Incidence and risk factors for postpartum mood and anxiety disorders among women veterans

An Evidence Map of the Women Veterans' Health Literature, 2016 to 2023: A Systematic Review

Importance

Women veterans are the fastest-growing veteran subpopulation in the US. Women veterans often experience military service-related health issues in addition to conditions common to all women. Because women veterans are more likely to receive care in the civilian setting than through the Department of Veterans Affairs (VA), all women's health clinicians should be equipped to provide patient-centered care for women veterans. The health care of women veterans requires evidence-based care informed by population-specific scientific literature. An updated evidence map evaluating women veteran-focused health literature is needed.

Objective

To map the scope and breadth of women veterans' health literature published from 2016 to 2023.

Evidence Review

In this systematic review, MEDLINE, Embase, and CINAHL Complete were searched for eligible articles published from 2016 to 2023. Articles reporting about US women veterans' health outcomes or on the experience of providing care to women veterans were included. Included articles were required to report patient-level outcomes that included either data for only women veterans or reported results separately for women veterans. Articles were grouped by primary focus area based on categories previously established by the VA Women's Health research agendas and prior evidence maps.

Findings

The volume of women veterans' health literature published between 2016 and 2023 of 932 articles was double that of the prior 8 years. The largest portion of this literature was focused on chronic medical conditions (137 articles [15%]), general mental health (203 articles [22%]), and interpersonal violence (121 articles 3[13%]). Areas of greatest growth included reproductive health (physical and mental), pain, suicide, and nonsuicidal self-injury. Additionally, emerging areas of inquiry were found, including military-related toxic exposures and harassment within the health care setting.

Conclusions and Relevance

In this systematic review of literature focused on the health of women veterans, the volume of literature was found to have doubled and expanded in important areas that aligned with VA research priorities. However, despite the growth in research related to women veterans, several important research gaps remain within this field of study. Research addressing health issues pertinent to a growing and aging women veterans' population will require rigorous research and program evaluations.

The impact of adverse childhood experiences on postpartum post-traumatic stress disorder in women: A prospective cohort study in China

BACKGROUND

Women are more prone to experience adverse childhood experiences (ACEs), placing them at higher risk of postpartum mental health disorders. However, research on ACEs, particularly their association with postpartum Post-Traumatic Stress Disorder (PTSD) in non-Western contexts, is limited.

OBJECTIVE

To utilize a cumulative risk approach and latent class analysis (LCA) to operationalize ACEs among postpartum women in China and examine their association with postpartum PTSD.

METHODS

In this prospective cohort study, 856 eligible participants from a tertiary hospital in Guangdong province of China between October 2022 and August 2023 completed assessments of demographic and obstetric characteristics, and ACEs within 2-3 days postpartum, followed by PTSD evaluation at 42 days postpartum. The cumulative risk approach and LCA were employed to operationalize ACEs, and their association with postpartum PTSD was assessed using log-binomial regression models, adjusting for potential confounders.

RESULTS

Among the participants, 80.4 % (688/856) reported ACEs, with 18.2 % experiencing four or more ACEs, a threshold above which there was a particularly higher risk of postpartum PTSD in the adjusted model (OR = 8.27, 95 % CI = 3.08-22.20). LCA identified three groups: low ACEs, household and community violence, and multiple ACEs, with women in the multiple ACEs group exhibiting the most severe postpartum PTSD symptoms in the adjusted model (OR = 4.39, 95 % CI = 1.58-12.24).

CONCLUSIONS

This study demonstrates that ACEs are a significant risk factor for postpartum PTSD, especially for women who have experienced four or more ACEs, or multiple ACEs, placing them at particularly high risk for developing postpartum PTSD.

The Incidence of Postpartum Post-Traumatic Stress Disorder in Women Exposed to Adverse Childhood Experiences: A Systematic Review and Meta-Analysis

BACKGROUND

Adverse childhood experiences (ACEs) are known contributors to lifelong mental health challenges. Despite studies linking ACEs to increased risk of adverse postpartum mental health outcomes, a systematic review on the occurrence of postpartum post-traumatic stress disorder (PTSD) in women with ACEs is lacking.

METHODS

A systematic search was conducted in seven databases to retrieve studies from inception to January 31, 2024. A random-effects model was used to quantify weighted estimates of postpartum PTSD incidence. Statistical analysis was conducted using R software.

RESULTS

Seven studies were included in the system review. One study was identified as an outlier and excluded from the meta-analysis. Among the six remaining studies, 1186 women exposed to ACEs were identified, with 249 of them experiencing postpartum PTSD. The estimated incidence of postpartum PTSD among women exposed to ACEs was 22.6% (95% confidence interval [CI] 16.1%-29.8%). Subgroup analysis revealed significant variations in incidence depending on study settings (p < 0.01) and PTSD assessment methods (p < 0.01). Due to multicollinearity among the primary variables, a meta-regression to identify factors influencing study heterogeneity was not conducted.

CONCLUSION

The incidence of postpartum PTSD was 22.6% in women with ACEs, higher than that observed in the general obstetric population. This finding suggests the need to provide comprehensive postpartum care for these women.

A Community-Based Intervention for Mental Health and Wellbeing in Pregnancy and Postpartum: One Healthy Start Site's Story

Purpose

Perinatal mood and anxiety disorders (PMADs) are the leading cause for maternal morbidity and are associated with underlying causes of pregnancy-related death. Healthy Start (HS) programs around the country seek to lower the risk of maternal mortality through services that screen for and address social determinants of health, including mental health. This study used secondary data from the University of Houston Healthy Start (UHHS) to examine postpartum depression screening and referral rates among program participants and feedback from participating mothers about the program's mental health services.

Patient and Methods

Secondary quantitative data from the program's administration of services (n = 164) and secondary qualitative data from a sub-set of program participants (n = 23) were analyzed. Using data from the standardized HS tools (required for all sites), aggregate demographic data and screening results of depression and interpersonal violence were assessed. Anonymous qualitative data from focus groups were analyzed for themes related to mental health.

Results

Screening for postpartum depression was 97% with a 78% referral rate. Screening for interpersonal violence (IPV), a known correlate of PMADs, was 98% with a 100% referral rate for the 4 women who screened positive for IPV. Qualitative themes revealed close-knit relationships with case managers and doulas that encouraged disclosure of symptoms, honest discussions, and an increased desire to ask for help when needed. Emergent themes revealed that Persistence and authenticity were critical to gain participant trust; a culture of sisterhood positively participants' mental health; and case managers were proactive with emotional support and resource referral.

Conclusion

High rates of mental health screening and referral at the UHHS site were documented and participant stories revealed that trust with case managers was instrumental to their wellbeing. More robust data is needed to allow statistical comparisons are needed in future research.

The Impact of Military Trauma Exposures on Servicewomen's Pregnancy Outcomes: A Scoping Review

INTRODUCTION

Active-duty servicewomen and veterans make up nearly 20% of the United States military and may experience trauma specific to military service. Military-specific trauma includes combat deployment and military sexual trauma, exposure to which may result in posttraumatic stress disorder (PTSD). The purpose of this scoping review is to examine the extent to which military trauma exposures impact the pregnancy outcomes of active-duty servicewomen and women veterans.

METHODS

A systematic search of OVID MEDLINE, OVID Embase, and OVID PsycINFO from inception to September 25, 2023, identified studies examining associations between military trauma exposures and perinatal outcomes. Of the 614 studies identified, 464 were reviewed for relevance, with 16 meeting inclusion criteria.

RESULTS

Of the 16 included studies, 14 found associations between military trauma exposure and adverse pregnancy outcomes including preterm birth, gestational diabetes, hypertensive disorders of pregnancy, low birth weight, and perinatal mood and anxiety disorders. The risks of adverse pregnancy outcomes increased with the severity of PTSD, the recency of combat deployment, and repetitive deployment.

DISCUSSION

This scoping review strengthens the link between trauma exposures and adverse pregnancy outcomes for current and former military servicewomen. A gap in the literature persists regarding trauma exposure among active-duty servicewomen, which differs significantly from women veterans. As mental health conditions are the leading underlying cause of maternal mortality, standardized screening during the perinatal period for military-specific trauma exposures and PTSD is recommended for this population. Black servicewomen of junior enlisted rank carry disproportionate burdens of PTSD diagnosis and adverse pregnancy outcomes. Comprehensive prenatal and postpartum management may improve perinatal and neonatal outcomes for military servicewomen and provide an innovative approach to reducing existing racial disparities.