Sufficiency of Health Information During Pregnancy: What's Missing and for Whom? A Cross-Sectional Analysis Among Veterans

Abstract

Background:

Women Veterans often experience trauma and physical and mental health conditions that increase risk of adverse pregnancy outcomes. Information provision during pregnancy may facilitate improved outcomes. However, little evidence exists about information women Veterans receive during pregnancy, and their perceptions of it.

Materials and Methods:

We recruited pregnant Veterans from 15 Veterans Affairs medical centers. Through telephone surveys, women (N = 851) provided information about sociodemographic characteristics, military service, health, and pregnancy experiences. We asked postpartum women whether, during pregnancy, they received sufficient information about nine health topics. We calculated a composite score (range: 0–9) that reflected sufficiency of information received. Multivariable logistic regression models identified determinants of perceived sufficiency of information.

Results:

Mean age was 32.1 years. Most reported being White (56.3%), non-Hispanic (80.3%), married/living with a partner (85.1%), and employed (54.4%). Most (54.6%) had been diagnosed with depression (54.6%); one-quarter reported current depressive symptoms. Mean sufficiency of information score was 6.9. Topics that women most reported they did not receive sufficient information on included, what to expect during delivery (32.3%) and how their spouse/partner might support them during labor (40.3%). History of depression (β = −0.35, p = 0.03), current depressive symptoms (β = −0.66, p = 0.001), military sexual trauma (β = 0.37, p = 0.03), and experience of violence (β = 0.66, p = 0.03) were associated with lower sufficiency of information scores.

Conclusion:

Results indicate need for enhanced and tailored provision of information for Veterans during pregnancy, particularly among those with experience of trauma, past depression diagnoses, and current depressive symptoms. This may include optimizing care coordination and increasing access to childbirth education classes and doula support.

Introduction

Women of reproductive age (18–45 years) make up the fastest growing population accessing Veterans Affairs (VA) health benefits. Their numbers tripled from ∼160,000 in 2000 to 440,000 in 2015.^1,2 Utilization of VA maternity benefits has increased even more rapidly than growth in the number of women Veterans of reproductive age. The number of women VA patients with deliveries paid for by Veterans Health Administration increased more than 14-fold from 2000 to 2015 (from 260 to 3756).^2,3

Because VA facilities do not have the capacity to provide maternity services directly, the VA contracts with community-based providers, from which women Veterans receive perinatal care as well as 7 days of newborn coverage.⁴ During this time, women Veterans continue to receive other primary and specialist care within VA. Previous studies document resulting fragmentation and care coordination challenges and highlight the need for optimized care coordination for women Veterans in the perinatal period.^5
–7

Studies have shown that women Veterans commonly face physical and mental health conditions as well as trauma experiences that increase their risk of adverse pregnancy outcomes. Compared with non-Veteran women, women Veterans have an increased likelihood of cardiovascular disease, hypertension, obesity, and tobacco use.^8,9 These physical risk factors are associated with maternal and fetal mortality and a range of pregnancy-related morbidities, including pre-eclampsia, gestational diabetes, preterm birth, and low birthweight.^10

–14

Women Veterans who utilize VA maternity benefits also have a higher prevalence of posttraumatic stress disorder (PTSD) and depression than the civilian population, the overall population of women Veterans, and their non-VA Veteran peers who access maternity benefits through other insurance (e.g., Medicaid, employer sponsored).^15
–17 Research has shown that women with PTSD and depression are more likely to have gestational diabetes, preeclampsia, and preterm birth.^{18

–25}

Experience of trauma, including sexual trauma and intimate partner violence (IPV) is associated with perinatal depression, preterm birth, and low birth weight. Approximately half of women VA users experience lifetime sexual trauma, and 38% of all women Veterans experience military sexual trauma (MST).^26
–28 Creech et al. found that 14% of pregnant Veterans had experienced IPV within the prior year.²⁹ Given the prevalence and the implications of sexual trauma and IPV on infant and maternal health outcomes, it is important to understand the role that these experiences play during pregnancy care.

Because women Veterans face substantial underlying risks and care fragmentation during pregnancy, VA has implemented a maternity care coordination program.³⁰ This program requires that each Veteran utilizing VA maternity benefits has an assigned Maternity Care Coordinator (MCC) who assesses their needs, provides information, acts as a contact between the Veteran and providers, and links Veterans with necessary resources.

The MCCs provide these services in part through the Maternity Care Coordinator Telephone Care Program (MCC-TCP), which includes up to eight structured calls to the Veteran at designated time points during pregnancy and in the postpartum period.³¹ These calls address VA maternity benefits, chronic health problems, smoking cessation, depression and suicide screening, interpersonal violence screening, pregnancy-related classes, breastfeeding support, women infants and children (WIC) program, postpartum obstetric care, family planning, and transitioning back to VA primary care. Some topics are discussed with every Veteran and some are addressed only if pertinent to the Veteran.

Accessible and comprehensive information provision is an essential aspect of patient-centered care that facilitates patient-led decision making.^32
–34 Sharing of health information is particularly important during pregnancy as women navigate rapid physical and emotional change and have repeated contact with multiple health providers.^35,36

Previous studies suggest that health information provision may give rise to improved health outcomes by promoting effective patient engagement and by facilitating social support, healthy decision making, and adherence to medical instructions.^{37

–44} Research has also linked provider communication of health information with patient satisfaction, which is, in turn, associated with better health outcomes.^{37,45

–49} Conversely, studies have also shown that perceived lack of access to information is associated with poor pregnancy outcomes, including preterm birth and infant mortality.⁵⁰

Provision of information may offer the greatest benefits for women who face high risks of adverse pregnancy outcomes. Past research documents that people of color and those with lower socioeconomic status or education level may perceive incomplete or biased information from providers during prenatal care; this influences the ability to fully understand the risks and benefits of care options and, ultimately, to make decisions related to their pregnancy and birth.^51
–53 This is pertinent to VA because 42% of women Veterans identify as a racial or ethnic minority, and poverty is a substantial problem among women Veterans.^2,54,55

Because information provision plays such an important role in experiences of care as well as health outcomes, it is important to understand women's perception of the information that they receive during pregnancy.³⁹ Additionally, the complex health profiles of the growing number of women utilizing VA maternity benefits makes it particularly important to identify the extent to which women Veterans receive adequate information during pregnancy. However, limited evidence exists about their experiences and perceptions of information receipt during pregnancy.

The objectives of this study were to describe Veteran's perceptions of the sufficiency of information received during pregnancy and identify the predictors of perceived sufficiency of information. Results of this study may be used to identify gaps in information provision during prenatal care and enable more nuanced and tailored prenatal care provision, which may ultimately contribute to improved maternal and infant health outcomes.

Materials and Methods

Sample

This study leveraged survey data collected from January 2016 through January 2021 for the Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study.^17,56 COMFORT is a longitudinal, prospective, multisite, observational cohort study of pregnant and postpartum Veterans at 15 VA facilities nationwide.

Pregnant Veterans were identified by their local VA MCC and invited by mail and a follow-up phone call to participate in the study by completing two telephone surveys, at ∼20 weeks of pregnancy and at ∼12 weeks postpartum. The surveys collected information about participant demographics, mental health, physical health, social support, military experience, medical care during pregnancy, experience of labor and delivery, and their newborn's health. COMFORT was approved by the Veterans Administration Central Institutional Review Board (CIRB).

Dependent variable: perceived sufficiency of information received during pregnancy

To ascertain perceptions of sufficiency of information received during pregnancy, participants were asked on the postpartum survey whether they felt they had received enough information about each of nine health topics: physical changes during pregnancy, emotional changes during pregnancy, warning signs of complications during pregnancy, the effects of medications on their baby, what to expect during labor and birth, how a spouse/partner might provide support during labor and delivery, medical tests and procedures that might be needed during pregnancy, recommended weight gain during pregnancy, and whether they were informed about their progress during labor.

Participants responded to each topic with either “Yes” or “No.” We coded these responses as 0 (no) or 1 (yes) and calculated a composite score that reflected sufficiency of information received during pregnancy for each participant by summing scores for each individual health topic. The sufficiency of information score ranges from 0 (low) to 9 (high).

We operationalized sufficiency of information as a continuous variable after examining the variable in several other ways (e.g., dichotomously based on the number of satisfied/unsatisfied responses, in tertiles based on sum scores response) and exploring patterns in the data to determine whether there were specific items for which participants frequently responded that they had received insufficient information. Because response patterns were random, we determined that a continuous variable would allow for the most straightforward interpretation.

Independent variables: COMFORT survey

Independent variables were selected based on their perceived and documented relationship to access to information, information needs during pregnancy, or to pregnancy outcome. We included race, socioeconomic status, age, select physical and mental health comorbidities, and MST.^{50

–53,57

–66} We also included several variables related to pregnancy experiences, including parity, timing of the first prenatal visit, continuity of care, provider type^{44,67

–75} participation in childbirth and breastfeeding classes, and MCC contact. Lastly, social support was included because of its established influence on pregnancy outcomes and association with informational support.^76,77 Below we detail the operationalization of the independent variables we examined.

Sociodemographic characteristics

We included the following demographic variables: participant race, ethnicity, marital status, age, and employment status. We examined self-reported race as White, Black, and other. Ethnicity was defined as women reporting being of Hispanic/Latinx descent or not. Marital status was defined as married and/or living with a partner, or not married (single, separated/divorced, or widowed). Employment status dichotomized into employed (full-time or part-time) or not employed (including unemployed, homemaker, and student).

Military-related characteristics

Experience of MST was identified with a two-item measure that is commonly used across the VHA, and which assesses a Veteran's experience of unwanted sexual attention or contact while in the military.⁷⁸

Health history

To identify potential high-risk pregnancies, we included experience of health problems during pregnancy as a dichotomous variable based on an affirmative self-response to any of the following conditions: diabetes and/or hypertension diagnosed before pregnancy, gestational diabetes and/or hypertension, pre-eclampsia or eclampsia, fibroids, asthma, multiple gestation pregnancy, and preterm labor and/or delivery. Mental health history was assessed by asking women whether they had ever been diagnosed with depression, anxiety, or PTSD. Additionally, perinatal depression was measured using the Edinburgh Postnatal Depression Scale (EPDS).⁷⁹ Because scores of 10 or more indicate depression symptoms during pregnancy, we dichotomized responses into <10 or 10+.

Pregnancy experience

Pregnancy variables included gestational age at delivery (weeks) and a variable indicating whether this was a participant's first pregnancy. Participants' experience of prenatal care within and outside the VA was measured by including number of weeks of pregnancy at first prenatal appointment (≤12 weeks; ≥13 weeks), type of prenatal provider (obstetrician or midwife/nurse practitioner), whether they had the same provider for prenatal care and delivery, if they had taken childbirth and/or breastfeeding classes, and whether and how frequently the participant spoke with the VA MCC (less than once a month, monthly, more than once a month).

Social support during pregnancy was measured by asking participants who or what resources they sought out for support during pregnancy (e.g., partner, immediate family, friends). Additionally, experience of interpersonal violence was analyzed with the Extended-Hit, Insult, Threaten, Scream (E-HITS) scale.²⁹ Based on previous work with women Veterans, we dichotomized total scores into <7 and 7+.^29,80 Scores of 7+ indicate experience of IPV.

Analysis

We began by examining descriptive statistics on our sample, using frequency (n) and percent (%) for categorical variables and mean, standard deviation, and range for continuous variables. Next, we conducted linear regression analysis using generalized estimating equations to identify the bivariate association between independent variables and patient-reported sufficiency of information received during pregnancy. Then we ran a multivariable model to examine the significant variables from our bivariate models and to rule out potential confounding. Finally, we ran a separate multivariable model specifying backward selection.

We ran a sensitivity analysis to identify whether excluding the item that measures sufficiency of information provided during labor (as opposed to during prenatal care) influenced results from our main model. All analyses were conducted using SAS version 9.2 (SAS Institute, Inc., Cary, NC).

Results

Table 1 presents participant characteristics. Among the 851 Veterans in our sample, mean age was 32.1 years old (±4.6). Most women reported being White (56.3%), non-Hispanic (80.3%), married or living with a partner (85.1%), and employed full- or part-time (54.4%). A large proportion of our participants had comorbid health conditions; 30% reported having health problems during the pregnancy. Over half (54.6%) had previously been diagnosed with depression, and a large proportion had been diagnosed with anxiety (47.4%) or PTSD (40.1%). Nearly a quarter (23.5%) of women had depression symptoms (EPDS score ≥10) at the time of their prenatal survey.

Table 1.

Participant Characteristics

Characteristic	Total (N = 851)
Characteristic	Mean ± SD, range
Sufficiency of information score	6.9 ± 2.4 (0–9)
Age (years)	32.1 ± 4.6 (20–49)
Gestational age at delivery (weeks)	38.7 ± 2.1 (26–42)
Weeks postpartum at postpartum interview	6.9 ± 3.5 (1–36)
	n (%)
Race
White	479 (56.3)
Black	198 (23.3)
Other	174 (20.4)
Hispanic/Latinx ethnicity	168 (19.7)
Employment status
Employed	463 (54.4)
Unemployed/homemaker/student	380 (44.6)
Marital status
Married or living with partner	724 (85.1)
Single/divorced/widowed	103 (12.1)
Health problems during pregnancy	255 (30.0)
Previous mental health diagnoses
Depression	465 (54.6)
Anxiety disorder	403 (47.4)
PTSD	341 (40.1)
EPDS score ≥10	200 (23.5)
Experienced MST	455 (53.5)
Interpersonal violence scale score
<7	486 (57.1)
7+	78 (9.2)
First pregnancy	288 (33.8)
Weeks pregnant at first prenatal visit
≤12	718 (84.4)
13+	127 (14.9)
Prenatal provider
OB/Gyn	691 (81.2)
Midwife/NP	122 (14.3)
Same provider during pregnancy and labor/delivery	545 (64.0)
Attended childbirth classes	183 (21.5)
Attended breastfeeding classes	160 (18.8)
Received any MCC services during pregnancy	700 (82.3)
Frequency of contact with MCC
Less than once per month	348 (40.9)
Once/month	270 (31.7)
More than once per month	89 (10.5)
Sources of social support during pregnancy
Immediate family	778 (91.4)
Friends	680 (79.9)

Some percentages may not sum to 100% due to missing data. Missing data are high for Interpersonal Violence (33.7% missing) and frequency of contact with MCC (16.9% missing) as these variables were added later to the COMFORT survey.

COMFORT, Center for Maternal and Infant Outcomes Research in Translation; EPDS, Edinburgh Postnatal Depression Scale; MCC, Maternity Care Coordinator; MST, military sexual trauma; NP, nurse practitioner; OB/Gyn, obstetrician/gynecologist; PTSD, posttraumatic stress disorder; SD, standard deviation.

Over half of our sample (53.5%) of our sample report experiencing MST and 9% indicated IPV in the past year. Most, 64%, reported that the same provider cared for them during pregnancy and delivery. Roughly one in five women attended childbirth (21.5%) or breastfeeding (18.8%) classes. The vast majority received support from an immediate family member (91.4%) or friends (79.9%) during pregnancy.

The average score of sufficiency of information received during pregnancy was 6.9 ± 2.4 (range: 0–9). Figure 1 depicts the items used in defining sufficiency of information received during pregnancy. Over 80% of our sample reported receiving enough information on physical (84.8%) and emotional (82.1%) changes, medical tests and procedures that might be needed during pregnancy (83.9%), progress during labor (83.8%), warning signs of complications (81.2%), and medications that might affect the baby (81.2%). Fewer women reported receiving enough information on recommended weight gain during pregnancy (70.3%), what to expect during labor and delivery (67.7%), and how their spouse/partner might support them during labor and delivery (59.7%; Fig. 1).

FIG. 1.

Percent of women in sample reporting that they received sufficient information during pregnancy, by topic.

Several variables in our models were associated with receipt of sufficient information during pregnancy. Women who were employed had higher information sufficiency scores, on average, compared with those who reported being unemployed, a homemaker, or a student (β = 0.60, standard error [SE] = 0.16, p = 0.0003). Both self-reported history of depression and current depressive symptoms were associated with lower information sufficiency scores (β = −0.35, SE = 0.16, p = 0.03; β = −0.66, SE = 0.19, p = 0.001; respectively).

History of trauma, both MST and IPV, was associated with lower sufficiency of information scores. Women who had experienced MST had a score 0.37 points lower than women who did not experience MST, on average (SE = 0.17; p = 0.03). Women who experienced IPV in the past year scored 0.66 points lower, on average, than women who did not experience IPV (SE = 0.30; p = 0.03).

Several pregnancy-related factors were also significantly associated with sufficiency of information scores: having the same provider for prenatal care and delivery/labor as well as attending childbirth classes increased scores by roughly 0.40 points (p < 0.05 for both). Finally, social support from an immediate family member was associated with a 0.62-point increase, on average, compared with women who report not having social support from an immediate family member (p = 0.03; Table 2).

Table 2.

Associations Between Individual Characteristics and Self-Reported Sufficiency of Information Received During Pregnancy

	β (SE)	p
Age (years)	−0.002 (0.02)	0.91
Gestational age at delivery (weeks)	0.09 (0.04)	0.02
Race (yes vs. no)
White	0.24 (0.16)	0.14
Black	−0.33 (0.19)	0.08
Other	−0.006 (0.20)	0.98
Hispanic/Latinx Ethnicity (yes vs. no)	−0.14 (0.20)	0.50
Employment status (employed vs. unemployed/homemaker/student)	0.60 (0.16)	0.0003
Marital status (married or living with partner vs. single/divorced/widowed)	0.46 (0.25)	0.07
Complications or health problems during pregnancy (yes vs. no)	0.05 (0.18)	0.79
Previous mental health diagnoses (yes vs. no)
Depression	−0.35 (0.16)	0.03
PTSD	−0.23 (0.17)	0.16
Anxiety disorder	0.16 (0.16)	0.32
EPDS score ≥10 (vs. <10)	−0.66 (0.19)	0.001
Experienced MST	−0.37 (0.17)	0.03
Interpersonal Violence Scale Score (7+ vs. <7)	−0.66 (0.30)	0.03
First pregnancy	0.19 (0.17)	0.28
Weeks pregnant at first prenatal visit (≤12 vs. 13+)	0.23 (0.23)	0.32
Prenatal provider (midwife/NP vs. OB/Gyn)	0.32 (0.23)	0.16
Same provider during pregnancy and labor/delivery	0.43 (0.17)	0.01
Attended childbirth classes	0.42 (0.20)	0.03
Attended breastfeeding classes	0.23 (0.21)	0.26
Received any MCC services during pregnancy	0.26 (0.22)	0.24
Frequency of contact with MCC
Less than once per month vs. once per month	−0.38 (0.19)	0.05
More than once per month vs. once per month	−0.03 (0.29)	0.92
Sources of social support during pregnancy
Immediate family	0.62 (0.29)	0.03
Friends	0.36 (0.20)	0.07

Bold values are statistically significant.

Our multivariable model included employment, past diagnosis of depression, EPDS score, any MST, past-year IPV, same provider for prenatal care and delivery, attended childbirth classes, and social support from an immediate family member. This model indicated that EPDS score and having the same provider for prenatal care and delivery were the only statistically significant predictors of sufficiency of information received during pregnancy. Depression was associated with a 0.63 (±0.26; p = 0.02) point decrease in information sufficiency and having the same provider throughout pregnancy and for delivery increased the sufficiency score by 0.46 (±0.22; p = 0.04) points after adjusting for the other factors in the model (results not shown).

A backward selection model further removed provider consistency and only left EPDS score ≥10 as the strongest predictor of sufficiency of information received in pregnancy (β = −0.85 ± 0.25, p = 0.001 for EPDS ≥10 vs. EPDS <10; data not shown). The sensitivity analysis shows that excluding the measure of sufficiency of information provided during labor does not change the results (Supplemental Appendix SA1).

Discussion

Our results identify the extent to which women Veterans feel that they received sufficient pregnancy-related information during prenatal care. The average sufficiency of information score (6.9) suggests that while most women in our sample felt that they received sufficient information across topics, a substantial percentage (between 15% and 40%, depending on topic area) felt that they did not. Women Veterans were most likely to report that they received insufficient information on what to expect and ways that their partner could support them in labor and birth. These results are important because prior research suggests that lack of knowledge regarding what to expect in labor may lead to a sequela of fear of labor, early presentation to the hospital, and increased likelihood of interventions, such as unwarranted cesarean section.⁸¹

We found that important information gaps exist even in topics where fewer women Veterans report that they received insufficient information. For example, almost 20% of women Veterans reported that they did not receive sufficient information about emotional changes in pregnancy. This finding underscores the need to identify those at risk of depression and connect them with mental health information and resources before delivery, particularly considering the high prevalence of previous mental health diagnoses and reported depressive symptomology in our sample.

Our results also identify that women with previous diagnosis experience of trauma (MST and IPV), diagnosis of depression, or an EPDS score >10 are more likely to report receipt of insufficient information. These results are important given the established links between mental health issues and trauma and poor perinatal outcomes.^18,19,82,83 This study aligns with research showing that depression and trauma influence the experience of care during pregnancy and offers a unique contribution by identifying factors that influence perceptions of sufficiency of information received during prenatal care.^56,84
–86

Future qualitative research could generate valuable insights into why those who have experienced trauma and depression are more likely to report receiving insufficient information during prenatal care. One plausible explanation is that women with depression or trauma experiences are less satisfied with care generally and this influences their perception of information sufficiency.^87,88

Our recent research currently under review indicates that women Veterans favor more depression screening within VA.⁸⁹ VA is presently exploring tools to ensure that women have greater access to depression care during pregnancy, such as through the Reach Out, stay Strong, Essentials (ROSE) program, an evidence-based intervention for prevention of perinatal depression that can be delivered via telehealth and is recommended by the United States Preventive Services Task Force for the prevention of perinatal depression. Programs such as ROSE will contribute to improving information provision for women with depression and other mental health concerns during the perinatal period.⁹⁰

Our results reinforce the importance of VA investment in programs that provide maternity care coordination and information, including the MCC-TCP program. Cordasco et al. show that the implementation of MCC-TCP is feasible and scalable, and that utilization is high among women Veterans.³¹ However, the current MCC-TCP content does not include information about what to expect and how partners might support during labor and delivery. Refining the content of the MCC-TCP to include this information is one potential approach to address the main information gaps identified in this study. Investment in programs like MCC-TCP, and ensuring that these programs are accessible to all veterans and are meeting their information needs, is critical to ensure that Veterans have access to the wide range of care and information required during the perinatal period.⁹¹

One notable finding from our study is the degree to which women lack information regarding labor and delivery, and how their partner might support them during that time. Research shows that women who have participated in childbirth education classes, which provide information about what to expect in labor, and have access to continuous support during labor are more likely to experience positive birth outcomes, including normal vaginal delivery, favorable Apgar scores, and satisfaction with the birth experience.^92,93

Although VA pays for childbirth education classes, less than a quarter of women in our sample attended them. This suggests that addressing barriers (e.g., clarifying processes for claiming this benefit, eliminating the requirement for pregnant Veterans to pay for the classes up front and then file for reimbursement) and increasing access to childbirth education classes is an important strategy to improving pregnant Veterans' access to necessary information.

Another strategy to address this gap may be increased support for women Veterans to utilize doulas. Doulas provide support beyond what is typically provided in the VA MCC-TCP. The MCC-TCP provides support and information to the Veteran during pregnancy through structured phone calls that conclude several weeks before the Veteran's delivery date for most women. MCC-TCP call content is structured and typically focuses on health screening, assistance with billing, and accessing specialty care.

Doulas could fill a gap because they typically provide care in person and they can extend tailored support and information in the prenatal period, through labor and delivery, and into the postpartum period to encourage optimal maternal and infant outcomes. Doulas also commonly work with the partners of pregnant women to enable them to provide better support.⁹⁴ Doula support is associated with reduced likelihood of cesarean deliveries, decreased use of analgesia and anesthesia, shorter labors, and higher Apgar scores.⁹⁵ Additionally, Hans et al. found that doula services improved infant-care behaviors among a racially diverse sample of low-income women.⁹⁶

This study has several strengths and limitations. Recall and social desirability bias may affect responses. The survey question on which we base our analysis queries information provision by providers. Because women get pregnancy-related information from a multitude of sources, it is difficult to isolate sufficiency of information received from providers from that received from other sources. Future research could explore locations of information sourcing among pregnant Veterans.

Additionally, the survey utilized binary variables questions (which do not allow nuanced response) to assess sufficiency of information in nine topics (emotional changes during pregnancy, recommended weight gain, etc.) using an unvalidated scale. There are many additional topics that women should be informed about in the prenatal period (postpartum transitions, breastfeeding, etc.) and, therefore, many potential information needs not addressed by this study. Future research could explore prenatal information needs qualitatively to enable more in-depth analysis and potentially increase validity.

Lastly, our survey did not allow for granular analysis of contact with MCC. To fully understand the potential of these programs to provide information during and after pregnancy, it is important to further analyze the accessibility of MCC-TCP and the extent to which it meets women's information needs. The study also has important strengths. We enrolled a large sample of women Veterans from 15 different sites across the country, allowing for a diverse sample and wider generalizability to women Veterans. We also had access to a wide variety of health and sociodemographic data collected from the survey and electronic health records.

Conclusion

Our results indicate a need for enhanced and tailored provision of information for women Veterans during pregnancy and labor and delivery, particularly among those with experience of trauma, past depression diagnoses, and EPDS scores suggestive of perinatal depression.

In the context of VA, this may include optimized care coordination, tailored MCC-TCP call content, increasing access to childbirth education classes, and expanded resourcing for doula support. Future research could analyze associations between sufficiency of information and expressed need for information, satisfaction with maternity care, service utilization, and health outcomes, particularly among those with identified risk factors. Such research could explore patient and provider perspectives on identifying and meeting information needs. Future research could also examine the feasibility of tailoring enhanced information provision initiatives, such as MCC-TCP, to focus on information gaps identified in this study.

Footnotes

Acknowledgment

The authors thank Dr. Jennifer Gierisch for contributions to conceptual framing.

Authors' Contributions

K.L.S.: conceptualization, methodology, writing—original draft, visualization; A.K.-D.: methodology, formal analysis, writing—review and editing; K.M.G.: conceptualization, writing—review and editing; M.M.S.: writing—review and editing; A.O.: writing—review and editing; K.M.: conceptualization, writing—review and editing, supervision, and funding acquisition. All authors have read and approved the final article.

Disclaimer

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the U.S. Government.

Author Disclosure Statement

The authors have nothing to disclose.

Funding Information

This work was supported by the Veterans Health Administration Health Services Research & Development IIR13-81 (K.M.). Dr. Sheahan's effort was covered by a VA Office of Academic Affiliations Health Services Research Postdoctoral Fellowship (TPH-2100). This work was also supported by the Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT; Project No. CIN 13-410) at the Durham VA Health Care System.

Supplementary Material

Supplemental Appendix SA1

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