Military-Civilian Partnerships to Expand Emergency Obstetric Care for Both Civilian and Military Mothers-to-Be | Pregnancy | JAMA Network Open | JAMA Network
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Invited Commentary
Health Policy
January 10, 2022

Military-Civilian Partnerships to Expand Emergency Obstetric Care for Both Civilian and Military Mothers-to-Be

Author Affiliations
  • 1Department of Surgery, University of California, San Francisco, San Francisco
  • 2Department of Surgery, The Uniformed Services University for the Health Sciences, Bethesda, Maryland
  • 3Military Health System Strategic Partnerships, American College of Surgeons, Chicago, Illinois
JAMA Netw Open. 2022;5(1):e2142843. doi:10.1001/jamanetworkopen.2021.42843

The best outcome of a pregnancy when there is fetal or maternal distress is prompt delivery of the fetus. However, as documented in the study by Uribe-Leitz et al1 entitled, “Geospatial Analysis of Access to Emergency Cesarian Delivery for Military and Civilian Populations in the US,” only 70% of civilian women currently have access to cesarean delivery within 30 minutes of their home. That percentage is further reduced among women covered by military TRICARE insurance, in which prompt access to emergency obstetric care is available to only 50% of pregnant women. Using geospatial analysis of existing military medical treatment facilities (MTFs), the authors found that expanding obstetric capabilities at these MTFs could benefit an additional 160 000 TRICARE beneficiaries and more than 2 million civilian women, particularly those living in rural areas of the western and southeastern US.1

Time-sensitive diseases and the need for access to prompt treatment were first recognized in the field of trauma care. The so-called golden hour from injury to trauma center treatment has been widely embraced in both military and civilian settings and has been documented to improve survival and decrease morbidity.2,3 Similar concepts have subsequently emerged in the treatment of acute coronary syndromes (eg, door-to-balloon time) and stroke (eg, time is brain, referring to the time to clot lysis with tissue plasminogen activator). The time to emergency obstetric care has received less attention, but it should be clear from the study by Uribe-Leitz et al1 that many regions of our country are currently underserved in that specialty.

Military-civilian partnerships in trauma care have existed since the early 2000s and allow for the exchange of lessons learned on the battlefield among military and civilian health care professionals while keeping combat casualty teams prepared for deployment.4 These partnerships are particularly important to avoid the peacetime consequences of decreased exposure to patients with severe injuries. A landmark report by the National Academies of Sciences, Engineering, and Medicine5 estimated that a comprehensive US military-civilian trauma system using MTFs would provide access to timely trauma care for an additional 45 million people who currently live in underserved areas, with the potential to save 20 000 to 30 000 lives each year. A subsequent study by Lee et al6 explored geographic proximity between military and civilian trauma centers and identified selected MTFs that could substantially decrease the time to treatment for patients with major trauma in key areas of the country.

Establishing new military-civilian partnerships using MTFs is not without challenges. First, there must be a documented need within the community for the MTF to engage in the care of civilian patients. Second, there must be a commitment by the Department of Defense and the Defense Health Agency to augment capabilities in selected military hospitals to meet the desired goals, be they for trauma or obstetric care. Solutions to issues such as malpractice coverage for military personnel providing treatment to non-TRICARE beneficiaries as well as billing practices need to be established. On the other hand, an integrated military-civilian emergency obstetric care system would address the need to keep female military personnel healthy while increasing case volumes at MTFs that can augment the readiness of military obstetric clinicians, especially for humanitarian missions.

At this time in history, with documented decreases in surgical volume at MTFs, military-civilian partnerships are more important than ever.7 The Military Health System strategic partnership with the American College of Surgeons has developed a guide to assist in establishing new military-civilian partnerships.8 The value of such partnerships has been well established and, in the case of maternity care, moms and babies throughout the country stand to benefit.

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Article Information

Published: January 10, 2022. doi:10.1001/jamanetworkopen.2021.42843

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Knudson MM. JAMA Network Open.

Corresponding Author: M. Margaret Knudson MD, University of California, San Francisco, Department of Surgery, Zuckerberg San Francisco General Hospital and Trauma Center, 1001 Potrero Ave, Ward 3A, San Francisco, CA 94110 (;

Conflict of Interest Disclosures: None reported.

Uribe-Leitz  T, Matsas  B, Dalton  MK,  et al.  Geospatial analysis of access to emergency cesarean delivery for military and civilian populations in the US.   JAMA Netw Open. 2022;5(1):e2142835. doi:10.1001/jamanetworkopen.2021.42835Google Scholar
Kotwal  RS, Howard  JT, Orman  JA,  et al.  The effect of a golden hour policy on the morbidity and mortality of combat casualties.   JAMA Surg. 2016;151(1):15-24. doi:10.1001/jamasurg.2015.3104 PubMedGoogle ScholarCrossref
Harmsen  AMK, Giannakopoulos  GF, Moerbeek  PR, Jansma  EP, Bonjer  HJ, Bloemers  FW.  The influence of prehospital time on trauma patients outcome: a systematic review.   Injury. 2015;46(4):602-609. doi:10.1016/j.injury.2015.01.008 PubMedGoogle ScholarCrossref
Knudson  MM.  A perfect storm: 2019 Scudder Oration on Trauma.   J Am Coll Surg. 2020;230(3):269-282. doi:10.1016/j.jamcollsurg.2019.11.009 PubMedGoogle ScholarCrossref
Berwick D, Downey A, Cornett E, eds; Committee on Military Trauma Care’s Learning Health System and Its Translation to the Civilian Sector; Board on Health Sciences Policy; Board on the Health of Select Populations; Health and Medicine Division; National Academies of Sciences, Engineering, and Medicine.  A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury. National Academies Press; 2016.
Lee  BC, McEvoy  CS, Norris  EA  et al. Building trauma capability: geographic proximity between military treatment facilities and civilian trauma centers in the continental United States. Paper presented at: virtual American College of Surgeons Committee on Trauma 43rd Annual Resident Trauma Papers Competition, Region 13; October 2020.
Dalton  MK, Remick  KN, Mathias  M,  et al.  Analysis of surgical volume in military medical treatment facilities and clinical combat readiness of US military surgeons.   JAMA Surg. Published online October 27, 2021. doi:10.1001/jamasurg.2021.5331 PubMedGoogle Scholar
American College of Surgeons. The Blue Book: Military-Civilian Partnerships for Trauma Training, Sustainment, and Readiness. American College of Surgeons; 2020. Accessed November 29, 2021.
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