Pregnancy and Mental Health Among Women Veterans
Returning from Iraq and Afghanistan
Kristin M. Mattocks, Ph.D.,1,2Melissa Skanderson, M.A.,1,2Joseph L. Goulet, Ph.D.,1,2
Cynthia Brandt, M.D.,1,3Julie Womack, C.N.M., Ph.D.,2Erin Krebs, M.D.,4Rani Desai, Ph.D.,2,5
Amy Justice, M.D., Ph.D.,1,2Elizabeth Yano, Ph.D.,6and Sally Haskell, M.D.1,2
Background: Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF=OIF) may experience signif-
icant stress during military service that can have lingering effects. Little is known about mental health problems
or treatment among pregnant OEF=OIF women veterans. The aim of this study was to determine the prevalence
of mental health problems among veterans who received pregnancy-related care in the Veterans Health Ad-
ministration (VHA) system.
Methods: Data from the Defense Manpower Data Center (DMDC) deployment roster of military discharges from
October 1, 2001, through April 30, 2008, were used to assemble an administrative cohort of female OEF=OIF
veterans enrolled in care at the VHA (n¼43,078). Pregnancy and mental health conditions were quantified
according to ICD-9-CM codes and specifications. Mental healthcare use and prenatal care were assessed by
analyzing VHA stop codes.
Results: During the study period, 2966 (7%) women received at least one episode of pregnancy-related care, and
32% of veterans with a pregnancy and 21% without a pregnancy received one or more mental health diagnoses
(p<0.0001). Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, post-
traumatic stress disorder (PTSD), bipolar disorder, or schizophrenia as those without a pregnancy.
Conclusions: Women OEF=OIF veterans commonly experience mental health problems after military service.
The burden of mental health conditions is higher among women with an identified instance of pregnancy than
among those without. Because women do not receive pregnancy care at the VHA, however, little is known about
ongoing concomitant prenatal and mental healthcare or about pregnancy outcomes among these women veterans.
Freedom, OEF), unprecedented numbers of women have
served in the U.S. military. More than 170,000 female soldiers
have been deployed to Iraq and Afghanistan, more than 20-
fold the number who served in the Vietnam era (7,500) and
more than four times the number deployed to the Gulf war
ince the inception of the wars in Iraq (Operation Iraqi
Freedom, OIF) and Afghanistan (Operation Enduring
Many returning OEF=OIF veterans struggle with mental
direct combat roles in the military, they serve in positions
(e.g., convoy driver, patrol) that put them in the line of direct
enemy fire and may cause significant stress.3Like the men,
many women returning from military service may experi-
ence mental health problems,4but the juxtaposition of
pregnancy and mental health-related issues is of special
concern because pregnancy itself can precipitate or exacer-
bate mental health conditions, and maternal anxiety during
1Yale University School of Medicine, Department of Internal Medicine, New Haven, Connecticut.
2VA Connecticut Healthcare System, West Haven, Connecticut.
3Yale University School of Medicine, Yale Center for Medical Informatics, New Haven, Connecticut.
4Center on Implementing Evidence-Based Practice, Roudebush VA Medical Center, Regenstrief Institute, Inc., and Department of
Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
5Yale University School of Medicine, Department of Psychiatry, New Haven, Connecticut.
6VA HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, VA Greater Los Angeles Healthcare System, Sepulveda,
and Department of Health Services, UCLA School of Public Health, Los Angeles, California.
JOURNAL OF WOMEN’S HEALTH
Volume 19, Number 12, 2010
ª Mary Ann Liebert, Inc.
pregnancy cangiverise topretermdeliveries andlower birth
Untreated mental health conditions during pregnancy
may give rise to poor pregnancy outcomes, including pre-
term delivery, low birth weight, and other adverse preg-
nancy outcomes.7–13If mental health problems persist and
remain untreated after pregnancy, they may impair the
infant’s healthcare needs and cognitive and emotional de-
velopment.14–18Several studies have begun to focus on
the importance of mental health treatment for pregnant
women, although sustaining mental health treatment
throughout the duration of the pregnancy remains a chal-
lenge.19Several studies have examined pregnancy out-
comes, including fertility disorders, miscarriages, and
birth defects among veterans,20,21but, little is known about
the prevalence of mental health problems among preg-
nant veterans or the degree to which they receive treat-
ment for their mental health conditions. Understanding care
use patterns and health outcomes among pregnant veter-
ans is challenging, as women traditionally have not used
Veterans Health Administration (VHA) healthcare.22Large-
scale studies examining women veterans’ health outcomes
are currently underway.23Interestingly, these studies sug-
gest that OEF=OIF women are among the fastest grow-
ing segments of new VHA users,24with as many as 44%
of women returning from OEF=OIF electing to use the
Although increasing numbers of OEF=OIF women veter-
ans use VHA services, the VHA does not provide routine
prenatalcare. Because womenremain anumericalminority in
the VHA, a majority of VHA facilities refer pregnant veterans
to community obstetrical providers via fee basis or contract
mechanisms.26,27. However, although women veterans may
leave the VHA to receive prenatal care, those who struggle
with concomitant physical and mental health problems dur-
ing pregnancy may choose to remain in the VHA system for
provisionofcarefor theseconditions. Thisdualsystem ofcare
maylead tolackofcoordination amongcare providers, which
may present problems for medical management of pregnancy
if non-VHA obstetrical providers are unaware of women
veterans’ mental health problems or medications they may be
taking for these problems.
The recent legislation allowing for 5 full years of health-
care for new combat veterans has resulted in and may con-
tinue to result in larger numbers of women entering VHA for
their healthcare needs. It is important to understand the
patterns of mental health diagnoses in these women, to un-
derstand what role pregnancy may be playing in the care of
female veterans, and to understand the overlap between
pregnancy and mental health conditions in these women.
Such an understanding will assist healthcare providers in
identifying groups of veterans at potential risk for poor
clinical outcomes and highlight the need for coordination of
care for some veterans across VHA and non-VHA health-
The purpose of this study is threefold: 1) to examine the
prevalence of pregnancy-related care among OEF=OIF vet-
erans of childbearing age enrolled for care in the VHA, (2) to
examine the degree to which women with pregnancy-related
extent to which women with a pregnancy diagnosis receive
mental healthcare at the VHA.
Materials and Methods
The VHA OEF=OIF roster is a database of veterans who
VHA healthcare between October 1, 2001, and April 30, 2008
(n¼406,802). The roster uses data from the Department of
Defense Manpower Data Center’s (DMDC) Contingency
Tracking System and includes information on veterans’ sex,
race, date of birth, deployment dates, armed forces branch
(Army, Navy, Air Force, Marines, or Coast Guard) and com-
ponent (National Guard, Reserve, or active duty). We in-
cluded women who were of childbearing age (up to 50 years
included 43,078 women who served in OEF=OIFand received
VHA healthcare after return from deployment.
Data on women veterans identified through the OEF=OIF
roster were then linked to administrative and clinical data
contained within the VHA National Patient Care Database
(NPCD) and Decision Support Systems (DSS). These data-
bases provide healthcare use information and cost data,
pharmacy and laboratory data, and health encounters and
coded diagnostic and procedure data associated with inpa-
tient and outpatient encounters.
Pregnancy and mental health conditions were quantified
by grouping diagnoses according to International Classification
of Diseases, Ninth Revision, Clinical Modification codes and
specifications.28To ensure independence of observations (i.e.,
one pregnancy per veteran), an index pregnancy was identi-
fied as the unit of analysis. The index pregnancy was defined
as the first pregnancy identified during the study period. An
index pregnancy was determined if a female veteran had any
one pregnancy-related ICD-9, current procedural terminol-
ogy (CPT), or V code within the 5-year observation period of
the available DSS data. Pregnancy-related codes included
ICD-9 codes for normal pregnancy and delivery (650–659),
(634–639), and complications of pregnancy (ICD-9 650–659,
630–633, 634–639, 640–649). CPT codes were as follows: nor-
malpregnancy anddelivery(59000–59430), ectopic pregnancy
(59130, 59140, 59135, 59136, 59151, 59150), abortion (59855–
59857, 59850–59852, 59840, 59841, 59830, 59851, 59852, 59850),
miscarriage (59812, 59820, 59821), cesarean section (59618–
59622, 59514, 59515, 59510, 59610–59614, 59525), and vaginal
delivery (59409, 59410, 59610–59614, 59425–59426, 59430,
59400). V codes are codes used to describe a reason for a
healthcare encounter and are often used as a status code for
pregnancy. Vcodes used for pregnancyincluded V22(normal
pregnancy), V23 (supervision of high-risk pregnancy), V24
(postpartum care and evaluation), V27 (outcome of delivery),
and V28 (antenatal screening).28
Because the VHA does not routinely capture pregnancy
outcomes, it is difficult to determine the period of pregnancy
among women veterans, and it is, therefore, difficult to cap-
ture any services that may occur during this period. To ad-
dress this problem, we created a pregnancy window that
extended from 10 months before the first pregnancy-related
code to 10 months after the first pregnancy-related code. The
width of the pregnancy window allows for differences in the
time that women may have first come to the VHA with
pregnancy. It allows us to capture data for the full terms of
women who receive an early pregnancy-related code, such as
at the time of a 6-week pregnancy test, but also allows us to
2160 MATTOCKS ET AL.
capture data for women who had no prior VHA pregnancy-
related care until labor and delivery.
We focused on mental health conditions (major and minor
depression, bipolar disorder, postraumatic stress disorder
[PTSD], schizophrenia, and anxiety disorder) that are highly
prevalent and often disabling conditions among veterans in
the VA. Veterans were considered to have mental health di-
agnoses if they had two or more outpatient or one or more
inpatient ICD-9-CM codes for major and mild depression,
bipolar disorder, PTSD, schizophrenia, anxiety disorder,
alcohol abuse or dependence, or drug abuse or dependence at
any time during the 5-year study period. In prior studies, we
have found that this requirement substantially improves the
accuracy of these codes for the actual clinical diagnosis.29
Mental health conditions were identified using ICD-9 codes
grouped into clusters of psychiatric disease diagnoses as
previously reported.30,31Mental healthcare use was assessed
using VHA stop codes, which are codes the VHA uses to
identify the clinical group responsible for provision of care.32
To evaluate mental healthcare during the index pregnancy
window, we used individual mental health clinic and psy-
chiatry codes (stop codes 502, 509, 510), PTSD group and
individual counseling codes (stop codes 516, 540, 562), sub-
stance abuse counseling codes (stop code 513), and sexual
trauma counseling for women codes (stop code 524).
To account for differences in use that may arise because of
physical trauma incurred during military service, we in-
cluded ICD-9 codes for the most commonly diagnosed con-
ditions among returning war veterans,33including ICD-9
codes 720.1–720.9 for back problems and 713.0–716.9, 716.21–
716.99, 718.1–718.29, and 718.5–719.99 for joint disorders. We
also assessed differences in use because of female genital
disorders (a diagnostic group of conditions comprising
ovarian, uterine, and vaginal disorders and abnormal Pap
smears), including ICD-9 codes 619.0–625.9. For physical
trauma-related conditions, we limited the data to diagnostic
codes that occurred either once or more for an inpatient stay
or twice ormore for an outpatient visit. This methodology has
been used in identification of psychiatric disorders in ad-
ministrative data34and in identification of HIV in Medicaid
represented well-screening visits rather than diagnoses, we
accepted any one inpatient or outpatient diagnostic code.
We used univariate statistics to describe the characteristics
of pregnant women veterans, and bivariate statistics, includ-
ing the t test for continuous variables and the chi-square test
for ordinal or dichotomous variables, to compare the demo-
graphic and clinical characteristics of women veterans with
and without pregnancy. Statistical analyses were performed
using SAS version 9.1.3 (SAS, Inc., Cary, NC). All statistical
tests were two-tailed.
A total of 43,078 women veterans enrolled in VHA care
during the 5-year study period and were between the ages of
18 and 50 during the study period. Overall, 2,966 of these
women (7%) had at least one code for a pregnancy-related
condition during the 5-year study period. Veterans with a
pregnancy during the study period were younger and more
likely to be Hispanic and unmarriedand to havea high school
related condition (p<0.0001) (Table 1). Veterans with a
pregnancy were also more likely to be enlisted service mem-
bers rather than officers and more likely to be active duty
service members at the time of last deployment rather than
members of the Guard or Reserves. Veterans with a preg-
nancy were also more likely to have separated from the mil-
itary between the years 2001 and 2004 than veterans without
a pregnancy. On average, women veterans experienced their
index pregnancy nearly 2 years after return from their last
military deployment. Veterans with a pregnancy were also
than those without a pregnancy and were more likely to re-
ceive treatment for female genital disorders. There were no
significant differences between the two groups in terms of
diagnosis of musculoskeletal or joint disorders.
The number of women veterans who had an index preg-
nancy grew steadily each year from 12 in 2002 to a maximum
of 955 in 2006, representing approximately 4% of eligible
OEF=OIF women veterans seen at the VHA each year (data
not shown). Most pregnancy-related care for women veterans
was provided on a fee-for-service basis or by contract pro-
viders outside the VHA (Table 2). A small proportion of wo-
men sought VHA care for miscarriages or spontaneous
large proportion of women veterans (75%) who had V codes
for pregnancy-related issues at the VHA, care was sought for
recorded at the time of the visit. In contrast, a large proportion
of women received inpatient (55%) or outpatient (44%) non-
VHA care for normal pregnancy and delivery.
Overall, 32% of women veterans with an index pregnancy
received one or more distinct mental health diagnoses, com-
pared with 21% of women veterans without a pregnancy-
related condition (p<0.0001) (Table 3). Compared with all
women veterans enrolled in VHA care, women with a preg-
nancy were more likely to have a diagnosis of major depres-
sion, mild depression, PTSD, anxiety, schizophrenia, bipolar
disorder, and alcohol and drug abuse=dependence during the
5-year study period. The most common mental health diag-
noses among veterans with a pregnancy were anxiety, de-
pression, and PTSD, with these veterans experiencing over
twice the rates of anxiety, depression, and PTSD as veterans
without a pregnancy. Sixteen percent of veterans with a
pregnancy had a single mental health diagnosis, 11% had two
distinct diagnoses, and nearly 6% had three or more different
mental health diagnoses. In contrast, 11% of nonpregnant
women had a single mental health diagnosis, 7% had two
distinct mental health diagnoses, and 2% had three or more
different mental health diagnoses during the study period
(p<0.0001). More than half of all veterans with a pregnancy
who had mental health conditions were diagnosed with their
mental health condition at VHA facilities on or before their
firstpregnancy-related code.The proportion ofwomen witha
mental health diagnosis who received their diagnosis before
pregnancy was 66% for PTSD, 62% for depression, and 55%
for bipolar disorder. In contrast, only 5% of women were di-
agnosed with anxiety disorder before their pregnancies.
Over 30% of pregnant veterans sought care from VA
mental health providers during the index pregnancy, with an
average of 6.6 mental health visits during the pregnancy
(Table 4). Nine percent of pregnant veterans sought care for
PTSD, 2% of pregnant veterans received substance abuse
PREGNANCY AND MENTAL HEALTH IN WOMEN VETERANS 2161
counseling, and 1% of pregnant veterans received care related
to sexual trauma.
mental health conditions among female OEF=OIF veterans
small proportion of OEF=OIF women receiving care in the
VHA received pregnancy-related care during the study pe-
riod (7%), a substantial proportion of these women (32%)
suffered from a mental health problem. Perhaps most sur-
prisingly, the rates of anxiety, major=minor depression, and
Table 1. Characteristics of Operation Enduring Freedom=Operation Iraqi Freedom Women Veterans
Seen at Veterans Health Administration Healthcare Facilities (n¼43,078)
All female veterans without
(n¼40,112) n (%)
Age (mean, SE)
Days to pregnancy since return from
last deployment (mean, SE)
<High school or high school graduate
Some college or college graduate
Year of return from last deployment
Female genital disorders
VHA healthcare use
General medicine visits (mean, SD)
Primary care visits (mean, SD)
Psychiatric visits (mean, SD)
Use of fee basis=contract care (non-VHA care)
All female veterans with
(n¼2966) n (%)
SD, standard deviation; SE, standard error.
2162MATTOCKS ET AL.
PTSD were over twice as high among women veterans who
had a diagnosis of pregnancy during the study period com-
pared with women veterans without a pregnancy diagnosis.
Several possible reasons exist for this difference. One is that
women veterans with mental health disorders may be more
likely to seek treatment at VHA facilities than women veter-
ans without mental health disorders22and may be more likely
than their male counterparts to come to the VHA with emo-
tional problems.36Consequently, these women may already
be seeking VHA care for mental health, and their pregnancies
were recorded during the course of their mental health
treatment. Other women veterans who are enrolled in VHA
care but are not using mental health or other services may
receive prenatal and obstetrical care outside the VHA and not
report their pregnancies to the VHA.
Second, research suggests that combat veterans may be
morelikelytoengage inhigh-risk behaviorsupon returnfrom
war.37Consequently, women experiencing mental health
problems may be more at risk for pregnancy, as depressive
symptoms have been associated with unprotected sex among
women.38,39Finally, although our study found that >60% of
women with a pregnancy diagnosis were diagnosed with
depression before pregnancy, the higher rates of depression
among those with a pregnancy diagnosis may be partially
due to postpartum depression. We also found that women
a pregnancy diagnosis during the study period. This may be a
result of women with service-connected disabilities being
more likely to use VHA services40and, therefore, being more
likely to have their pregnancies recorded while seeking care
for other conditions.
By creating our pregnancy window, we were able to de-
termine if pregnant veterans were receiving VHA mental
health services during the likely course of their pregnancy.
care at most of its locations, we were unable to determine if
these women were receiving prenatal care or the degree to
which prenatal care was coordinated with ongoing VHA
mental healthcare. Furthermore, we were not able to deter-
mine if these mental health problems had an impact on ma-
ternal, fetal, or infant health.
Comparing the findings in this study with other research
on psychiatric disorders in pregnancy and women of child-
bearing age is important to further our understanding of this
field of inquiry. The overall rate of psychiatric disorders in
study was higher than the rate of mental health problems
among pregnant civilian women in other published studies,
which ranged from 8.5% to 25%.41–50Only one other study
Table 2. Type and Location of Pregnancy Care
Among Veterans with Pregnancy Diagnosis (n¼2966)
Type of pregnancy code
related codes n (%)
VA ICD-9 codes
Ectopic or molar
Fee basis pregnancy care
Normal pregnancy=delivery (650–659)
Ectopic=molar pregnancy (630–633)
Fee basis care ICD9-CM codes
Normal pregnancy=delivery (650–659)
Ectopic=molar pregnancy (630–633)
Table 3. Mental Health Diagnoses and Behavior Problems Among Operation Enduring Freedom=Operation
Iraqi Freedom Women Veterans Seen at Veterans Administration Healthcare Facilities 2003–2008
All female veterans
diagnosis n (%)
All female veterans
diagnosis n (%)p
% pregnant women
MH condition on
or before first
Any MH diagnosis
MH, mental health; PTSD, posttraumatic stress disorder.
356 ( 12)
PREGNANCY AND MENTAL HEALTH IN WOMEN VETERANS2163
had an equally high prevalence (32%) of some form of psy-
chiatric condition during pregnancy.51The prevalence of de-
pression in this study was similar to that in other published
studies,43,52but rates for PTSD and anxiety disorder were
significantly higher than in other studies.12,53–56Making
comparisons between veteran women and other study pop-
ulations remains a challenge, as measurement of psychiatric
disorders in pregnancy varies considerably across studies,
and with some conditions, such as anxiety, few validated in-
struments are available for accurate measurement.57,58
Observed differences in the prevalence of psychiatric dis-
orders during pregnancy between our study and other pub-
lished studies may be due to differences in study populations
as well as differences in screening instruments and diagnostic
criteria for these conditions. Understanding the degree to
which war-related experiences, including combat exposure,
prolonged and repeated military deployments, and military
sexual trauma, affect women veterans during their pregnan-
cies is crucial. Although a recent study evaluated the risk
factors for depressive symptoms during pregnancy,59sur-
prisingly few studies have examined other mental health
conditions that are frequently associated with combat expo-
sure, such as PTSD. Although one study noted a link between
PTSD and preterm delivery,13no studies have evaluated the
link between mental health diagnoses and pregnancy out-
comes among women veterans with combat exposure. We
were able to assess mental health diagnoses in our study but
we were not able to link these diagnoses to combat-related
exposure or stress incurred during military service. Future
research should investigate the possible link between combat-
related exposure and mental health problems during preg-
In our study, a substantial proportion of women veterans
received their prenatal care from fee basis or contract pro-
viders outside the VHA system. Although the VHA has made
significant strides in improving the overall quality of care
provided to its women veterans through the development of
specialized women’s health clinics and teams of women’s
health providers, caring for pregnant veterans presents two
major problems for the VHA. First, because the VHA does not
on fee basis or contract providers for prenatal and obstetrical
care, a system of dual and fragmented care has been estab-
lished for pregnant veterans. Given that pregnant veterans
with concomitant mental health burdens may have difficulty
navigating both VA and private healthcare systems, the VHA
should consider practice interventions that integrate care
management and support for navigating and coordinating
care for these women.
Second, the VHA does not routinely screen or monitor the
quality of prenatal care provided by fee basis or contract
providers, nor does it routinely collect or evaluate pregnancy
outcomes. Consequently, little is known about the quality of
prenatal care received by pregnant veterans, the extent to
which prenatal care is coordinated with ongoing VHA mental
healthcare, or the outcomes of pregnancies among women
veterans. To address this problem, the VHA should consider
from community obstetrical providers and tracking preg-
nancy outcomes among its women veterans.
Our study has several limitations. First, as we have no data
on women veterans who havenot accessedVHA services, our
findings are not generalizable to all women veterans. Another
limitation is that OEF=OIF veterans were not systematically
assessed using validated self-report measures about preg-
nancy outcomes and mental health conditions. We relied on
ICD9-CM, CPT, and V codes in VHA administrative data-
bases to assess pregnancy and mental health conditions.
Consequently, we likely underestimated the prevalence of
pregnancy among women veterans, and our findings are
subject to possible misclassification because of incomplete
data. Finally, the width of our pregnancy window may have
captured two separate pregnancies from one woman during
that time; therefore, our results may be an overestimation of
the association between pregnancy and mental health.
Nevertheless, our results point to a need for the VHA to
continue to understand the overlap between pregnancy and
mental health conditions in VHA patients. By doing so, the
VHA will be better able to identify groups of women veterans
at potential risk for poor clinical outcomes. In addition, these
results highlight the importance of coordination of care for
women veterans across VHA and non-VHA healthcare. Fu-
ture studies should examine the effects of depression and
PTSD on pregnancy outcomes among women veterans, the
degree to which women veterans are receiving high-quality
prenatal care, and the impact of mental health treatment on
pregnancy outcomes among women veterans.
This work was funded by VA HSR&D Merit Award
(Cynthia Brandt, p1). The views expressed in this article are
Table 4. Mental Healthcare Use Among Pregnant Women During Pregnancy Window
Type of visit
% or n pregnant women
Mental health clinic, individual (clinic stop code 502)
Average number of mental health clinic visits during index pregnancy window
PTSD, individual or group (clinic stop codes 516, 540, 562)
Average number of PTSD support group visits during index pregnancy window
Substance abuse treatment, individual (clinic stop code 513)
Average number of substance abuse treatment visits during index pregnancy window
Sexual trauma counseling (clinic stop code 524)
Average number of sexual trauma counseling visits during index pregnancy window
Services for returning veterans (clinic stop code 571, 572)
2164MATTOCKS ET AL.
those of the authors and do not necessarily reflect the position
or policy of the Department of Veterans Affairs.
The authors have no conflicts of interest to report.
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Address correspondence to:
Kristin Mattocks, Ph.D.
VA Connecticut Healthcare System
950 Campbell Avenue, 11-ACSLG
West Haven, CT 06516
2166MATTOCKS ET AL.