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In this issue of AJPH, MacDorman et al. (p. 1673) add a new analysis of cause of death data, underscoring that inequities in maternal mortality persist. Findings highlight the importance of identifying causes and accelerating actions to address racial inequities in maternal mortality. This is essential for changing the narrative about why Black people are more likely to experience pregnancy-related deaths than are nonHispanic White, Hispanic, and others. We must use methods of inquiry that continue to askwhyateach level (https:// bit.ly/2TwnO4l; Figure 1). Asking why leads us away from \"mother blame\" narratives or a singular focus on health behaviors of birthing people and toward naming structural racism asa root cause and assessing unequal treatment in the health care system.1The authors report that the maternal mortality rate for Black people is 3.5 times that of White people. Their analysis on cause of death addresses why we see these unacceptable inequities. Their findings suggest that the excess maternal deaths are attributable to higher rates of eclampsia and preeclampsia, postpartum cardiomyopathy, and obstetric embolism. Thus, increased vigilance for cardiovascular problems during and after pregnancy may reduce disparities in maternal mortality.

To mark the 30th anniversary of The American Journal of Managed Care (AJMC), each issue in 2025 includes a special feature: reflections from a thought leader on what has changed-and what has not-over the past 3 decades and what's next for managed care. The November issue features a conversation with Laurie C. Zephyrin, MD, MPH, MBA, senior vice president for achieving equitable outcomes at the Commonwealth Fund.

BackgroundMost US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services.ObjectivesTo inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients.DesignCross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant.ParticipantsVeteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients).Main MeasuresWe used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations.Key ResultsAmong nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA’s 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%).ConclusionsOverweight and obesity are common among veterans served by the VHA. VHA’s weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups—such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans—may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.

To estimate the cost of maternal morbidity for all 2019 pregnancies and births in the United States. Using data from 2010 to 2020, we developed a cost analysis model that calculated the excess cases of outcomes attributed to nine maternal morbidity conditions with evidence of outcomes in the literature. We then modeled the associated medical and nonmedical costs of each outcome incurred by birthing people and their children in 2019, projected through five years postpartum. We estimated that the total cost of nine maternal morbidity conditions for all pregnancies and births in 2019 was $32.3 billion from conception to five years postpartum, amounting to $8,624 in societal costs per birthing person. We found only nine maternal morbidity conditions with sufficient supporting evidence of linkages to outcomes and costs. The lack of comprehensive data for other conditions suggests that maternal morbidity exacts a higher toll on society than we found. Although this study likely provides lower bound cost estimates, it establishes the substantial adverse societal impact of maternal morbidity and suggests further opportunities to invest in maternal health.

BackgroundLittle is known about contraceptive care for the growing population of women veterans who receive care in the Veterans Administration (VA) healthcare system.ObjectiveTo determine rates of contraceptive use, unmet need for prescription contraception, and unintended pregnancy among reproductive-aged women veterans.Design and ParticipantsWe conducted a cross-sectional, telephone-based survey with a national sample of 2302 women veterans aged 18–44 years who had received primary care in the VA within the prior 12 months.Main MeasuresDescriptive statistics were used to estimate rates of contraceptive use and unintended pregnancy in the total sample. We also estimated the unmet need for prescription contraception in the subset of women at risk for unintended pregnancy. For comparison, we calculated age-adjusted US population estimates using data from the 2011–2013 National Survey of Family Growth (NSFG).Key ResultsOverall, 62% of women veterans reported current use of contraception, compared to 68% of women in the age-adjusted US population. Among the subset of women at risk for unintended pregnancy, 27% of women veterans were not using prescription contraception, compared to 30% in the US population. Among women veterans, the annual unintended pregnancy rate was 26 per 1000 women; 37% of pregnancies were unintended. In the age-adjusted US population, the annual rate of unintended pregnancy was 34 per 1000 women; 35% of pregnancies were unintended.ConclusionsWhile rates of contraceptive use, unmet contraceptive need, and unintended pregnancy among women veterans served by the VA are similar to those in the US population, these rates are suboptimal in both populations, with over a quarter of women who are at risk for unintended pregnancy not using prescription contraception, and unintended pregnancies accounting for over a third of all pregnancies. Efforts to improve contraceptive service delivery and to reduce unintended pregnancy are needed for both veteran and civilian populations.

Veterans concurrently using both Veterans Affairs (VA) and community providers and facilities have increased coordination needs related to bridging their care across health care settings. Women Veterans commonly require a combination of VA and community care if they have women-specific specialty care needs, such as gynecologic malignancies. We assessed VA women's health providers' and administrators' perceptions of coordination challenges for Veterans' gynecologic cancer care, and potential approaches for addressing these challenges. We carried out semistructured qualitative interviews with field-based key informants (VA gynecologists, women's health medical directors, and other staff directly involved in women's health care coordination) at 15 VA facilities. Transcripts were summarized in a template to capture key points. Themes were identified and iteratively revised (inductively/deductively) via a collaborative decision-making process utilizing matrices to compare content across interviews. Key informants (n=23) noted that services for patients with gynecologic cancers are provided through a combination of VA and community care with wide variation in care arrangements by facility. Care coordination challenges included care fragmentation, lack of role clarity and care tracking, and difficulties associated with VA and community provider communication, patient communication, patient records exchange, and authorizations. Care coordination roles suggested for addressing challenges included: care tracker, provider point-of-contact, patient liaison, and records administrator. Experiences in coordinating care for women Veterans with gynecologic malignancies receiving concurrent VA and community cancer care reveal challenges inherent in delivering care across health care systems, as well as potential approaches for addressing them.

ObjectiveTo estimate the cost of maternal morbidity for all 2019 pregnancies and births in the United States.MethodsUsing data from 2010 to 2020, we developed a cost analysis model that calculated the excess cases of outcomes attributed to nine maternal morbidity conditions with evidence of outcomes in the literature. We then modeled the associated medical and nonmedical costs of each outcome incurred by birthing people and their children in 2019, projected through five years postpartum.ResultsWe estimated that the total cost of nine maternal morbidity conditions for all pregnancies and births in 2019 was32.3 billion from conception to five years postpartum, amounting to 8,624 in societal costs per birthing person.ConclusionWe found only nine maternal morbidity conditions with sufficient supporting evidence of linkages to outcomes and costs. The lack of comprehensive data for other conditions suggests that maternal morbidity exacts a higher toll on society than we found.Policy implicationsAlthough this study likely provides lower bound cost estimates, it establishes the substantial adverse societal impact of maternal morbidity and suggests further opportunities to invest in maternal health.

ObjectivesTo identify the prevalence of women Veterans reporting receipt of counseling about health optimization prior to pregnancy, topics most frequently discussed, and factors associated with receipt of this care.MethodsWe analyzed data from a nationally representative, cross-sectional telephone survey of women Veterans (n = 2302) ages 18–45 who used VA for primary care in the previous year. Our sample included women who were (1) currently pregnant or trying to become pregnant, (2) not currently trying but planning for pregnancy in the future, or (3) unsure of pregnancy intention. Multivariable logistic regression was used to examine adjusted associations of patient- and provider-level factors with receipt of any counseling about health optimization prior to pregnancy (prepregnancy counseling) and with counseling on specific topics.ResultsAmong 512 women who were considering or unsure about pregnancy, fewer than half (49%) reported receiving any prepregnancy counseling from a VA provider in the past year. For those who did, the most frequently discussed topics included healthy weight (29%), medication safety (27%), smoking (27%), and folic acid use before pregnancy (27%). Factors positively associated with receipt of prepregnancy counseling include history of mental health conditions (aOR = 1.96, 95% CI: 1.28, 3.00) and receipt of primary care within a dedicated women’s health clinic (aOR = 2.07, 95% CI: 1.35, 3.18), whereas factors negatively associated include far-future and unsure pregnancy intentions (aOR = 0.35, 95% CI: 0.17, 0.71 and aOR = 0.33, 95% CI: 0.16, 0.70, respectively).Conclusions for PracticeRoutine assessment of pregnancy preferences in primary care could identify individuals to whom counseling about health optimization prior to pregnancy can be offered to promote patient-centered family planning care.

Abstract Coordinating care between Veterans Health Administration (VA) and community providers is essential for providing high-quality comprehensive maternity care to women veterans, particularly those with chronic medical or mental health issues. We iteratively developed and assessed feasibility, as well as facilitators and barriers, of implementing the VA Maternity Care Coordinator Telephone Care Program, and identified specific health needs of pregnant women Veterans served by the program. We used three Plan–Do–Study–Act cycles. The final program consisted of materials supporting seven structured phone calls spanning initiation of pregnancy care through six weeks postpartum. We used logs to measure veteran uptake and surveys and field notes to capture care-coordinator perceptions about potential program value and facilitators and barriers to implementing it. We conducted a medical record review assessing pregnant veterans’ need for coordination of services for physical and mental health problems and health behaviors. Veterans’ uptake was 60%. Implementation facilitators included conducting training sessions for program coordinators and tailoring materials to address differences across VA facilities. Implementation barriers included limited information and communication technology tools to support the program and lack of coordinator time for delivering the telephone care. Among 244 pregnant veterans, 41% had pre-pregnancy chronic physical problem(s); 34% mental health problem(s); 18% actively or recently smoked. Implementation of a telephone-based care coordination program for pregnant veterans was feasible. Effective program spread required tailoring for local variations in resources and processes, investing in information and communication technology tools and allocating coordinator time to deliver care. Pregnant women veterans have a substantial burden of physical health, mental health, and risky health behaviors needing care coordination. Pregnant women Veterans have a substantial burden of physical and mental health conditions needing care coordination. Implementation of a telephone-based care coordination program for pregnant Veterans is feasible.