Funded by the VA HSR&D (Project# SDR 10-012)

Spotlight on Women Cyberseminar Series
Understanding reproductive healthcare 

outcomes among women Veterans: A revi

recent research and future opportunitie

Kristin M. Mattocks, Ph.D.

Associate Chief of Staff/Research

VA Central Western Massachusetts

and

Laurie C. Zephyrin Zephyrin, MD, MPH, MBA

Director, Reproductive Health

Women Veterans Health Strategic Healthcare Group 

Presented for Women’s Health HSR&D Cyberseminar

January 31, 2012
Overview

1. Defining reproductive and gender‐specifi2. Profile of women Veterans in VA care

3. Research focusing on:

– Contraception– Pregnancy– Gender‐specific conditions conditions– Reproductive health preferences and experi

4. Overview of emerg g in VA reproductive h

programs and policies (Dr. Laurie Zephyri

5. Reproductive Health Working group
POLL QUESTION

What best describes describes your position position at the • Researcher• Cli i i Clinician

• Administrator/policymaker

• Other
Poll Question

• How much familiarity familiarity do you have wit

reproductive or gender‐specific researc

and/or policy at the VA?

– Very familiar– Moderately familiar– Somewhat familiar– A little bit familiar familiar– Not familiar at all
Reproductive Health Care

• Reproductive Health:

– “Reproductive health is a state of complet

physical, mental and social well‐being, and 

merely the absence of reproductive diseas

infirmity. Reproductive health deals with t

reproductive reproductive processes processes, functions functions and syst

all stages of life.”

– World Health Organization, 2011.
Gender‐Specific Care

• Ca er t at h is p ay rim rily rece ed iv by, a dn ta g

targ

women Veterans, including:

– Menstrual disorders Vaginitis/cer– C il erv cal D l i /ASCUS Dysplasia/ASCUS Pregnancy

– Benign breast conditions Ovarian cyst– Benign gynecologic conditions Female Infe

– Menopausal disorders Sexual dysfu– Osteoporosis Breast cance– Ovarian cancer Uterine canc– Female genital cancer Ectopic preg– Genital organ prolapse Urinary trac– Sexually transmitted transmitted diseases diseases (STDs) Endometrio

Endometrio

– Cervical cancer
Number of Women Veterans Using VA

D bl d ou e over Past D d eca e

Cohort: Women and men Veteran VHA users in year. Women in FY09: N=292,921; Men in FY09: N=4,846,869.

Source: WHEI analysis of ADUSH Monthly Enrollment Files, FY00–FY09.

.Sourcebook: Women Veterans in the Veterans Health Administration  ‐ Volume 1 (December 2010)
Women VA Patients: Three P

Source: Women’s Health Evaluation Initiative (WHEI) and the Women Veterans Health Strategic Healt

SourceBook: Women Veterans in the Veterans Health Administration V1: Sociodemographic Characteof VHA Care, 2011.
Gender‐Specific Healthcare Ne

• Basic gender‐specific specific services services:

– Breast examinations– Cervical cancer screening– Management of contraceptive medication– Menopause management

• Specialized gender‐specific services:

– Obstetric care– Gynecologic and breast cancers– Infertility care
VA Surveys of Women Veterans He

Programs & Practices

• Measured organizational organizational factors factors predic

predic

clinical quality

– Local PC delivery delivery arrangements arrangements (e g. ., wome

primary care clinic, designated WH provider in ge

primary care)

– WH service availability (e.g., onsite vs. offsite

and specialty women’s health care)

– Local authority over practice changes (e.g.,

determining staffing arrangements)

•Yano EM, Rose D, Bean-Mayberry, Canelo I, Washington DL. Impact of Practice Structure on the Quality of Care fo

2) Final Report. Sepulveda, CA: VA HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, Mar
Local PC Delivery Delivery Arrangement

Arrangement

Women's PC

Clinics

p<

Designated

WH Providers p<.005

44% gende

exams 

General PC

w/o Desig WH

p .005

0% 20% 40% 60% 80% 

w/o Desig WH p<.05

Percent of VA Facilities with each PC Delivery Arrangemen
Women s’ Health Service Service Availabi

Availabi

Cervical CA 

Screening

Mammograms

Screening 

p< 001

p<.

Contraceptive

Services

Mammograms

p<.

p<.001

B t CA

Non-Surg Breast

CA Tx p<.

0% 20% 40% 60% 

Breast CA

Surgery p<.

0% 20% 40% 60% 

Percent of VA Facilities with Onsite Availability
Women s’ Health Service Service Availabi

Availabi

• Declines Declines in onsite service service availability availability fo

other women’s health services

– Treatment for menstrual menstrual disorders disorders– Endometrial biopsies

Menopausal management 

–– Prenatal care

G l lil

p

– General gynecological surgery
Contraception Research
Contraceptive Care in the VA

Heal ht care System

• Borrero et al. examined national VA administrative d

Pharmacy Benefit Management ( ) PBM d b ata ase for 

female veterans aged 18‐45 who made at least one pcare visit in 2008.

– A d ssessed:

• Documentation of contraceptive coverage at any point 

2008

• Type of contraceptive method with regard to clinical ef

– “Most effective”: IUDs, implants, and surgical ster

– “Moderately effective”: Hormonal methods

– “Least effective”: Condoms, diaphrams, spermicid

• Key independent variables:

– Race/ethnicity– Receipt of care in a Women’s Health Clinic (WHC)

•

Borrero S, Mor M, Zhao X, McNeil M, Ibrahim S, Hayes P. Contraception, in press.
Contraceptive Care in the VA

Heal ht care System

Findings:

– Only 22% of female Veterans had documented method o

contraception, with little variation by race/ethnicity.

– Use of most effective methods:

• 4 2%. of women had IUD or implant implant use• 3.7% had surgical sterilization

– Fully adjusted models suggest Hispanic and African

women significantly significantly less likely to have documented documented

contraceptive method compared to white women (95% CI 0.76=0.88; OR=0.85, 95% CI 0.81‐0.89).

– Women who received care at Women’s Health Clinics m

signif l icant y more lk l i e y to have d d ocumented meth do of

contraception than women who received care in primar

clinics (OR=2.05, 95% CI, 1.97‐2.14)

Borrero S, Mor M, Zhao X, McNeil M, Ibrahim S, Hayes P. Contraception, in press.
The Department of Veterans Affairs | Office of Research & De

CHIR TRANSLATIONAL USE CASE PROJECT ­ CONTR

Contraception Use Amo

Women Veterans

CHIR WIP P t ti D b 13 20

PRESENTERS: 

Cynthia Brandt MD MPH1, 4

CHIR WIP

Presen

t

ation

–

Decem

ber 13, 20

Cynthia Brandt, MD, MPH1,

4

Julie Womack, CNM, APRN, PhD, Lead Investigator 1

Matthew Scotch, MPH, PhD, Co‐Investigator 

2

Sylvia Leung, BA, Project Coordinator

3 , BA, Project Coordinator

1 VA Connecticut Healthcare System – West Haven, CT, 2 Arizona State University, Department of

VA Palo Alto Health Care System, 4 Yale University, Center for Informatics, 5Yale Schoo
The Department of Veterans Affairs | Office of Research & De

Goals and Methods

•GOAL: To identify contraceptive information in VA progress may not contain accurate contraceptive use information, and thof progress notes may yield more accurate knowledge on the uscontraceptives among women Veterans than reliance on CPRS a•METHODS:  To compare information contained in CA progress

(using Natural Language Processing) with survey data on contr

from the Women Veterans Cohort Study (WVCS) West Haven from the Women Veterans Cohort Study (WVCS) West Haven. 

• 227 women with baseline survey data• 1700 progress notes

• PRELIMINARY RESULTS:

•43% of women who had completed baseline survey repor

using contraception.•In contrast, only 13% of VA progress notes accurately iden

In contrast, only 13% of VA progress notes accurately iden

contraceptive use.•Some contraceptive use was identified through chart revie

patient re

port
Unintended pregnancy and contrace

among active duty servicewomen among active duty servicewomen 

veterans

•

UNINTENDED

PREGNANCY

RATES

– 50-65%

•

UNINTENDED

PREGNA

Active Duty Servicewomen Female Military V

•

CONTRACEPTIVE

USE

– 70-85% sexually active– 40% use no contraception

50 62% t i t ti t ti

– UNKNOWN

•

CONTRACEPTIVE

US

– Prevalence: UNKNO

– 50-62% not using contraception at time 

of unplanned pregnancy

– OCP and Condoms most used– Barriers: Logistics, limited availability, 

id & ti t k l d

– Methods used: UNK– Barriers: Availabilit–

UNKOWN Barriers: 

provider 

& patient knowle

dge t i

•

EMERGENCY

CONTRACEPTION (EC)

– Limited provider & patient knowledge– Majorit

y feel it should be available

s

y

s

tem issues

•

EMERGENCY

CONTRA

– Barriers: 

UNKNOWN

Use:

UNKNOWN j y

–

UNKNOWN

Goyal V, Borrero S, Schwartz EB. Unintended pregnancy and contraception among active duty serveterans. Am J Obstet Gynecol. 2011. Dec

1 (Epub ahead of print)
Pregnancy
Pregnancy and Mental Health Am

OEF/OIF Women Veterans

• Study Aim: To understand the prevalence of co‐exis

pregnancy and mental h lh ea t conditions among OEF

women veterans

• Administrative cohort analysis of 43,078 OEF/OIF wo

V t e erans who h da used VA care at l t eas once b t e wee

2008.

• Utilized ICD‐9 and CPT codes to identify 2966 women 

OEF/OIF OEF/OIF women Veterans Veterans in VA care) who had at lea

pregnancy‐related code during study period.

• Also used ICD‐9 codes to ascertain co‐existing menta

diagnoses diagnoses (PTSD, depression depression, anxiety anxiety disorder disorder, schizo

schizo

and bipolar disorder)

Mattocks Mattocks K, Skanderson Skanderson M, Goulet J, Brandt C, Womack J, Krebs E, Desai R, Justice Justice A, Yano E, H

H

Pregnancy and mental health among women veterans returning from Iraq and Afghanista

Women’s Health, 2010: 19(12): 2159‐2166.
Mental health diagnoses among pregnan

non‐pregnant, veterans in VA care

Diagnosis All female Pregnant p % pregna

veterans

(n=40,112)

veterans

(n=2966)

with condpregnanc

Major depression 5% 12% <.0001 Mild depression 10% 24% <.0001 PTSD 9% 21% <.0001 Bipolar disorder 1% 3% <.0001 Schizophrenia 0.11% 0.33% <.0001 Any MHdiagnoses

20% 32% <.0001 

Substance abuse

disorder

2% 5% <.0001 
Study Implications: Pregnancy 

Mental Heal ht

• Many Women Veterans returning from war in

Iraq/ fh A g anistan suffer from significant mental h l

ea t

problems. Unclear if mental health conditions a dire

of combat exposure.

• Because most pregnancy‐related care is provided ou

(and outcomes not communicated back to VA), little 

regarding regarding pregnanc pregnancy o tcomes outcomes among women veter

eter

• Consequently, for women with co‐occuring mental h

problems, li l tt e is known regarding the impact of permood disorders among women veterans on infant he

well‐being.
The Department of Veterans Affairs | Office of Research & D

Preg

n

a

ncy Co

m

plicatio

n

s Am

o

n

g

OEF/OIF Wo

m

en Vete

GOALIdentify pregnancies resulting in delivery among OEF/OIF womenenrolled in VHA using administrative data, and determine the freq

eg a cy Co p cat o s o g O /O Wo e Vete 

enrolled in VHA using administrative data, and determine the freq

gestational diabetes (GDM)and preeclampsia among these pregnaMETHODS

Data source: Data source: Women Veterans Cohort Study includes women vete

Women Veterans Cohort Study, includes women vete

VHA OEF/OIF roster from 2001‐2010, linked to the VHA National Database, Decision Support System, and fee basis care

Pregnancy and delivery identification: Pregnancy and delivery identification: Identify deliveries through 

Identify deliveries through 

combinations of CPT codes, ICD‐9 codes, and V codesGDM and preeclampsia: ICD‐9 codes either associated with or occ

9 months 

p y rior to an identified deliver

y.

IMPACT•Enable follow‐up overtime to determine incidence of postpartumCVD among women with GDM or preeclampsiaCVD among women with GDM or preeclampsia•Provide information on postpartum care and usage among wome

Jodie Katon (VA Puget Sound), K Mattocks, E Yano, G Reiber
Outcomes, Utilization, and Cost

Pregnancy‐Rel d ate Care

• Methods: Pilot study of female Veterans at one VA f

who received fee basis care for pregnancy.

• Results:

– 33 women Veterans with complete pregnancy data

• 10% of pregnant veterans had at least 1 chronic medica

(hypertension and asthma most common).

• 39% had at least one psychiatric condition

• Adverse pregnancy outcomes in 36% of pregnant veter

– Most common was preterm delivery.

– Veterans with a psychiatric condition were signifi

more likely to have adverse pregnancy outcome.

Chireau M, Salz T, Brown H, Bastian L. Outcomes, utilization, and costs of pregnancy‐re

Federal Practitioner, September 2006.
Gender‐Specific Care
Dual Sources of Care for Gender‐Specific Conditions 

OEF/OIF Women V t e erans

• Study Aim: To examine the patterns, predictors, and costs of V

basis care for gender‐specific conditions among OEF/OIF wome

• Administrative cohort analysis of 64,334 women veterans in VA 

(2002‐2009).

• Used ICD‐9 codes to identify gender‐specific conditions, and VA 

files (claims data) to identify patterns and costs of non‐VA care 

conditions.

• Overall, 36% (21,707) of all OEF/OIF women veterans received 

gender‐specific specific diagnosis diagnosis. Twenty‐four percent percent of these wome

at least some non‐VA care for their condition.

Mattocks K, Zephyrin L, Herrera L, Haskell S, Frayne S, Yano E, Hayes, P, Brandt C. Dual sources 

gender‐specific specific conditions conditions among OEF/OIF OEF/OIF women veterans veterans. Under review.
Prevalence and Patterns of Care for Gender‐Specific Conditions am

Women Veterans (n=21,707)

S fC f G d Source of Care for Gender-S ifi C di i Specific Conditi

Any Fee Basis 

Condition Women with 

condition, N (%)

Fee Basis Only (%) Fee Basis and 

VA (%)

Menstrual disorders Menstrual disorders 7595 (12) 7595 (12) 4 5 

Other female genital disorders

6977 (11) 5 5 

Vaginitis 6684 (10) 3 2 

Cervical dysplasia Cervical dysplasia 6122 (10) 6122 (10) 3 6 Pregnancy 4674 (7) 9 46 Benign breast conditions 4239 (7) 17 23 Ovarian cyst 2314 (4) 8 8 Benig gy g nnecological 1876 (3) 9 8 

conditions

( )

Menopausal disorders 1680 (3) 1 1 Infertility 761 (1) 5 10 Sexual dysfunction 654 (1) 3 .01 

Cervical cancer 334 (0.53) 8 5 

Osteoporosis 228 (0.35) 9 3 

Genital organ prolapse 188 (0.29) 5 1 

Breast cancer 193 (0.30) 9 24 

Et i c op c pregnancy 105 (0 16) 105 (0.16) 37 11 Ovarian cancer 58 (0.09) 3 9 Female genital cancer 36 (0.06) 3 8 Uterus cancer 17 (0.03) 29 6 
Proportion of Women OEF/OIF Veterans Receiving F

Care for at Least One Gender‐Specific Condition, FY 2
Wh t a are women Vt 

e eran

experiences and p p erce tions o

reproductive and gender‐spe

care?
Women Veterans’ Reproductive Health Preference

E i xper ences: A Focus Group A li na ys s

• Study Aim: To characterize women Veterans’ experiences with, and p

for, reproductive health care in the VA.

• Methods:

– Focus group study of women Veterans Veterans receiving receiving care at 2 large VA 

Five focus groups were conducted with twenty‐five women Veter

• Results: Five main themes resulted from the focus group analysis:

– Women Veterans Veterans prefer VA clinics clinics (over outside outside providers) providers) for com

com

medical care.

– Women Veterans have had both positive and negative reproducti

experiences.

– Knowledge Knowledge gaps exist regarding regarding what reproductive reproductive health service

service

offers.

– Women Veterans believe the VA should provide additional covera

infertility and newborn care.

– Perceived Perceived gender discrimination discrimination shapes how women Veterans Veterans vie

Mattocks K, Nikolajaski C, Haskell S, Brandt C, McCall‐Hosenfeld J, Yano E, Pham T, Borrero S. Women veter

health preferences and experiences: A focus group analysis. Women’s Health Issues, 2011; 21(2): 124‐129.
Women Veterans had both positive and n

reprod i uct ve h lh ea t experiences

• Many women Veterans Veterans had positive positive experien

experien

–

“I got my fibroid tumors removed here at the VA, which wa

surgery. Now the VA is doing everything they possibly can f

conceive conceive because because I m’ in my 40 s’ and haven t haven’t yet conceived conceived ”.

• However, other women expressed concern about th

competency of medical residents providing care:

–

“I had a problem with an intern giving me a pap smear. I co

never done one before. He was looking at the clampy thing

was kind of fumbling and just picked one up and he goes, ‘I

doesn’t really matter, right?”
Women Veterans had limited knowle

regarding the scope of VA services ava

• Most women were not aware of the range of reprod

health services offered at the VA:

– “I didn’t know and I still don’t know what reproductive heal

are covered. It was my understanding that having children 

covered by the VA”.

• Other women wondered whether reproductive heal

services were tied to service‐connected disability sta

– “Does it depend on the percentage of disability you have? S

cover you through your pregnancy, but once you give birth, 

not covered? Or if you’re 100%, do they cover you and your 
Women Veterans’

G li ynecologic H lth ea
Sexual Violence Exposures and Women Veteran's Gynecologic Health (N=1004)

Funded by VA HSR&D, NRI 04‐194‐1

Anne G. Sadler, Brenda M. Booth, James C. Torner, Michelle A. Mengeling, Craig H. 

Study Design:

R lt • Cross‐sectional study, retrospective cohort

• 1004 Midwestern Veterans

• Computer assisted telephone survey

• Women age 52 or younger

Results:

• Approximately half had experie

sexual assault during their lifet

• Most (68%) reported sex impo

• Women age 52 or younger and 74% had engaged in sex wSadler, A. G., Mengeling, M. A., Fraley, S.S..,

Torner, J. C., & Booth, B. M. (2012‐ in

and 74% had engaged in sex w

during the past 6 months.

• Almost a quarter reported pain

intercourse and 35% used lubr

make sex comfortable.

press). Correlates of Sexual Functioning in

Women Veterans: Mental Health,

Gynecologic Health, Health Status, andSexual Assault History. International

• Factors associated with compr

functioning included: 1) gynecfrom completed sexual assault

disorders (PTSD, SUD, depressi

h lh l d l f l f Journal of Sexual Health, 24, 1‐18. health‐related quality of life.

• Problems with sexual function

intercourse associated with ev

lifetime sexual assault.
Urinary Incontinence and Mental H

• Goal  To study associations between urinary incontinen

symptoms, depression and post‐traumatic stress disorder 

women veterans.

• Secondary, cross‐sectional analysis in HSRD‐funded (Sadle

NRI 04‐194) retrospective cohort study: 968 women, mea

38.7 (8.7) years

• UI symptoms were common and bothersome

– 39% had UI symptoms ≥ few times monthly– 21% were “very much” or “greatly” bothered by UI– 17% had sought care for UI symptoms

• In multivariable analyses

– Prior sexual assault associated with both stress UI and urgency/m– PTSD associated with urgency/mixed UI

Catherine Bradley, MD, MSCE (PI), IE Nygaard, MA Mengeling, JC Torner, CK Stockdale,

BA Booth, AG Sadler; Iowa City VA.
Urogenital Symptoms, Depression and P

OEF

/OIF Women Veterans

• Goal

 Define the prevalence prevalence and natural natural hi

hi

urogenital symptoms and their associations w

depression, PTSD, sexual trauma and other

deployment

‐related exposures.

• VA HSR&D

‐funded epidemiologic study in

OEF/OIF/OND women veterans

– Longitudinal data collection – baseline and

1 year

– Nationwide, diverse sam

ple of women veterans e

within

2 years post

‐deployment

– Data collection ongoing, recruitment ~75% comp

enrolled to date)

Catherine Bradley, MD, MSCE (PI), IE Nygaard, JC Torner,

S Hillis, AG Sadler; Iowa City VA
Articles on Active Duty Women’s Health Issues Written 

Leaders of the Militar

y Women’s Health Research Interes

Rychnovsky, J., & Hunter, L. P. (2009). The relationship between sleep cfatigue in healthy postpartum women. Women's Health Issues, 19(1), 38-44Rychnovsky J & Brady M A (2008) Choosing a postpartum depressio

y

of the TriService Nursing Research Program

CAPT Jacque Rychnovsky

Jacqueline.Rychnovsky@med.navy.mil

Rychnovsky, J., & Brady, M. A. (2008). Choosing a postpartum depressioinstrument for your pediatric practice. Journal of Pediatric Health Care, 22Rychnovsky, J. D. (2007). Postpartum fatigue in the active-duty military Obstetric, Gynecologic, and Neonatal Nursing, 36(1), 38-46.Rychnovsky, J., & Beck, C. T. (2006). Screening for postpartum depressiowith the postpartum depression screening scale. Military Medicine, 171(11), Rh k yc

hnovsky, J. ( ) P t t f ti i th ti d t Di 

(2004). Postpartum fatigue i

n th

e active duty woman. Di

AAT3131499.

LTC Nancy Steele

Nancy.Steele@us.army.mil

Trego, L, Wilson, C & Steele, N. (2010). Shaping a Military Women’s HAgenda: Creating the Foundation for Evidence-based Care of the Future. B

Nursing, 2010 Oct;12(2):171-7.Trego, L. L., & Jordan, P. J. (2010). Military women's attitudes toward me

l l h d l d l 

LTC Lori Trego

lori.trego@us.army.mil

menstrual suppression in relation to the 

deployed environment: Developme

MWATMS-9 (short form). Women's Health Issues: Official Publication of tWomen's Health, 20(4), 287-293.Trego, L. L. (2009). Development of the military women's attitudes towar

suppression scale: From construct definition to pilot testing. J Nurs Meas, 1Trego, L. L. (2009). Theoretical substruction: Establishing links between 

measurement of military women's attitudes towards menstrual suppression operations. J Adv Nurs, 65(7), 1548-59.Trego, L. L. (2007). Military women's menstrual experiences and interest 

suppression during deployment. J Obstet Gynecol Neonatal Nurs, 36(4), 34

Lt C l C d Wil

Wilson C, Brothers M. (2010). Iron deficiency in women and its potential 

effectiveness. Nurs Clin North Am. 2010 Jun;45(

2):95-108. Lt C

ol Can

d

y Wilson

candy.wilson@us.af.mil

;45( ) 95

Wilson, C. (2006). Illness behaviors of military women managing genitou

secondary analysis. (Doctoral Dissertation, University of Colorado at DenveCenter, 2006). Dissertations Abstracts International, 67, 08.
Military Women’s Health Research Interes

L

p

Fa

Request an

A ti c ve D t u y

Women’s Health

Researcher Guide
Interested in reproductive healt

gender‐specific research?

• One possibility: possibility: Women Veterans Veterans Coho

Study (WVCS).

– Principal Investigators: Cindy Brandt and S

Haskell (VA Connecticut).

– Study Aim: To examine healthcare outcom

costs, and utili i zat on among OEF/OIF OEF/OIF Vete

– Data Sources:

• (1) OEF/OIF OEF/OIF roster, combined combined with VA adminis

adminis

data. N=~749,036 OEF/OIF Veterans (88,166 w

• (2) Prospective cohort survey (n=776; 415 wo
Demographic Characteristics of Separated Female an

OEF/OIF OEF/OIF V t e erans Who U d se VA H lth ea Care in FYs 20

Characteristics Females 

( 74 535)

Males

( 550 849)

Characteristics Females 

( 74 535

(n=74,535) (n=550,849) 

Race/ethnicity

White 28,974 (39) 275,849 (50) 

(n=74,535

Branch

Air Force 13,317 (18

Black 14,094 (19) 50,300 (9) ( Hispanic 7,816 (11) 57,415 (10) Others 5,502 (7) 30,240 (6) 

Age Gro p

Army 46,335 (62

Coast Guard 39 (0.1) Marines 2,942 (3) 

Age Group Navy 11 882 (16

16-30 35,604 (48) 241,292 (44) 31-40 21,837 (29) 145,319 (26) 41-50 12,763 (17) 120,296 (22)

Navy 11,882 (16

Unit Type 

Active Duty 41,542 (56

41 50 12,763 (17) 120,296 (22)

51-60 3,973 (5) 37,418 (7) 61-84 348 (.5) 6,470 (1) 

Reserve/Guard 32,993 (44
Laurie C. Zephyrin MD, MPH, MBA

D t epu y Di t rec or, R d ti eproductive H lt

ea

Women Veterans Health Strategic Healt

Group (VACO)
Younger Women Younger Women s Concer

’s Concer

Gynecology CareMaternity Care Maternity CarePreconception Care

Military Sexual Trauma (MSMilitary Military Sexual Trauma (MS

Flexible Appointments

Childcare and Elder Care Childcare Childcare and Elder Care

Acute and Chronic Illness
Middle-Aged Women Aged Women s Conce

’s Conce

Preventive CareMenopausal Needs Menopausal NeedsGynecology CareUrogynecological Care

Acute and Chronic Illness

Urogynecological Care

Mental Health Needs Mental Health Needs
Older Women Older Women s Concern

’s Concern

Geriatric CareGynecology CareUrogynecology CareGynecology CareUrogynecology Care

Pain Mana

gement

Inpatient Inpatient and Extended Extended Care

g

Grief Counseling

Acute an

d

C

hronic Illness
Medi l i l O /O /O dical 

D

iagnoses: Femal

e OEF/OIF/O

Veterans in VA 2002-2011 (Q1=78,08

DiagnosisMusculoskeletalMental Disorders

Percent of Women Pr

54%49%

Nervous System/Sense Organs

Digestive System

Genitourinary System

49%41%38%

Genitourinary System 39%RespiratoryEndocrine SystemDiseases of Skin

39%33%29%26% Diseases of Skin

Injury/PoisoningsInfectious and Parasitic Diseases

26%25%19%
R h/D A Research/Data Assessme

• Understand Understand reproductive reproductive health across • Describe system and patient characteris

Fee Basis gender specific specific services services

• Assess GYN provider distribution and ca• Develop care coordination tools for ma

care management and tracking

• Inform research agenda for reproductiv

health
Maternity Care Paradigm

Pregnancy • Preconception Care

• Safe Prescribing • VA OB/GYN Care

• Non

‐VA Ob Care

Pregnancy • Non

‐VA C

Completi

• Ob Recor

Co

‐Morbid

C diti

Non VA Ob Care

• VA Care

Coordination

• VA Care/F

Pos

Conditions
Questions?
Maternity Care Policy/Proce

• M i atern ty

Care C di i oordination

H db k an oo

k

– Will address coordination and follow

‐up of pre

care and streamlining streamlining of maternity maternity fee referra

referra

• Newborn Care Coverage

• Maternity Care Resources

– Standardizing Fee Basis processes for maternit– Maternit

y Reference Sheet

– VA

‐DoD pregnancy guidelines

– Tools: VA

‐DoD pregnancy guide for patients
VA-DoD Pregnancy Guid

https://www.qmo.amedd.army.mil/pregnancy/patient_binder.pdf
Review and implement Pol

• Emergency Contraception ROC• Emergency Contraception

– Advanced provision

52
Women’s Health Transformation Init

S bu

-i iti ti f N M d l f C i

niti

ative

of New M

od

el

s

of Care

• Improved Care Coordination

– Emergency Department (ED) Care

•

D

e e op e t v

elop

m

e

n

t

o

f

Assess e t m

e

n

t

Tool

• Provider Education

‐ Simulation

• Task force to assess delivery of RH services

in VA Emergency Emergency Departments Departments

• Safe prescribing in women of childbearing age

• Collaboration with information technology to implement 

decision support to increase provider and staff awarenes

teratogenic risk
Women’s Health Transformation Init

S bu

-i iti ti f N M d l f C i

niti

ative

of New M

od

el

s

of Care

• Improved Care Coordination

– Breast Cancer

• Tracking of abnormal test results• Breast Cancer Clinical Case Registry

• Planned Completion: September 2013
Reproductive Health Mod

• Qualit

C

• Access to

Care

Surgical Care

Preventative

Health and

Wellness

Integration

Models

Specialty

Services

• Policy • Resear

Models
Reproductive Health at the 
VA Reproductive Health

Working Group

• Reproductive Health Working g p rou offers

– A strong group of VA clinicians, researchers, a

policymakers working together on emerging

reproductive reproductive and gender‐specific specific health issue

issue

– Feedback on manuscripts and grants in progr– Feedback on reproductive health analysis pla– Collaboration across VA medical centers and

clinical/research expertise

– Opportunities for mentorship for junior inves– Information on national VA reproductive heal

programs and emerging policies/trends.
Reproductive Health Working Working G

• Interested in participating?• Contact Kristin Mattocks

(kristin mattocks@va gov kristin.mattocks@va.gov)

• Group currently meets 3rd Monday of e

month at 10 00 : Eastern ( hi t s will ch 

ang

• Next meeting: Monday, February 27th (t

be determined)
Contact Information for Autho

Incldd u e in this Presentation

• Lori Bastian: lori.bastian@va.gov• Sonya Borrero: borrsp@upmc.edu• Cate Bradley: catherine‐bradley@uiowa.edu• Cynthia Brandt: cynthia.brandt@va.gov• Vinita Goyal: vgoyal@wihri.org• Sally Haskell: sally.haskell@va.gov• Jodie Katon: jodie.katon@va.gov• Kristin Mattocks: kristin.mattocks@va.gov• Anne Sadler: anne.sadler@ g va. ov• Julie Womack: julie.womack@va.gov• Elizabeth Yano: elizabeth.yano@va.gov• Laurie Zep yh rin: laurie.zepy @ g h rin@va.gov