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Veterans Health: VA Should Improve Its Monitoring of Severe Maternal Complications and Mental Health Screenings

GAO-24-106209 Published: Jan 16, 2024. Publicly Released: Jan 16, 2024.
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Fast Facts

Pregnant veterans are more likely to have physical and mental health conditions that may lead to adverse maternal outcomes or complications. The Department of Veterans Affairs currently monitors maternal deaths and screens pregnant and postpartum veterans for mental health conditions.

But VA hasn't said when it will start reviewing screening results or what demographic data it will use when monitoring severe maternal complications to address disparities. Until VA reviews screenings and has information on complications, it may be harder for VA to improve veterans' maternal care and outcomes.

We recommended VA address these issues.

A pregnant person sitting across from a medical worker with a clipboard

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Highlights

What GAO Found

The Department of Veterans Affairs (VA) set a goal to understand and reduce veterans' maternal deaths and severe maternal morbidity, which is an unexpected outcome or complication of labor and delivery resulting in significant health consequences. VA data showed that 13 veterans died from pregnancy-related causes out of about 40,000 VA-paid delivery hospitalizations from fiscal years 2011 through 2020, 11 of whom were White. Further, GAO's analysis indicates the severe maternal morbidity rate increased from 93.5 per 10,000 VA-paid delivery hospitalizations in fiscal year 2011 to 184.6 per 10,000 in fiscal year 2020. This rate was highest among Black or African American veterans. VA monitors information on maternal deaths by race and ethnicity, and intends to start monitoring severe maternal morbidity rates. However, VA has not specified whether it will monitor these rates by race and ethnicity, among other veteran characteristics. Doing so would enhance VA's ability to improve this adverse maternal health outcome by identifying needed medical interventions or care coordination improvements for particular populations.

Severe Maternal Morbidity Rates by Veterans' Race, Fiscal Years 2011—2020

Severe Maternal Morbidity Rates by Veterans' Race, Fiscal Years 2011—2020

Note: VA data capture the number of veterans who had at least one severe maternal morbidity that was not a blood products transfusion as of labor and delivery, using the Centers for Disease Control and Prevention's definition of such morbidity and the Office of Management and Budget's categories of race. American Indian or Alaska Native, Asian, and Native Hawaiian or other Pacific Islander veterans had fewer than 1,000 VA-paid delivery hospitalizations each from fiscal years 2011 through 2020; thus, rates for these groups may be subject to fluctuations if calculated for different periods.

According to research, mental health conditions may increase the risk for severe maternal health complications, as well as the risk of maternal death by suicide. VA requires that each VA medical center designate a maternity care coordinator to serve as a liaison among pregnant and postpartum veterans and their health care providers. These staff are required to screen veterans for depression, suicide risk, and, as of October 2023, anxiety and post-traumatic stress disorder. VA officials have taken initial steps to monitor the occurrence and results of these screenings by hiring knowledgeable staff to help identify relevant data. However, VA officials have yet to determine when they will begin such monitoring or how frequently it will occur. As a result, VA may not have necessary information to ensure screenings are completed, which may be particularly important as the new screenings are implemented. Further, VA may lack information on ways to improve maternity care coordination based on screening results.

Why GAO Did This Study

Pregnant veterans are more likely than other pregnant women to have physical and mental health conditions that may contribute to adverse maternal health outcomes, according to research. Veterans' hospital deliveries, a service VA pays for by referral to community providers, grew by about 85 percent (from 2,567 to 4,766 deliveries) from fiscal years 2011 through 2020.

Congress included a provision in statute for GAO to review veterans' maternal health. This report, among other objectives, examines available VA data on, and VA's monitoring of, maternal health outcomes, as well as mental health screenings for pregnant and postpartum veterans.

GAO analyzed VA data on deaths and severe maternal morbidity among pregnant and postpartum veterans from fiscal years 2011 through 2020 (the most recent data available); reviewed VA policy and guidance on maternity care coordination; and interviewed VA officials and VA medical center staff. Staff were from four medical centers GAO selected for variation in the average number of deliveries among veterans, among other factors.

Recommendations

GAO is making two recommendations to VA to monitor (1) trends in severe maternal morbidity by veteran characteristics, such as race and ethnicity; and (2) maternity care coordinators' screening of veterans for mental health conditions, including the completion of these screenings and screening results. VA concurred with GAO's recommendations.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs The Secretary of Veterans Affairs should ensure that as OWH begins monitoring SMM on an ongoing basis, it disaggregates and reviews data on trends in SMM by veteran characteristics, such as race and ethnicity, age, or whether veterans lived in a rural area. (Recommendation 1)
Open
The Department of Veterans Affairs (VA) concurred with this recommendation. In July 2024, VA shared certain data it had compiled on severe maternal morbidity among veterans by race, ethnicity, and the location of their residences (rural or urban) for fiscal years 2019 through 2023 and the first quarter of fiscal year 2024, among other information. We will continue to monitor the agency's progress addressing the recommendation, including VA's plans to develop quarterly reports with these data as well to collect additional data by veterans' age.
Department of Veterans Affairs The Secretary of Veterans Affairs should ensure that OWH finalizes the development of and implements a systematic process to compile and review data on MCC screening of veterans for mental health conditions on an ongoing basis. This process should include data on MCCs' completion of required mental health screenings, as well as screening results. (Recommendation 2)
Open
VA concurred with this recommendation. VA indicated in its agency comments that it expected to develop a process to compile and review data on when maternity care coordinators complete required mental health screenings as well as the screening results. As of August 2024, VA stated that it was in the process of refining a dashboard it plans to use for this purpose. According to VA, these refinements, which VA indicated it expects to complete in December 2024, will address end user requirements and maximize the dashboard's effectiveness and report functionality. GAO will continue to monitor the status of this recommendation and consider VA's actions once completed.

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Topics

DeathsElectronic health recordsHealth careHealth care providersHospitalizationMental healthMorbidityMortalityPost-traumatic stress disordersPregnancyPrimary careSuicideVeteransVeterans medical centersWomen