Women Veterans: Reproductive Health Across the Life Course
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1 Women Veterans: Reproductive Health Across the Life Course Laurie Zephyrin MD, MPH, MBA, FACOG Acting Assistant Deputy Under Secretary for Health for Community Care, Director, Reproductive Health Alicia Christy, MD, MS Deputy Director Reproductive Health Women s Health Services Veterans Health Administration 2017 National Women Veterans Summit 1
2 Agenda Overview of Reproductive Health for Women Veterans Laurie Zephyrin, MD, MPH, MBA Alicia Christy, MD, MS Preconception and Infertility Ginny L. Ryan, MD, MA, FACOG Stephanie Edmonds, PhD, MPH, RN Maternity Care Coordination Heather Able, MSN, RNC 4 Perinatal Depression: Impact and Treatment Michael O Hara, PhD 5 Facilitated Discussion with Panel 2
3 OVERVIEW OF REPRODUCTIVE HEALTH FOR WOMEN VETERANS Laurie Zephyrin, MD, MPH, MBA Alicia Christy, MD, MS 3
4 Age Distribution of Women Veteran Patients 14,000 # Women Veteran Patients 12,000 10,000 8,000 6,000 4,000 FY00 FY06 FY15 2, Cohort: Women Veteran patients with non-missing ages years (inclusive). Women in F Y00: N=159,553; FY06: N=245,270; FY15: N=439,615. Source: WHEI Master Database, FY15 4
5 Women Veterans Using VA Care Unique healthcare needs: Nearly 25% of women Veterans have experienced Military Sexual Trauma 73 % of women Veterans ages have a Service-connected disability > 30% of women Veterans use non-va Care in the Community FY15 Statistics Women Men Average Age > 12 Outpatient Encounters 51% 44% Mental Health Substance Use Condition 48% 31% Musculoskeletal Injury 59% 48% 5
6 Reproductive Health of Women Veterans Zephyrin, L. C., Katon, J. G., & Yano, E. M. (2014). Strategies for transforming reproductive healthcare delivery in an integrated healthcare system: a national model with system-wide implications. Curr Opin Obstet Gynecol, 26(6),
7 Military Service, Fertility, and Pregnancy Military Service Related Exposures Deployment Sexual assault & MST Reproductive tract injuries Environmental & Occupational exposures PTSD, Depression, Anxiety disorders Fertility and Pregnancy Outcomes Sexual dysfunction? + +? + Delay/opt not to have children? +??? Infertility? + +?? Pregnancy complications? +?? + Preterm delivery? +?? + Much more research is needed 7
8 Women s Health Services Provided at VA Gynecologic care (Basic and Specialty) Contraceptive care and counseling Mammography Breast and cervical cancer screening and treatment Menopause-related care Services not provided at VA facilities: Obstetrical/maternity care Specialty Infertility services 8
9 Maternity Care Transitions Use of VA maternity care has increased by 44% in the past 5 years Nearly all VA maternity care is outsourced 9
10 VHA Directive 1332 Infertility Evaluation and Treatment Female Veterans (available to all enrolled Veterans) Laboratory blood testing (i.e., follicle-stimulating hormone (FSH), thyroid stimulating hormone) Genetic counseling and testing Pelvic and/or transvaginal ultrasound Hysterosalpingogram Saline infused sonohysterogram Surgical correction of structural pathology consistent with standard of care including operative laparoscopy and operative hysteroscopy Reversal of tubal ligation (tubal reanastomosis) Hormonal therapies (e.g., controlled ovarian hyperstimulation) Oral medication for ovulation induction (e.g., clomiphene) Injectable gonadotropin medications for ovulation induction (i.e., human menopausal gonadotropins) Additional hormonal therapies as approved by VA Pharmacy Benefits Management Intrauterine insemination Oocyte cryopreservation for medically indicated conditions Male Veterans (available to all enrolled Veterans) Laboratory blood testing (i.e., serum testosterone, FSH, luteinizing hormone, estradiol, etc.) Genetic counseling and testing Transrectal and/or scrotal ultrasonography Semen analysis Evaluation and treatment of erectile dysfunction Surgical correction of structural pathology (e.g., varicocelectomy, Peyronie s repair) Vasectomy reversal (vasovasostomy) Hormonal therapies (e.g., clomiphene citrate, human chorionic gonadotropin, phosphodiesterase type 5 medications, testosterone) Sperm retrieval techniques Post-ejaculatory urinalysis Sperm cryopreservation for medically indicated conditions 10
11 Infertility Care Implementation Public Law gave VA the authority to provide Assisted Reproductive Technology (ART) services to include In-vitro Fertilization (IVF) to Veterans and non-veterans spouses when the eligible Veteran has a service connected condition that results in their inability to procreate without the use of fertility treatment January 2017 regulation released Implementation through VA Care in the Community 11
12 Implementing a Veteran-centered Growth Strategy to Meet the IVF Needs Veteran-Centered Growth Strategy Goal State Growing a national network takes time. Third-Party Administrator s (TPA) focusing efforts on areas where there is demand and available providers who are willing to enroll Expanding network of Reproductive Endocrinology and Infertility (REI) specialists for Veterans with service related injuries resulting in infertility and their spouses 12
13 PRECONCEPTION AND INFERTILITY Ginny L. Ryan, MD, MA, FACOG Stephanie Edmonds, PhD, MPH, MBA 13
14 Overview Preconception Health What is preconception health? What are some important things to do before I get pregnant? What about Zika? Infertility What is infertility? What can cause infertility? What services does the VA provide for infertility? 14
15 Sexual Assault and Fertility Compared to female Veterans who have never experienced sexual assault, women who experienced sexual assault were: More likely to report delaying having children or deciding to never have children More likely to report yes to Have you ever wanted to have a baby but couldn't? Ryan GL, Mengeling MA, Booth BM, Torner JC, Syrop CH, Sadler AG. Voluntary and involuntary childlessness in female veterans: associations with sexual assault. Fertil Steril 2014;102:
16 What should you do if you want to get pregnant next year? Meet with your primary care provider Take a prenatal vitamin or multivitamin If you smoke, stop smoking Be aware of alcohol use Eat a healthy diet Exercise Avoid travel to places with Zika 16
17 Zika and Pregnancy Virus from mosquitoes Men can spread virus through sex for up to 6 months Can cause birth defects in baby If you want to get pregnant you and your male partner should avoid travel to these places Visit CDC website or discuss with your provider for more information 17
18 What is Infertility? No pregnancy after 12 months of unprotected, regular sexual intercourse Women 35 years of age or older should seek infertility care after 6 months of trying Known reason for infertility, treatment should start right away 18
19 What Causes Infertility? Other 5% Unexplained 25% Male 30% Both 10% Female 30% 19
20 What Services does the VA Provide for Infertility? All enrolled Veterans Counseling Testing like ultrasounds, blood work, ovulation predictor kits, and semen testing Some treatments Medicines Intrauterine insemination (IUI) Freezing of eggs or sperm, tubal or vasectomy reversal, retrieval Married Veterans with a service-connected condition leading to infertility In-vitro fertilization (IVF) Non-Veteran spouse covered by VA benefits 20
21 MATERNITY CARE COORDINATION Heather Able, MSN, RNC 21
22 Maternity Care Coordination Overview Maternity Care Coordination Each VA medical facility has a Maternity Care Coordinator (MCC) to assist women Veterans navigate VA health care services during her pregnancy. The MCC: Facilitates communication between the Veteran, VA providers and community health care providers. Provides support and education. Assists with lactation needs Screens for post-partum needs Reintegrates Veteran into VA healthcare 22
23 Postpartum/Return to VA Healthcare After delivery, the MCC ensures: Postpartum contraception is initiated Community OB provider discharges Veteran back to her VA to resume care around 8 weeks postpartum. Veteran should have a preventative health visit with Women s Health Primary Care Provider around 12 weeks postpartum to ensure proper healing and restoration of health after delivery. Communication will continue with Veteran as long as she is breastfeeding or when she resumes care with WHPCP if she is not breastfeeding. 23
24 Locating a Maternity Care Coordinator VA-WOMEN ( ) Provides women Veterans, their families, friends and caregivers information on eligibility, health care, and benefits. Warm hand off to Women Veteran Program Managers. Eligibility Benefits Healthcare Claims Survivor Benefits Services Locate WVPM 24
25 VA/DoD Purple Pregnancy Book Pregnancy and Childbirth: A Goal Oriented Guide to Prenatal Care and the DoD/VA Pregnancy Passport is available to all pregnant Veterans to help document their pregnancy as well as provide evidenced based guidance each step of the way through pregnancy 25
26 MyVA Maternity Care Card A wallet-size card for patient use that provides a single location for vital health care provider names and phone numbers including the maternity care coordinator and the women Veteran program manager s 26
27 Text4baby ZERO TO THREE and Text4baby TM VA is Federal Partner with Text4baby TM, the largest mobile health initiative in the nation. Text4baby TM provides critical information to pregnant women Veterans and mothers with infants under age one. Enrollment To enroll in the Text4baby TM service, women Veterans can text BABY (or BEBE for Spanish) to and receive at least three free text messages a week containing expert health topics and safety information, timed to their due date or baby s birth date. 27
28 Maternity Resources First Quality Enterprises Inc. Breastfeeding Supplies 28
29 PERINATAL DEPRESSION: IMPACT AND TREATMENT Michael O Hara, PhD 29
30 Burden of Depression in Women Leading cause of disability (lost years of health life) among women in the world aged 15 to 44 years In the U.S. depression is a leading cause of non-obstetric hospitalizations among women aged Sources: World Health Organization. (2008).The Global Burden of Disease: 2004 Update. Geneva: WHO. Levit et al. (2008) HCUP Facts and Figures, Statistics on Hospital-based Care in the United States. Rockville, MD: AHRQ. 30
31 Burden of Perinatal Depression For mother Personal suffering, continued depression, poor health For the child Delayed prenatal care, shorter gestation Fussiness, feeding problems, poor weight gain Delays in cognitive skills, social skills, language Behavioral problems, insecure attachment Later depression For the family Relationship discord, divorce 31
32 Burden of Perinatal Depression (Continued) Low mood Loss of pleasure Feeling slowed down Loss of appetite Tired all the time Trouble concentrating Excessive guilt Thoughts of suicide 32
33 Screening for Depression after Childbirth Recommended by U.S. Preventative Services Task Force American College of Obstetricians and Gynecologists Association of Women s Health, Obstetric and Neonatal Nurses American Academy of Pediatrics Endorsed by VA Women s Health Services More importantly, it offers the opportunity to Reduce suffering in women Reduce morbidity in children 33
34 MomMoodBooster Online treatment program for postpartum depressed women veterans 6 sessions over 6 weeks Based largely on Cognitive Behavioral Therapy approach Regular Phone Coach support Developed with support from NIMH Supported by the VA Office of Rural Health and VA Office of Women s Health Services Danaher BG, Milgrom J, et al. (2013). MomMoodBooster Web-Based Intervention for Postpartum Depression: Feasibility Trial Results. Journal of Medical Internet Research, 15(11), e242 URL Milgrom J, Danaher BG, et al. (2016). Internet Cognitive Behavioral Therapy for Women With Postnatal Depression: A Randomized Controlled Trial of MumMoodBooster. Journal of Medical Internet Research, 2016;18(3):e54, URL: 34
35 Eligibility and Enrollment for MomMoodBooster A woman is eligible if she: Is a Veteran Has had a baby in the past 18 months Is feeling down or depressed Has access to a high speed internet connection Is willing to participate in six sessions over a six week period A woman may be directly referred by VA staff such as maternity care coordinators or self-referred For more information about the VA Office of Rural Health ONLINE PPD TREATMENT PROGRAM, Please contact the MomMoodBooster program: or www2.psychology.uiowa.edu/mommoodbooster/ 35
36 Summary Postpartum depression is a serious mental health problem It is burdensome for women, their children and families It can become chronic and affect the developing child There are easy ways to detect PPD There are efficacious treatments for PPD The VA is making available an online treatment program that can serve all women Veterans 36
37 FACILITATED DISCUSSION WITH PANEL 37
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