washington, Yano, Simon, & Sun, 2006). However, less is known regarding women veterans who use VA prenatal benefits. Among women veterans deployed to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) who use VA health care and have a delivery paid for by VA, 9% have a prepregnancy diagnosis of depression and 17% have a prepregnancy diagnosis of posttraumatic stress disorder (PTSD) documented in the VA medical records (Katon et al., 2014). Therefore, receiving continued VA services for their non–pregnancy-related conditions during and after pregnancy may be beneficial to overall health outcomes for pregnant women veterans. It is unclear whether these findings are generalizable to all women veterans using VA prenatal benefits. Understanding the characteristics of women veterans who use and do not use VA prenatal benefits is essential for VA providers, and non-VA providers paid to provide prenatal care to women veterans, to address the unique needs of this population and ensure continuity of care during pregnancy and after delivery. Our objective was to describe characteristics of women veterans and resumption of VA care after delivery by use of VA prenatal benefits. Materials and Methods Data Source and Study Population We used data from the National Survey of Women Veterans (NSWV). The sampling frame and weights for this survey have been described previously (Washington et al., 2010). In brief, this was a national telephone survey, conducted from 2008 to 2009, that used a population-based stratified random sample of women veterans including VA users and nonusers. Stratifications were based on VA use/nonuse and military service period. Inclusion criteria were being a woman veteran of the regular armed forces or a member of the National Guard or Reserves who completed a tour of active duty. Exclusion criteria were current active military duty, VA employment, hospitalization, or residence in a long-term care facility. Eighty-six percent of screened and eligible women veterans consented to survey participation.
The NSWV collected data on VA and non-VA health care utilization, demographic characteristics, veteran-specific characteristics, history of medical and mental health diagnoses, and women veterans’ perceptions of VA. In this analysis, we sought to identify a subsample of women veterans who potentially had the opportunity to use VA prenatal benefits; therefore, we included only eligible women veterans who were current or former VA users, had ever had a pregnancy with a live birth, whose last use of VA occurred in 1996 or later, and who were no more than 45 years old (of childbearing age) in 1996 (when VA initiated maternity benefits; Figure 1). We excluded women who reported that they left VA before pregnancy or delivery because, owing to the way the survey questions were constructed, we could not separate those who left before pregnancy from those who left while they were pregnant. The NSWV received Institutional Review Board approval from VA Greater Los Angeles, and the survey was also approved by the U.S. Office of Management and Budget. This study was granted an exemption from full review by the VA Puget Sound Institutional Review Board. Analysis Variables Use of prenatal care purchased or provided by VA, collectively referred to as “VA prenatal benefits,” and resumption of VA health care use after delivery were defined based on responses to survey questions. Figure 1 illustrates the survey questions and our categorizations regarding use of VA prenatal benefits and resumption of VA health care use after delivery. Women were first asked whether their prenatal care was purchased or provided by VA. Those who answered affirmatively were then asked where this care was received. Women whose prenatal care was provided on-site at the VA or who received prenatal care at a “facility outside of the VA, but paid for by the VA” were considered users of VA prenatal benefits. Women were next asked, “After your delivery, how soon, if at all, did you go back to using VA health care?” Women who reported using VA on-site prenatal care exclusively were not asked about resuming VA health care use after delivery as, unlike other groups, they continued to receive on-site VA care during pregnancy and were therefore presumed not to have left VA. Demographic variables included current age group (18–24, 25–34, 35 years old), currently married (yes, no), education (4-year college graduate or not), employed (yes, no), uninsured (lack of any public or private insurance, yes, no), and race/ ethnicity (White, non-Hispanic; Black, non-Hispanic; Hispanic; and other). Responses for variables that change over time (e.g., age) reflect respondents’ status at the time of the survey. Veteran-specific characteristics included service connected disability rating (none, 0–40%, 50–100%). Respondents were asked if they had ever been diagnosed with depression or PTSD. Additionally, respondents completed a two-item screen for current depression symptoms and a screen for current PTSD symptoms (Washington, Davis, Der-Martirosian, & Yano, 2013). Statistical Analysis Demographic characteristics, veteran-specific characteristics, mental health, and resumption of VA use after delivery were compared by use of VA prenatal benefits, using c2 tests. All analyses used appropriate sampling weights and the STATA ‘subpop’ command to obtain weighted percentages accounting for the survey design and frequencies of the subpopulation of
J.G. Katon et al. / Women's Health Issues 25-4 (2015) 377–381
379
Figure 1. Findings related to Department of Veterans Affairs (VA) prenatal benefits in the National Survey of Women Veterans.
interest; statistical tests used the Rao–Scott adjustment (Rao & Scott, 1981; StataCorp, 2015; Washington et al., 2010). All statistical tests were two-sided with an alpha level of 0.05. When observed cell counts were less than 10, the Pearson exact test statistic was used. Analyses were carried out using STATA version 12 (StataCorp, 2013). Results The original survey included 3,611 respondents. After sequentially removing those who did not meet our eligibility criteria (Figure 1), our analytic sample included 334 women veterans: 97 who used VA prenatal benefits and 237 who did not use VA prenatal benefits. For the analysis of resumption of VA health care use after delivery, after excluding those who received prenatal care exclusively at VA (n ¼ 28) and those missing a response regarding resumption of VA health care (n ¼ 9), the analytic sample included 297 women veterans: 170 who resumed VA care after delivery and 127 who did not (Figure 1). At the time of the survey, the 45% of women veterans in our analytic sample were 35 years or younger and married (Table 1). Just over one-half were of White, non-Hispanic ethnicity, and nearly one-quarter had a disability acquired during military service (service-connected disability) of 50% to 100%. Mental health disorders included self-reported previously diagnosed depression in 34%, self-reported previously diagnosed PTSD in 10%, positive current screening for depression symptoms in 17.5%, and positive current screening for PTSD symptoms in 24.2%. Compared with those who did not use VA prenatal
benefits, those who did were younger, less likely to be currently employed, and more likely to be uninsured, although owing to the small sample size these differences were not all significant. Finally, compared with those who did not use VA prenatal benefits, those who did were more likely to have a service connected disability rating of 50% to 100%, more likely to have self-reported previously diagnosed depression, and more likely to screen positive for current symptoms of depression or PTSD. Overall, 60% of women veterans resumed VA health care use after delivery (Table 2). Compared with those who did not use VA prenatal benefits, those who did were more likely to resume VA health care use (90.9% vs. 52.8%; p < .001), with the greatest resumption of VA health use occurring in the initial three months. Discussion Our results indicate that, among pregnant women veterans, those use VA prenatal benefits are, on average, higher risk than those who do not use these benefits. Compared with those who choose not use VA prenatal benefits, Women veterans who use these benefits have lower levels of employment and education and greater mental health morbidity. Although nearly all women who use VA prenatal benefits return to VA care within 1 year of delivery, women who do not use these benefits are less likely to do so. The high rates of mental health morbidity are concerning because depression and PTSD are associated with an increased risk of adverse outcomes for both the mother and child (Grote et al., 2010; Morland et al., 2007; Seng, Low, Sperlich, Ronis, & Liberzon, 2011; Shaw et al., 2014; Yonkers et al., 2014). In the
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J.G. Katon et al. / Women's Health Issues 25-4 (2015) 377–381
Table 1 Characteristics of Women Veterans with Pregnancies in the National Survey of Women Veterans 2008–2009, by Use of Department of Veterans Affairs (VA) Prenatal Benefits (n ¼ 334) Characteristic
Demographic characteristics, %y Age group (y) 18–24 25–34 35 Currently married 4-Year college degree Employed Uninsured Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic All others Veteran specific (%)y Service connected disability None 0–40% 50–100% Mental health (%)y History of diagnosed depression History of diagnosed PTSD Depression symptoms PTSD symptoms
Total
Used VA Prenatal Benefits*
p Value
Yes
No
12.8 42.0 45.2 74.1 31.4 54.6 16.1
39.9 30.4 29.7 65.8 16.4 29.7 25.8
3.7 45.8 50.5 76.9 36.4 62.9 12.9
54.5 24.1 14.4 7.0
72.4 18.0 5.7 3.9
48.5 26.2 17.3 8.0
45.9 31.6 22.5
30.1 18.2 51.7
51.2 36.1 12.7
34.0 10.0 17.5 24.2
62.5 9.8 46.1 52.5
24.5 10.0 8.0 14.8
.002
.45 .15 .06 .19 .30
.02
.02 .98 .01 .02
Abbreviation: PTSD, posttraumatic stress disorder. * Includes prenatal care provided at VA (on-site prenatal care) and prenatal care provided at a facility outside VA, but paid for by VA (non-VA purchased prenatal care). y Weighted percent calculated using sampling weights and the ‘subpop’ command in STATA.
general population of pregnant women, the prevalence of PTSD is 8%, and prevalence of depression is estimated to be between 8% and 12% (Grote et al., 2010; Yonkers et al., 2014), whereas approximately 5% of pregnant women have a confirmed history of medically diagnosed depression (Bowers et al., 2013). In contrast, among women using VA prenatal benefits, rates of selfreported previous diagnosis of PTSD and depression were 9.8% and 62.5%, respectively, and approximately one-half screened positive for current PTSD or depression symptoms. Even among women veterans who did not use VA prenatal benefits, 24% had a self-reported history of previously diagnosed depression, although rates of self-reported history of diagnosed PTSD and current symptoms of PTSD and depression were similar to those in the general population. Thus, pregnant women veterans seem Table 2 Resumption of Department of Veterans Affairs (VA) Health Care Use after Delivery in the National Survey of Women Veterans 2008–2009, by Use of VA Prenatal Benefits (n ¼ 297)* p Value
Group
Total
Used VA Prenatal Benefits Yes
No
Returned to VA after delivery (%)y Quit VA (%)y
60.1 39.9
90.9 9.1
52.8 47.2
