As we approach Memorial Day, it is worth noting that there have never been more women serving in the U.S. military, and consequently more women veterans, than there are right now. Many are in their childbearing years, including the majority of women servicemembers, 37 percent of all women veterans, and 42 percent of women veterans who use VA Health Care. Therefore, health and safety during pregnancy, birth, and postpartum are a critical concern for Congress, the Department of Defense, and the Department of Veterans Affairs (VA).
This issue is one of growing urgency given the high percentage of servicemembers and veterans who are Black women, and the current well-documented maternal health crisis for pregnant and birthing Black Americans who, compared with their white peers, are two to three times more likely to die during pregnancy and childbirth.
Servicemembers and veterans have better access to health care and education than the general population. However, data have repeatedly shown that neither health care access nor education are sufficient for reducing inequities in outcomes for Black pregnant and birthing people in the United States. This is also true among servicemembers and veterans. Newly emerging data indicate that Black pregnant and birthing servicemembers experience racial inequities. In a study of more than 15,000 births across 13 military hospitals, 2.7 percent of Black birthing servicemembers had severe complications compared with 1.7 percent of white servicemembers. Similarly, evidence indicates that among pregnant and birthing veterans who use the VA, Black veterans have a higher rate of severe complications than white veterans do.
Black pregnant and birthing veterans, particularly those using VA Health Care, face unique challenges. Veterans already face an uphill battle when it comes to healthy pregnancies. They are more likely to have adverse childhood experiences, including physical or sexual abuse, which are associated with poorer pregnancy outcomes, such as preterm birth. Military service also comes with unique risks like sexual trauma, musculoskeletal injuries, mental health issues, and environmental and occupational exposures. These all can increase risk of poor pregnancy outcomes. These concerns are borne out in recent research that suggests veterans using VA pregnancy benefits have increased risk for preterm birth and pregnancy complications compared to their nonveteran peers and veterans not using VA pregnancy benefits.
The VA has included pregnancy-related care in its medical benefits package since 1996. Recent estimates indicate that approximately 4,000 veterans use this benefit every year. For all labor and delivery care and nearly all prenatal care, the VA pays for veterans to see providers in their communities. Though this care is paid for by their VA benefits, it leaves the veteran in a precarious position, navigating among multiple doctors, clinics, and hospitals. Further, community providers are often unaware of history and risks military personnel and veterans carry: sexual trauma, depression, and posttraumatic stress disorder, all of which can make pregnancy and pregnancy-related care fraught for patients.
The VA has taken steps to help pregnant and postpartum veterans navigate these challenges. The maternity care coordination policy implemented in 2012 required all VA Health Care systems to have a designated maternity care coordinator. Unfortunately, implementation has been uneven.
More needs to be done as improving birth outcomes will require consistent access to services like culturally concordant midwifery and independent community-based birth center care, as well as doula support. Currently, these kinds of services are not widely available, as VA policy does not include doula coverage and there are ongoing barriers related to payment for independent birth centers. Legislation and allocated funding would be necessary to ensure access to prenatal and birth assistance for servicemembers and veterans.
Similarly, it will be important to dedicate funding to ensure that VA maternity care coordination is fully resourced, especially as demand for pregnancy-related care among veterans increases. Coordinators also need access (i.e., through telehealth and other technologies) to connect veterans to a range of providers trained in administering care during this critical pregnancy and postpartum period (e.g., reproductive mental health providers, lactation consultants, maternity specialists).
Additionally, there is need for providers outside the VA system to become familiar with the unique needs of this population. Finally, we need to incorporate military and veteran status into data that track maternal health outcomes to better understand how the health care system is working for pregnant and birthing servicemembers and veterans.
Women have served in the U.S. military officially and unofficially since the Revolutionary War. The rapid increase in women servicemembers and veterans since the early 2000s requires that we take steps to ensure their — and their babies’ —health.