Veteran Postpartum Health: VA Care Team Perspectives on Care Coordination, Health Equity, and Trauma-Informed Care

ABSTRACT

Introduction

A growing number of veterans are having children, and pregnancy is an opportunity to engage with health care. Within the Veterans Health Administration (VA), the VA maternity care coordination program supports veterans before, during, and after pregnancy, which are periods that inherently involve transitions between clinicians and risk care fragmentation. Postpartum transitions in care are known to be especially tenuous, with low rates of primary care reengagement. The objective of this study is to better understand this transition from the perspectives of the VA care teams.

Materials and Methods

Eight semi-structured qualitative interviews with VA team members who work in maternity care were conducted at a single VA center’s regional network. Interviews explored the transition from maternity care to primary care to understand the care team’s perspective at three levels: patient, clinician, and systems. Rapid qualitative analysis was used to identify emergent themes.

Results

Participants identified facilitators and opportunities for improvement in the postpartum transition of care. Patient–clinician trust is a key facilitator in the transition from maternity to primary care for veterans, and the breadth of VA services emerged as a key system-level facilitator to success. Interviewees also highlighted opportunities for improvement, including more trauma-informed practices for nonbinary veterans, increased care coordination between VA and community staff, and the need for training in postpartum health with an emphasis on health equity for primary care clinicians.

Conclusions

The Department of Veterans Affairs Healthcare System care team perspectives may inform practice changes to support the transition from maternity to primary care for veterans. To move toward health equity, a system-level approach to policy and programming is necessary to reduce barriers to primary care reengagement. This study was limited in terms of sample size, and future research should explore veteran perspectives on VA postpartum care transitions.

INTRODUCTION

With steadily increasing numbers of women and gender-diverse individuals serving in the U.S. military in the last two decades, an increased number of reproductive-aged veterans are relying on maternity care benefits from the U.S. Department of Veterans Affairs Health Care System (VA).^1,2 The Department of Veterans Affairs Healthcare System does not typically provide on-site obstetric services but instead purchases community–based obstetric care.³ The transition between care systems can lead to care fragmentation and potential discontinuity, especially in the postpartum period.^4–6 To address this, the VA maternity care coordination (MCC) program was launched in 2012 to support the goal of more seamless transitions and ensure appropriate care for veterans before, during, and after pregnancy.^4,6 MCC programs involve designated MCC staff, primary care physicians, obstetricians and gynecologists, pharmacists, and billing staff. A systematic review of MCC programs found that they are associated with increased engagement in care, cost savings, and improved maternal–infant outcomes.⁷ Limited study of the VA MCC program suggests that it plays a critical role for veterans as they navigate both VA and non-VA systems, coordinating maternity, medical, and mental health services.⁸

There are unique considerations for the postpartum transition in maternal health care of veterans, as prior quantitative studies suggest that veterans have adequate prenatal care engagement but low rates, and racial disparities, in reengagement in primary care after delivery.^9,10 Furthermore, maternal health equity is a crucial consideration as racial, ethnic, and geographic disparities in maternal outcomes are stark in the general U.S. population. The VA serves a population with a higher representation of Black, American Indian/Alaska Native, and rural individuals than the general population, underscoring the importance of supporting maternal care practices that promote equity.¹¹ Another consideration is the higher complexity of maternal health concerns more prevalent among veterans, including mental health conditions (such as anxiety, depression, and posttraumatic stress disorder) and pregnancy complications (such as gestational diabetes and hypertension).^12–14 For veterans with complex medical and mental health conditions, trauma-informed practices—guided by choice, safety, collaboration, trustworthiness, and empowerment—may be an integral part of maternal health care.¹⁵

To ensure that the VA MCC meets its aim of appropriate coordination and engagement in care for veterans using maternity care, it is important to better understand the barriers and facilitators to care these MCC teams encounter, with a focus on care coordination, health equity, and trauma-informed care. Thus, the objective of this study is to explore VA care teams’ perspectives on caring for veterans during the postpartum period.

MATERIALS AND METHODS

In this single-site pilot qualitative study, we conducted semi-structured interviews with VA clinical team members to learn about care and care coordination for veterans during the postpartum period.

Participant Selection

We used an intentional sampling technique to identify participants who met the following inclusion criteria: (1) VA Palo Alto Health Care System employee and (2) involved in VA women’s health and directly or indirectly with the MCC program. The scope of participants allowed our team to deeply explore care teams’ perspectives. The total sample size was guided by VA rules for locally initiated projects that limit the number of employees interviewed¹⁶; small samples in such qualitative work are often adequate to reach thematic saturation.¹⁷ Participants were recruited through VA email. Involvement in this study was voluntary, and participants were not compensated.

Interview Guide Development

We developed a semi-structured interview guide to explore barriers and facilitators to VA MCC in the postpartum period.^18,19 We structured the guide based on the health equity implementation framework, focusing on patient, clinical team, and system-level organization factors.²⁰ The interview guide began with an appreciative inquiry as an open-ended method to allow the interviewee to direct the conversation.²¹ After appreciative inquiry, we explored the following key domains around maternity care: MCC, maternal health equity, and trauma-informed care.²²

Interview Process

D.D.G. and M.S. conducted all interviews virtually via Zoom.²³ Interviews were 1 hour long, audio-recorded, and transcribed through Zoom. Either D.D.G. or M.S. led the interview, whereas the other took notes during the interview using a structured notes template based on the interview guide. Thematic saturation was achieved.

Data Analysis

We used a rapid qualitative analysis to identify latent themes from the interviews.²⁴ Two coders (M.S. and D.D.G.) conducted first-round independent coding of a structured interview notes template leveraging the health equity implementation framework (patient, clinician, and system factors) and interview domains (MCC, maternal health equity, and trauma-informed care). We then developed a summary template matrix to identify patterns across the interviews and iterate on the codebook; consensus was used to synthesize the final themes and illustrative quotes presented in results.

Reflexivity Statement

The research team provided a unique lens for this study, including research experience (women’s health, health equity, sociology, and perinatal outcomes) and clinical experience (family medicine, women’s health, and internal medicine). Interview guide development was shaped by team members’ research, clinical, and veteran care experience. When conducting interviews and qualitative analysis, lived experiences as women of color informed probing questions and emergent themes.

RESULTS

Table I shows the participants’ demographics. Participants described facilitators and barriers to providing VA maternity care for postpartum veterans. We found that trust, patient-centered care, and trauma-informed practices were important patient and clinician-level factors that either facilitated or impeded postpartum care. Key system-level factors included care coordination, education, and policy.

Facilitators to Care

Table II shows facilitators to care. Participants described three major patient-level factors impacting postpartum transitions: trust between the patient and clinician, the veteran’s social history, and the extent to which patient-centered care principles were demonstrated. Building trust is a critical piece of a successful maternity care transition between different health care professionals and clinics. The importance of trust was reflected in participants’ discussion of maintaining longitudinal relationships, engaging in conversations around military service, social history, racial issues, and the intersection of identities of patients. Participants also identified more intentional and skillful communication as a gateway into “patient-centered care.” In terms of relationship building, one participant said, “My patient felt a connection to me because I had been taking care of her for many years. She trusted who I referred her to and would always contact me for any issues/concerns.”

Participants described trauma-informed practices as necessary to build trust and create safe environments to avoid exacerbating the stress that patients with histories of different types of traumas might be experiencing. Allowing patients to feel autonomous and in control was described as an important component of effective patient–provider communication. For example, participants highlighted the importance of giving patients a sense of control over physical exams and procedures, including pelvic and breast exams and intrauterine device (IUD) insertions. In the context of sexual trauma, one participant shared, “The patient needs to know they have control over physical exams, and the provider needs to be cognizant of this control. Communication between the two is key.”

System-level factors impacting postpartum care experiences included access to VA specialty services and programmatic interventions. The VA’s investment in a separate women’s clinic has helped some veterans, particularly those with a history of military sexual trauma, feel safer when accessing care. Participants who worked directly in or in collaboration with the women’s clinic at the VA noted the positive impact that it has on many veterans receiving postpartum care. One participant shared the importance of having a designated health psychologist who knows about postpartum depression and trauma on the team as well. A majority of participants expressed gratitude for the multitude of VA specialty services that exist to support veterans, which can be leveraged during the postpartum period. One participant named this range of services as a motivating factor for many women reaccessing care in the VA postpartum, “The VA has pelvic floor therapy, a gynecologist, and many in-house services they can offer … mental health care in the VA is so great and inspires a lot of women to get support again at the VA.”

Barriers to Care and Opportunities for Improvement

Interview participants also described barriers to care and opportunities for improvement for veterans postpartum, including providing trauma-informed care for nonbinary veterans, better care coordination, standardized postpartum and racial inequity education for health care professionals, and addressing environmental determinants of access to health care (included in Table III). Several participants shared the need for health care professionals and the VA at large to better support nonbinary gender veterans. Participants reflected on the binary nature of the VA environment, highlighting that although the “women’s health clinic” offers a safe space for some veterans, it may alienate nonbinary veterans. Participants emphasized the importance that health care staff and professionals come from a culturally humble position and communicate openly to patients about gender identity.

Participants also identified opportunities to strengthen care coordination, including data collection and medical records sharing, to stay updated on the health of veterans once they transition into community care for obstetrics. Participants identified system-level barriers to care coordination, including transfer of records between VA and community clinicians and billing obstacles; for example, it is the responsibility of veterans to contact the billing office if they get an unexplained charge, necessitating time and effort, amid what is often an already stressful period of life and health transition. Participants further brainstormed ways of improving the processes in place, including sharing of best trauma-informed maternity care practices with community care clinicians. One participant shared, “The VA has some of the most internationally recognized centers for taking care of women and women-related trauma. The VA could perhaps consult community care clinicians with some of these trauma pieces.”

As care coordination was discussed in this context, participants identified a need for more education regarding trauma, racial inequities, and postpartum health in primary care training and women’s health mini-residencies at the VA.²⁵ For example, one participant noted that they were not trained to follow up on pregnancy history that involved gestational diabetes and hypertension. One participant described a locally developed postpartum checklist and named it as a regular practice they use for all patients. Reflecting on the existence of racial inequities in postpartum care, participants described how stigmatizing assumptions around Black motherhood and lack of community resources negatively impact care for patients. They described opportunities to track and educate colleagues on racial health equity outcomes regarding maternity care, as well as promote more education around interpersonal approaches to promote racial health equity. Finally, participants described a need for more education and training for staff on the issue of trauma in veterans, “There is a lot more that we can do and educate/train providers on this issue as new providers come on board. How do we make sure they have sensitivity/awareness training around trauma veterans experience?”

Suggestions for improvement included system-level policies working toward standardizing the maternity care transition process and clinical care nationally. For example, interviewees named implementing standard content and timing (e.g., 10 weeks) for primary care visits post-delivery and sending blood pressure cuffs to veterans who have hypertension or are at risk of preeclampsia. Participants universally named issues with financial coverage of maternity care as a system-level barrier during this transition: “We should really look at the patient-level factors that prevent engagement and ongoing care and follow through. How can the VA and its providers impact transport vouchers? Childcare support?”

DISCUSSION

Our interviews with care team members identified facilitators and barriers to care VA maternity care across patient, clinician, and system-level factors. The interviews highlighted needs for VA care team education in order to equitably serve a diverse veteran population.

Veterans who use VA healthcare are disproportionately from lower income strata, from racial and ethnic minority groups, and have a higher prevalence of medical and mental illnesss.²⁶ This underscores the importance of postpartum health equity and trauma-informed staff training. Clinicians who have participated in trauma-informed care training describe having increased knowledge, attitudes, and skills around how to implement trauma-informed care in their own practices.²⁷ Early evidence of training of this nature shows success in settings outside of the VA.²⁸ The VA currently has a few educational modules available for continued medical education accreditation, including one titled “Trauma-Informed Care and Women Veterans,” but there is an unmet opportunity for trauma-informed training specific to those caring for pregnant and postpartum veterans.

Our study identified that standardized education combined with tools—such as the postpartum care checklist used at our study site and other guideline-based resources²⁹—may be a way to support postpartum care provided by primary care clinicians. Previous studies show that access to postpartum care resources can improve clinical knowledge in this area.³⁰ Such resources may be a promising approach to explore systematic care for veterans as they transition from community-based clinicians back to the VA.

The postpartum to primary care transition also presents opportunities to improve the community care experience for veterans, as described in other VA–community care studies.^31,32 As an integrated health care system, the VA is poised to better facilitate this transition of care through policies that specifically promote the recommendations our participants shared, including medical record sharing, billing, and easier communication streams between the maternity care team on- and off-site in a timely manner.

A systematic review of VA and non-VA care reiterates that care at the VA is often better by many metrics, particularly with regard to the safety and effectiveness of care.³³ However, VA centers were less likely to offer full-spectrum reproductive services. Policy changes that could further promote efficient and quality care for veterans include on-site VA postpartum care as well as VA-paid community newborn care that extends beyond the current 7 days of coverage. Improving care coordination may improve health equity at the VA, as the failure to transition from obstetrical to primary care has been shown to harm postpartum health and exacerbate disparities in maternal outcomes.³⁴

Limitations

Our research includes a small sample size of eight interviewees, although the literature suggests that such small sample sizes can still reliably yield applicable results and reach thematic saturation.¹⁷ Another limitation is that our study scope focused on the VA care team, and those interviewed do not represent the diverse lived experiences of veterans themselves. Further research can explore veteran perspectives on VA maternity care.

CONCLUSIONS

Interviewees involved in MCC identified patient, care team, and system-level facilitators and barriers to VA maternity care in the postpartum period. To better meet the postpartum needs of veterans, the VA should focus on opportunities in care coordination, health equity, and trauma-informed care. These perspectives may inform VA education programs and policy changes to support the transition from maternity to primary care for veterans.

FUNDING

This work was made possible by Health Services R&D (Program 824): Locally Initiated Project (LIP) Funding from VA Ci2i.

CONFLICT OF INTEREST STATEMENT

None declared.

REFERENCES

Author notes