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IIR 13-081 – HSR&D Study

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IIR 13-081
Patterns and Experiences of VA Maternity Care Coordination for Women Veterans
Kristin Michelle Mattocks PhD MPH
VA Central Western Massachusetts Healthcare System, Leeds, MA
Leeds, MA
Funding Period: May 2015 - March 2021

Over the past decade, the number of women Veterans using VHA care has more than doubled, growing from 159,630 to 316,903 between FY00 and FY10. A substantial proportion of these women Veterans are of reproductive age, with over 90% of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) women Veterans age 45 years or less. As a result, VHA has substantially increased its attention to reproductive health care, including pregnancy-related care for these women Veterans. Recent evidence suggests the number of women Veterans delivering babies using VHA maternity benefits has nearly doubled in the past five years, and yet beyond a small handful of studies describing demographic and clinical characteristics of pregnant Veterans, little information exists regarding how these women access and utilize maternity care. Focused research on understanding pregnancy and maternity care for women Veterans has been recently identified as a critical next step in VHA's mission to provide high quality care for women Veterans. Furthermore, because nearly all maternity care is provided by community obstetrical providers through the non-VA care program, virtually nothing is known about how women Veterans access and use maternity care services, how their maternity care is coordinated, or how ongoing VHA care (e.g., primary care, specialty care, mental health care) is managed during and after pregnancy.

The objectives of this study are to: (a) investigate prevailing approaches for maternity care for women Veterans by conducting semi-structured interviews with women's primary care, gynecologic, mental health providers, Women Veteran Program; (b) explore pregnant Veterans' perspectives of and experiences with pregnancy, mental health and maternity care coordination during and after pregnancy; (c) examine selected maternal and infant health outcomes among women Veterans enrolled in the study

We plan to recruit pregnant Veterans (n=500) at 13 VA facilities across the country. We will survey the pregnant Veterans at approximately 20 weeks of pregnancy and again at 12 weeks postpartum. We will collect information regarding perceptions of maternity care coordination, as well as pregnancy experiences, co-existing physical and mental health conditions during pregnancy, social support, and postpartum health of both mother and baby. All surveys will be conducted using RedCap and will be administered by a study coordinator. Concurrently, we will be conducting interviews with women's primary care, gynecologic, mental health providers, Women Veteran Program Managers (WVPMs), Maternity Care Coordinators and fee basis/community obstetricians to understand the process of maternity care coordination for women Veterans and identify barriers to ideal maternity care coordination. All audio recordings will be transcribed by the VA Qualitative Research Core at the Salt Lake City VA Healthcare System. Analysis of qualitative data will be conducted using ATLAS.ti, a qualitative data analysis software program allowing fluid "interaction" of data across types and sources. For the quantitative data, we will summarize sample characteristics using descriptive statistics and bivariate analyses. We will apply regression analysis to explore the relationship between independent predictors and the outcomes of interest.

To date, 541 pregnant Veterans across 15 sites throughout United States have been recruited into the COMFORT study. Of these 581 women, 406 have delivered their babies and have completed interview The average age of the COMFORT cohort is 33 years (SD=4.6), 54% are Non-Hispanic, white, 62% are married, 35% report first pregnancy, 50% served in the Army, 74% served in OEF/OIF/OND, and 52% were using VA Choice. Among these women, 56% had a history of depression, 40% suffered from PTSD, and 46% had a diagnoses of anxiety. Twenty-nine percent of women had suffered from MST. Post-delivery interviews have been completed with 75% (406/541) of these Veterans (280 women have also completed survey #3), of which 31% delivered by Caesarean section. Twelve percent of deliveries occurred prior to 37 weeks gestation, which surpasses the national average of 11.5%. Similarly, 9% of infants were born weighing 5.8 pounds or less (low birthweight), which is higher than the national average of 7.9%. Overall, 18% of infants were admitted to intensive care units following birth, with 38% of these infants remaining in intensive care for 3 days or less. A majority (90%) of infants had health insurance at birth, and among those that didn't, the major reason for lack of insurance was inability to secure Medicaid coverage prior to birth.


A comprehension of site variation among Veterans receiving non-VA maternity care, may aid in targeting future efforts which seek to enhance pregnancy care outcomes and expand non-VA provider networks.


Journal Articles

  1. Mattocks KM, Kroll-Desrosiers A, Kinney R, Bastian LA, Bean-Mayberry B, Goldstein KM, Shivakumar G, Copeland L. Racial Differences in the Cesarean Section Rates Among Women Veterans Using Department of Veterans Affairs Community Care. Medical care. 2021 Feb 1; 59(2):131-138.
  2. Creech SK, Pulverman CS, Kroll-Desrosiers A, Kinney R, Dichter ME, Mattocks K. Intimate Partner Violence Among Pregnant Veterans: Prevalence, Associated Mental Health Conditions, and Health Care Utilization. Journal of general internal medicine. 2021 Jan 19.
  3. Kroll-Desrosiers AR, Crawford SL, Moore Simas TA, Clark MA, Mattocks KM. Treatment and Management of Depression Symptoms in Pregnant Veterans: Varying Experiences of Mental Health Care in the Prenatal Period. The Psychiatric quarterly. 2020 Jun 1; 91(2):475-493.
  4. Grekin R, Zivin K, Hall SV, Van T, Mattocks KM. Predictors of Veterans Affairs Health Service Utilization by Women Veterans during Pregnancy. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2020 Jul 1; 30(4):292-298.
  5. Keddem S, Solomon P, Marcus SC, Schapira MM, Mattocks KM. Disparities in Breastfeeding Among Military Veterans. Journal of human lactation : official journal of International Lactation Consultant Association. 2020 Feb 1; 36(1):64-73.
  6. Mattocks K, Casares J, Brown A, Bean-Mayberry B, Goldstein KM, Driscoll M, Haskell S, Bastian L, Brandt C. Women Veterans' Experiences with Perceived Gender Bias in U.S. Department of Veterans Affairs Specialty Care. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2020 Mar 1; 30(2):113-119.
  7. Gross GM, Kroll-Desrosiers A, Mattocks K. A Longitudinal Investigation of Military Sexual Trauma and Perinatal Depression. Journal of women's health (2002). 2020 Jan 1; 29(1):38-45.
  8. Kroll-Desrosiers AR, Crawford SL, Moore Simas TA, Clark MA, Bastian LA, Mattocks KM. Rates and Correlates of Depression Symptoms in a Sample of Pregnant Veterans Receiving Veterans Health Administration Care. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 Jul 1; 29(4):333-340.
  9. Mattocks KM, Kroll-Desrosiers A, Kinney R, Singer S. Understanding Maternity Care Coordination for Women Veterans Using an Integrated Care Model Approach. Journal of general internal medicine. 2019 May 1; 34(Suppl 1):50-57.
  10. Kroll-Desrosiers AR, Crawford SL, Moore Simas TA, Clark MA, Mattocks KM. Bridging the Gap for Perinatal Veterans: Care by Mental Health Providers at the Veterans Health Administration. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 May 1; 29(3):274-282.
  11. Mattocks KM, Baldor R, Bean-Mayberry B, Cucciare M, Gerber MR, Goldstein KM, Hammer KD, Hill EE, Kroll-Desrosiers A, Prochazka AV, Sadler AG, Bastian L. Factors Impacting Perceived Access to Early Prenatal Care among Pregnant Veterans Enrolled in the Department of Veterans Affairs. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2019 Jan 1; 29(1):56-63.

DRA: Health Systems, Other Conditions
DRE: none
Keywords: Care Coordination, Reproductive Care (Gynecological)
MeSH Terms: none

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