Obstetric Care in the U.S. Military

Abstract

INTRODUCTION: Pregnant women with TRICARE (universal insurance coverage to members of US Armed Services and their dependents) can receive obstetric care under direct care/salary-based (DC) or purchased care/fee-for-service (PC) system. The objective of this study was to compare intra-partum obstetric care between direct and purchased care systems in TRICARE. METHODS: TRICARE (2006–2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (normal vaginal, cesarean and instrumental vaginal) and co-morbid conditions (gestational diabetes and hypertension) along with complications, including post-partum hemorrhage (PPH), lacerations, infection and thrombotic events were compared between two systems of care. RESULTS: A total of 440,138 deliveries were identified. The mean age of mothers in DC and PC was 26.7 years and 27.3 years, respectively (P<.001). A higher proportion of mothers in DC had gestational diabetes (6.9% vs 4.9%, P<.001) and gestational hypertension (5.8% vs 4.7%, P<.001). Proportion of cesarean delivery (25.8% vs 30.9%, P<.001) and instrumental vaginal delivery (5.3% vs 6.4%, P<.001) was lower in DC compared to PC. Complications such as PPH (4.9% vs 3.4%, P<.001) and perineal lacerations (8.3% vs 6.4%, P<.001) were significantly higher in DC as compared to PC. CONCLUSION: We found that the direct/military (salary-based) system had fewer interventions (such as operative deliveries) and higher complication rates. Study of the direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the US.