Expanding Perinatal Care Beyond Obstetrics: The National Veterans Affairs Maternity Care Coordinator Program

Abstract

Pregnant and postpartum individuals in the United States experience high rates of adverse pregnancy outcomes, despite multiple obstetric initiatives to address this public health crisis. Perinatal care that meaningfully addresses long-term factors that impact pregnancy outcomes, such as chronic mental and physical conditions, adverse social and environmental factors, structural racism, birth-related morbidity and trauma, and transitions to parenting, must go beyond obstetric care sites to include health care providers who deliver care across the lifespan. Veteran’s Health Administration (VHA), the nation’s largest integrated health care system, has reimagined the integration of individualized pregnancy-related care coordination within a health care system that does not directly provide obstetric care. The VHA Maternity Care Coordinator Program provides a feasible, effective, and replicable model that is relevant to other integrated health care systems.

Pregnant and postpartum individuals in the United States experience unacceptably high rates of adverse pregnancy outcomes. This has been associated with system-level factors such as the lack of universal health care, an undersupply of obstetric providers (especially midwives), a lack of guaranteed paid parental leave, and minimal postpartum support. ¹ National initiatives have often focused on improving the delivery of obstetric care to address common causes of maternal morbidity and mortality such as postpartum hemorrhage or hypertension, ² and educating pregnant people and families to identify pregnancy danger signs. ³ However, there is a growing understanding that factors beginning before pregnancy and continuing afterwards differentially elevate risk for minoritized and other high-risk populations such as veterans, including political and social determinants of health, structural racism, and fragmented, inequitable access to care and resources.^4,5 Pregnant and postpartum individuals in the United States are also increasingly older and have more medical and behavioral health comorbidities than prior generations, ⁶ increasing the importance of pregnancy-related care that is integrated with primary and specialty care providers.^7,8

The Veterans Health Administration (VHA) cares for a diverse and obstetrically high-risk population. Veterans using VHA pregnancy benefits are more likely to be older, from a racially minoritized population, living in a rural area, ⁹ diagnosed with a mental health condition, ¹⁰ and at risk of pregnancy complications such as pre-term birth, pre-eclampsia, and gestational diabetes,^11–13 when compared to their civilian counterparts. Maternal mortality among veterans trends higher than the national maternal mortality ratio, though direct comparisons are difficult given that the number of veteran births is relatively small at around 12,000 births per year. ¹⁴ The VHA maternal mortality review committee reported that maternal mortality (i.e., pregnancy-related death during pregnancy and up to 42 days postpartum) among veterans (2011–2020) was 37.8 deaths per 100,000 live births. Among pregnancy-associated deaths (i.e., death from all causes through the first year postpartum), 50% had experienced adverse social determinants of health and 81% had at least one mental health diagnosis. Notably, 50% of all these deaths occurred in late postpartum period with more than half (56.2%) related to suicide. ¹⁵

Caring for childbearing veterans provides an important example of the critical role that primary care, behavioral health, specialty care, and emergency care providers must play in order to respond to the elevated risk of maternal death and other adverse pregnancy outcomes throughout the first 1–2 years postpartum. Patients facing unstable housing, food insecurity, relationship stressors and other life disruptions benefit from higher frequency touchpoints and strategies to address barriers to obtaining resources, both social and medical. Likewise, individuals experiencing chronic mental or physical conditions may suffer dangerous exacerbations during pregnancy and postpartum that could be avoided through thoughtful preconception education and treatment planning. ¹⁶ Solidifying reproductive goals and contraceptive choice is an ongoing priority between pregnancies that often falls beyond the scope of basic pregnancy-related care.

Unlike the Department of Defense (DoD) which provides obstetric care to active-duty service members and dependents, VHA does not provide pregnancy and postpartum care directly to veterans. Rather, the cost of obstetric care in the community is covered for all veterans who are eligible and enrolled in VHA care. However, VHA does provide ongoing robust primary care, mental health care, emergency care, and specialty care, as well as the social support services needed to address a variety of needs, including housing, food insecurity, gun safety, and relationship support. It is increasingly evident that in the context of this high-risk population, maternity care is optimized when supported by a network of collaborating multi-specialty providers who maintain continuity with the patient.

As the number of pregnancy-capable veterans has increased, VHA has reimagined innovative ways to direct resources and care coordination toward this population. Leading this initiative is the workforce of health navigators—known as maternity care coordinators (MCCs)—who are assigned to every VHA facility across the national health care system. ¹⁷ The MCC program is grounded in VHA’s mission to provide exceptional health care that improves overall health and well-being and aims to support universal access and achieve optimal outcomes for every pregnant veteran. ¹⁴ The collective MCC caseload includes more than 17,000 pregnant people per year. ¹⁴ Providing individualized care at this scale is a daunting task, especially given that care coordination is time consuming, labor intensive, and often thought to be beyond the scope of what is possible even for obstetric care providers, let alone providers working in a non-obstetric health care system.

First piloted in 2012, the MCC program is staffed primarily by nurses and social workers who are tasked with routine telephone or virtual communication with pregnant and postpartum veterans, including those who continue to a live birth and those who experience pregnancy loss. ¹⁴ While the MCC program is not a peer-to-peer program, some MCC’s are veterans but more significantly, all MCCs provide care specifically tailored to the veteran experience. Using a standardized, evidence-based program manual, veterans are contacted a minimum of four times during the pregnancy (each trimester and shortly after delivery) and four times (every 3 months) through the first year postpartum. Each contact includes a structured outline of topics tailored to the current state of pregnancy or postpartum. MCCs conduct screenings for depression, anxiety, relationship health and safety, and housing and food security as well as discuss key topics such as postpartum contraceptive considerations, lactation, and any medical conditions impacting pregnancy and postpartum periods. (See Table 1).

Table 1.

Maternity Care Coordinator (MCC) Contact Intervals and Content

Contact	1st trimester (tri-1)	Tri-2	Tri-3	Tri-4 immediate postpartum (PP)	3-months PP	6-months PP	9-months PP	12-months PP
Tobacco use	X				X
Alcohol use	X				X
Housing and Food security	X		X	X	X	X	X	X
PTSD a		X
EPDS b	X		X	X	X	X	X	X
RHSS/IPV c	X		X	X	X	X	X	X
Family planning			X		X		X
MiscarriageFetal demiseInfant loss	If needed
Safe to sleep			X	X	X
Whole health						X	X	X

^aPost-traumatic Stress Disorder (PTSD).

^bEdinburgh Postnatal Depression Scale (EPDS).

^cRelationship Health and Safety Screen (RHSS), Intimate Partner Violence (IPV).

MCC’s follow-up on referrals to diverse medical or social resources within the VHA and the local community, such as the Housing and Urban Development-Veterans Affairs Supportive Housing program, ¹⁸ medical supplies like breast pumps and maternity bras, specialty care in the community when needed (e.g., maternal fetal medicine), and local food and storm recovery resources. ¹⁹ They can ensure that a veteran moving from one region to another is connected via warm handoff to the receiving MCC in the veteran’s new home. MCCs routinely exceed the baseline level of contact as they work to connect providers across specialties within the VHA and streamline referral and communication between the VHA and the community, including outpatient and inpatient care. MCCs continue their work postpartum and are key in ensuring patients are reintegrated into their primary care after pregnancy.

The MCC program has been refined following input from several sources, including the results of the VHA maternal mortality review committee, reproductive health research across the VHA, and feedback from veterans, providers, and administrators.^15,20 This has resulted in extending care through the first full year after pregnancy rather than ending after the first 6 weeks as was initially done, expanding the frequency and number of evidence-based screenings, and improving the capacity for referrals as needed. Annual educational training and monthly community of practice calls are held to support the MCCs and keep them abreast of trends in the veteran population and new research related to best care practices. MCCs are also able to continuously cross-collaborate through a robust virtual community of practice and resource websites. MCC templated notes, screeners, and screening results have been integrated into the electronic health record such that data can be abstracted for the purpose of research and improving care policy and practice.

Significantly, MCCs maintain individualized continuity throughout the perinatal period as a dedicated support person and advisor while veterans navigate the often-complicated experience of pregnancy, birth, and the transition to parenting. This continuity of emotional support is often lacking in our current health care system and has been shown to be a protective factor associated with increased quality of care and improved pregnancy outcomes, supporting the health and well-being of the pregnant person along with their entire family and community. ²¹

The findings of MCC program evaluations have helped refine and expand the MCC program to its current state of universal coverage. In 2018, Cordasco et al. conducted an implementation-focused analysis of feasibility, facilitators, and barriers of the MCC program. ¹⁷ Facilitators to implementing the program included training sessions for program coordinators and the need to address differences across VHA facilities, while barriers included limited communication technology tools and time constraints among the MCCs. A 2025 study by Farkas et al. investigating the relationship between primary care providers (PCPs) and MCCs reported that the majority of MCCs had a positive collaboration experience with PCPs, though their level of contact varied across the system. They also reported that not all PCPs felt well equipped to care for pregnant patients, ¹⁹ an important insight that is actively being incorporated into training initiatives for PCPs. A 2018 study by Katon et al. reported that MCCs were successful in helping veterans navigate care, including finding obstetric providers in the community and managing billing issues. ²² A 2025 study by Mattocks et al. evaluating outcomes of a doula pilot program for veterans reported that MCC’s welcomed partnerships with doulas in caring for patients. ²³

As the program expands, further analysis of the impact on patient outcomes is needed. Currently, the VHA Office of Women’s Health is actively collecting patient experience data via qualitative interviews and surveys specifically examining the expansion of the MCC program to provide care through the first year postpartum. These data are still being analyzed but have reflected unique aspects of the program. As one veteran stated:

“VA maternity care has far surpassed any of my expectations and provided top notch service. My older child was born while I was on active duty and I wish I had access to some of these resources, like mental health services and PT, during that pregnancy. The coordination and facilitation of benefits made this the best pregnancy and postpartum experience I have ever had as a mother of 3 (one on active duty, one on private insurance before I had applied for VA health care and now one with the VA), I cannot thank the…VA enough.”

Ongoing monitoring of the impact of the MCC program should include outcomes like severe maternal morbidity and mortality, preterm birth, low birth weight, hypertensive disorders of pregnancy, gestational diabetes, completed referrals for care, gestational age at care initiation, health care utilization, and continued assessment of veterans’ qualitative and quantitative experiences of care.

The VHA is the largest integrated national health care system in the United States, serving a uniquely high-risk population. However, the care coordination challenges addressed by the MCC program are not unique. Pregnancy care is often identified as siloed and episodic care that occurs outside of routine health care with a lack of follow-up and integration with ongoing care. This approach to pregnancy and postpartum care can no longer adequately meet the needs of childbearing people, especially individuals who are vulnerable to the harms of care fragmentation and access barriers. ⁸ Delays in return to primary care, the overuse of emergency care, disrupted medication management, insufficient access to behavioral health care, and the failure to recognize and address social stressors like housing instability and intimate partner violence all have the potential to lead to care gaps that are associated with preventable causes of pregnancy-associated morbidity and mortality. ²⁴

In contrast, the VHA MCC program is a national model offering an individualized approach that strives to wholistically identify needs and coordinate resources. Stepwise implementation of the MCC program included the development of a maternal health strategic plan based on broad stakeholder engagement, staff training, and policy changes to ensure compliance. Implementation challenges included limited staffing resources and acquiring leadership buy-in for adequate staffing in an environment where hiring is difficult.

In addition to reducing preventable adverse outcomes, care navigation may reduce overall health system costs.^25–29 MCC care navigation keeps Veterans connected with VHA services, allowing system gains due to increased preventive care, improved complication management, and an overall increase in health care utilization. In settings with more loosely linked networks, or where private payors are covering services for individual patients in a variety of settings, it may be more challenging to characterize the cost savings from an MCC program, although private payors and accountable care organizations (ACOs) share a similar goal to avoid adverse outcomes and the higher costs associated with them.

The VHA MCC program has garnered interest from the Indian Health System, ²⁰ another federally managed health care system where coordinated patient navigation could be implemented nationally. Similarly, pregnancy-related care coordination could be implemented at the DoD Defense Health Agency and would provide a consistent care model extending from active-duty service through transition to veteran care. Outside the realm of federal health care systems, the increasing trend toward large health care conglomerates may also provide ready platforms for similar programs. A 2020 review of health care trends in the United States found that the top 10 integrated health care systems each had locations across state lines in 14 or more states. ³⁰ Medicaid, which finances 4 out of every 10 births in the United States and has recently expanded the option of coverage through the first full year postpartum, ³¹ might also find benefits from implementing individualized patient navigation directed toward improving maternal health and reducing racial disparities. Additionally, ACOs, both Medicaid- and private payor-based, focus on care coordination to ensure improved outcomes and cost savings ³² and might benefit from a care coordination model tailored to the unique needs of pregnant and postpartum patients. There is potential for VHA to partner with all of these high-volume, integrated health care systems to implement similar perinatal care coordination programs.

Health Equity Implications

Veterans who quality for maternity care coverage at VHA are more likely to have pregnancy complications, be of advanced maternal age, come from a minoritized population, or live in a rural area than the general population of pregnancy-capable individuals in the United States.^9–13 MCCs provide services to every pregnant veteran who desires such care, regardless of geographic location or socioeconomic status. The MCC program thereby insures universal access to individualized care coordination and support for all veterans. Embedded within a national multispecialty health system, it demonstrates how perinatal care can be reimagined in an integrated care delivery model. Instead of treating pregnancy as a siloed episode of care, the MCC program connects pregnancy-related care to the broader health care network, enabling coordinated support as patients transition from pregnancy through the postpartum period and into parenting.

Authors’ Contributions

J.C.: Conceptualization, writing—original draft, writing—review and editing, supervision; A.J.: Conceptualization, writing—review and editing; S.H.-S.: Conceptualization, writing—review and editing; J.D.: Writing—review and editing; E.W.P.: Conceptualization, writing—original draft, writing—review and editing, supervision.