Date of Award

Fall 1-1-2025

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Nursing

First Advisor

Womack, Julie

Abstract

Active duty servicewomen (ADSW) have increased risk for mental health conditions compared to civilian women. Civilian research demonstrates that women with mental health conditions experience serious pregnancy complications at rates 50% higher than those without mental health conditions. Although mental health conditions are the leading underlying cause of maternal mortality, there is limited research on the prevalence of perinatal mental health conditions among active duty servicewomen (ADSWs) or their association with adverse pregnancy outcomes. This study aimed to explore associations of mental health conditions and adverse pregnancy outcomes in a population of ADSW. Methods Department of Defense Birth and Infant Health Research program data were used to identify a cohort of live birth pregnancies among ADSW that started and ended between 01 October 2016 and 31 December 2021. Mental health conditions (trauma/stressor-related disorders, anxiety/panic, depression, eating disorders, suicidal ideation/attempt) and adverse pregnancy outcomes (gestational hypertension, gestational diabetes, peripartum cardiomyopathy, postpartum hemorrhage, preterm birth) were identified using ICD codes from medical encounter data. Mental health conditions were measured within three timeframes: pre-pregnancy (the year prior to last menstrual period), pregnancy (from last menstrual period to date of delivery), postpartum (the year following delivery), and overall (pre-pregnancy through postpartum) to determine prevalence. Mental health conditions were assessed as any diagnosis or none, and as a count of comorbid diagnoses (1, 2, or 3+). Adverse pregnancy outcomes were also assessed as a composite variable (any outcome or none). Modified Poisson regression models estimated adjusted risk ratios (aRRs) with 95% CIs to quantify associations of mental health diagnoses (pre-pregnancy and/or during pregnancy) with adverse pregnancy outcomes, overall and stratified by demographic characteristics. Results Overall, 62,729 deliveries among 54,471 ADSW were included. The prevalence of diagnosed mental health conditions from 1 year prior to pregnancy through 1 year postpartum was 33.8%. Trauma and stressor-related disorders were most prevalent (23.1%), followed by anxiety/panic disorders (16.9%), depressive disorders (14.6%), suicidal ideation/attempt (1.6%), and eating disorders (0.4%). The prevalence of mental health conditions was higher in the postpartum period (22.0%) compared to during pregnancy (18.4%) and prior to pregnancy (15.0%). Overall, higher prevalence of these conditions was found among non-Hispanic Black ADSWs (37.4%), and those who were unmarried (38.4%), never deployed (34.9%), and in the Army (37.4%) and Navy (36.4%). Deliveries among ADSW with at least one diagnosed mental health conditions relative to those with none had an increased risk of an adverse pregnancy outcome (aRR 1.07, 95% CI 1.04,1.11). In stratified analyses, the highest risks were found in among White, non-Hispanic ADSW (aRR 1.11, 95% CI 1.06,1.17) and officers (aRR 1.18, 95% CI 1.09,1.29). Deliveries among ADSW with 3+ comorbid mental health conditions vs. none had the highest risk for an adverse pregnancy outcome (aRR 1.17, 95% CI 1.10,1.25), although risks remained elevated for those with 1 or 2 comorbid diagnoses vs. none (aRR 1.04, 95% CI 1.00,1.08 and aRR 1.08, 95% CI 1.03,1.14, respectively). Individually, mental health conditions were associated with increased risk of preterm birth (aRR 1.18, 99% CI 1.08,1.29) and gestational diabetes (aRR 1.14, 99% CI 1.04, 1.25). There was no association between mental health conditions and hypertensive disorders of pregnancy (aRR 1.05, 99% CI 0.99, 1.11). Conclusions This study highlights the increased burden of mental health conditions among ADSW, particularly those from racial or ethnically minoritized backgrounds, and the need for specialized perinatal mental health providers. ADSW with mental health conditions were at increased risk for adverse pregnancy outcomes, and risk varied by demographic subgroups and number of comorbid mental health diagnoses. Enhanced screening and subsequent treatment of these mental health diagnoses can be a mechanism to decrease adverse pregnancy outcomes and improve health outcomes for the entire military family.

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