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IIR 14-099 – HSR&D Study

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IIR 14-099
Pregnancy Outcomes of Veterans (PROVE)
Ciaran S. Phibbs PhD MA BA
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: April 2015 - September 2017

BACKGROUND/RATIONALE:
Reproductive outcomes are sensitive to many factors, including environmental exposures and maternal co-morbidities. The PI has conducted a preliminary study with VA fee data that found that maternal PTSD is associated with spontaneous preterm delivery. The PTSD study only had data on the fact that a spontaneous preterm delivery occurred, with no data on extent of prematurity, other causes of preterm delivery, or infant outcomes. This study will fill a significant gap in our knowledge of the effect of maternal PTSD on preterm delivery

OBJECTIVE(S):
The project will use linked VA and California data to:
Aim 1: Elucidate the effect of maternal PTSD on birth outcomes, confirming the increased risk of preterm birth, quantifying the distribution and character of such preterm births, and exploring other outcomes such as maternal complications (e.g., preeclampsia) and neonatal mortality.
Aim 2: Determine how pregnancy outcomes for Veterans differ from those of the general population and provide information on the pregnancy risks and outcomes of veterans.

METHODS:
We linked VA data with the California 2000-2012 birth cohort linked data (VS-PDD) using birth certificates, infant death certificates, fetal death certificates, discharge abstracts for the mothers and infants. This allowed the identification of deliveries to VA enrollees and the ability to add VA data about them (e.g., PTSD diagnosis). We linked 17,495 deliveries to enrolled women Veterans, of whom VA covered 1,292). The comparison population was very large at over 500,000 birth/year. We used regression analysis to control for medical (e.g., PTSD, hypertension) and social-demographic (e.g., age, race/ethnicity) risk factors to examine reproductive outcomes for different populations for a wide range of reproductive outcomes (e.g., preterm delivery, birth weight, pregnancy complications such as preeclampsia, congenital anomalies). We compared VA enrollees to the non-VA population, and within VA enrollees, we compared those who had VA cover their delivery with those who used other types of insurance to cover their delivery.

FINDINGS/RESULTS:
-The risk of preterm delivery associated with active PTSD during pregnancy was the same as our previous study with less complete data, OR 1.30. These preterm deliveries were more likely to be moderately preterm (32-36 weeks), than very preterm (<32 weeks), the OR for very preterm was 1.15.
-The pregnancy outcomes of Veterans were similar to those of the general population in California, except that deliveries to VA-enrolled Veterans were more likely to result in a NICU admission (OR=1.13).
-Most Veterans used other sources of insurance to cover their deliveries; private insurance covered about 50% of deliveries and Medicaid coverage about 25%. The VA-covered share increased over time, especially after the 2010 change that allowed VA to also cover the baby, and was 12% by the end of the study period. DoD covered about 15% of these deliveries.
-There were some differences between Veterans who used VA to pay for their delivery and Veterans who used other types of insurance; VA-covered deliveries had a higher rate of preeclampsia (OR 1.64) and NICU admission (OR 1.34).

IMPACT:
No impact yet, but the findings have been shared with VA Women's Health Services, and they are being considered for implications for VA policies.

The preliminary data have been shared with VA Women's Health Services, and were used to help them reply to a request for information to support proposed legislation to expand the VA coverage of the infant up to 42 days.

PUBLICATIONS:

Journal Articles

  1. Shaw JG, Asch SM, Katon JG, Shaw KA, Kimerling R, Frayne SM, Phibbs CS. Post-traumatic Stress Disorder and Antepartum Complications: a Novel Risk Factor for Gestational Diabetes and Preeclampsia. Paediatric and perinatal epidemiology. 2017 May 1; 31(3):185-194.
  2. Shaw JG, Asch SM, Kimerling R, Frayne SM, Shaw KA, Phibbs CS. Posttraumatic stress disorder and risk of spontaneous preterm birth. Obstetrics and gynecology. 2014 Dec 1; 124(6):1111-9.


DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Epidemiology, Etiology, Prognosis
Keywords: Gender Differences, Outcomes - Patient, PTSD, Reproductive Care (Gynecological), Risk Factors
MeSH Terms: none