Obstetric Care in the U.S. Military: Comparison of Direct and Purchased Care System Within TRICARE [11R]

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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.


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.


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.


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.

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