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Both PTSD Symptoms and Moral Injury are Associated with Adverse Perinatal Outcomes among Women Veterans

Women Veterans are exposed to a wider range and greater frequency of highly stressful and/or traumatic experiences across their lives as compared to their civilian counterparts (i.e., longer durations of childhood sexual abuse). In turn, these experiences are associated with a range of negative consequences for mental health (i.e., PTSD). Both PTSD and moral injury may have implications for women's pregnancy-related outcomes after they leave military service. This longitudinal study is the first to examine the impact of PTSD symptoms and moral injury on adverse perinatal outcomes among women who became pregnant in the first three years after separating from military service (n = 318). Perinatal outcomes included experiencing an adverse pregnancy outcome (e.g., preterm birth, gestational diabetes), postpartum depression and/or anxiety, and perception of a difficult pregnancy. Self-report measures were used to assess the degree to which Veterans experienced distress related to transgressions of deeply held moral beliefs (moral injury) while in the military, as well as PTSD symptoms. Potential confounders included demographics, socioeconomic status, and lifetime trauma.


  • After adjusting for age, racial/ethnic minority status, socioeconomic status, and lifetime trauma, both PTSD symptoms and moral injury were associated with adverse perinatal outcomes.
  • Only women with greater PTSD symptoms were more likely to report having postpartum depression/anxiety, and to describe their pregnancy as being more difficult.


  • The new VA/DoD clinical practice guidelines on pregnancy management published in March 2018 incorporate the importance of screening for mental health conditions regularly during pregnancy, as well as the coordination of care between medical and mental health providers to prevent adverse perinatal outcomes. These findings specifically support increased screening for PTSD and moral injury, in order to increase access to treatment for these problems as warranted.


  • PTSD symptoms, moral injury, and perinatal outcomes were measured by self-report, which relies on a respondents’ perceptions and memory and may be subject to some level of response bias.
  • Unmeasured factors such as medication use, substance use, chronic health conditions, and the use of prenatal care may have impacted associations.

Dr. Nillni is with the National Center for PTSD at VA Boston Healthcare System; Dr. Finley is with The Elizabeth Dole Center of Excellence for Veteran and Caregiver Research; Dr. Copeland is with the VA Central Western Massachusetts Healthcare System; and Dr. Vogt is with the National Center for PTSD at VA Boston Healthcare System and is part of HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR).

Nillni Y, Shayani D, Finley E, Copeland L, Perkins D, and Vogt D. The Impact of PTSD and Moral Injury on Women Veterans’ Perinatal Outcomes Following Separation from Military Service. Journal of Traumatic Stress. June 2020;33(3):248-56.

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