AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 38:447454 (2000)

Pregnancy Outcomes Among U.S.

Women Vietnam Veterans
Han K. Kang, DrPH,
1
Clare M. Mahan, PhD,
1
Kyung Y. Lee, PhD,
1
Carol A. Magee, PhD,
1
Susan H. Mather, MD, MPH,
1
and Genevieve Matanoski, MD, DrPH
2
Background Since the 19651975 Vietnam War, there has been persistent concern
that women who served in the U.S. military in Vietnam may have experienced adverse
pregnancy outcomes.
Methods We compared self-reported pregnancy outcomes for 4,140 women Vietnam
veterans with those of 4,140 contemporary women veterans who were not deployed to
Vietnam. As a measure of association, we calculated odds ratios (OR) and 95%
condence intervals (CI) using logistic regression adjusting for age at conception, race,
education, military nursing status, smoking, drinking and other exposures during
pregnancy.
Result There was no statistically signicant association between military service in
Vietnam and index pregnancies resulting in miscarriage or stillbirth, low birth weight,
pre-term delivery, or infant death. The risk of having children with ``moderate-to-severe''
birth defects was signicantly elevated among Vietnam veterans (adjusted OR1.46,
95% CI 1.062.02).
Conclusion The risk of birth defects among index children was signicantly associated
with mother's military service in Vietnam. Am. J. Ind. Med. 38:447454, 2000.
Published 2000 Wiley-Liss, Inc.
y
KEY WORDS: women veterans; Vietnam war; pregnancy outcomes
INTRODUCTION
The possibility of long-term health effects including
adverse reproductive health outcomes resulting from
military service in Vietnam has been a subject of research
interest in the United States over the past two decades [CDC
Vietnam Experience Study, 1988; Stellman et al., 1988].
The U.S. Congress, responding to concerns of many women
Vietnam veterans, legislatively mandated a comprehensive
health study of women Vietnam veterans. This mandate led
to three separate but related epidemiologic studies of
women Vietnam era veterans: (1) post-Vietnam service
mortality follow-up; (2) assessment of psychologic health
outcomes; and (3) reproductive health outcomes. Results
of the rst two studies were published or submitted to
Congress previously [Thomas et al., 1991; Dalager and
Kang, 1996]. The present report deals with the third
study.
The studies of reproductive outcomes among male
veterans have been mostly negative in that service in
Vietnam was not associated with the risk of fathering a child
with birth defects, spontaneous abortion, stillbirth or
neonatal death [Erickson et al., 1984; Donovan et al.,
1984; Aschengrau and Monson, 1989, 1990]. However, in
the recent ``Ranch Hand study'', neural tube defects (spina
bida, anencephaly) were reported in four children of U.S.
Air Force personnel who sprayed Agent Orange and other
1
Environmental Epidemiology Service, Veterans Health Administration Department of
Veterans Affairs, Washington, DC 20036-3406.
2
Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland
Contract grant sponsor: Medical Research Service, Office of Research and Development,
Department of Veterans Affairs.
*Correspondence to: Dr. Han K. Kang, Environmental Epidemiology Service, Department of
Veterans Affairs, 1120 20th Street N.W., Suite 950, Washington, D.C. 20036-3406. E-mail:
han.kang@mail.va.gov
Accepted 23 May 2000
Published 2000 Wiley-Liss, Inc.
y
This article is a US
Government work and, as such, is in the public domain in
the United States of America.
herbicides in Vietnam, while none was observed among
children of control veterans [Wolfe et al., 1995]. Further-
more, when the CDC birth defects study was reanalyzed
using the exposure opportunity index based upon interview
data, the risk of spina bida was signicantly associated
with the highest estimated level of Agent Orange exposure
[Erickson et al., 1984]. Based on these data and others, an
Institute of Medicine panel suggested an association
between herbicide exposure in Vietnam and an increased
risk of spina bida in children [IOM, 1996].
Although results of studies of male Vietnam veterans
are potentially useful in assessing health consequences of
Vietnam service for women, a further study of gender-
specic health outcomes for women was desired. Maternal
exposures to toxicants are more directly associated with
adverse pregnancy outcomes, while evidence for the effects
of paternal exposure on pregnancy outcomes is very limited
and indirect [Ofce of Technology Assessment, 1985;
Moore and Persaud, 1998].
Many potential risk factors for abnormal reproductive
outcomes existed in Vietnam for women veterans, including
psychological stresses of war, various infections, substance
abuse, and Agent Orange contaminated with dioxin [Baker
et al., 1989; Bates et al., 1990; Jordan et al., 1991]. Other
potential risk factors associated with military hospital
nursing conditions in Vietnam included physical stress,
and exposure to waste anesthetic gases and ethyleneoxide
[Custis, 1990; Rowland et al., 1996; Biovin, 1997].
We conducted a historical cohort study of 8,280 women
veterans, comparing the pregnancy outcomes of 4,140
women Vietnam veterans with those of 4,140 non-Vietnam
veterans in the military during the same era. Due to
difculty in identifying a large number of women exposed
to any particular aspect of Vietnam service with any degree
of certainty, the study was a ``Vietnam experience'' type of
study rather than of specic exposures.
MATERIAL AND METHODS
Study Subjects
The U.S. Army and Joint Services Environmental
Support Group compiled manually a list of Army women
veterans who served in Vietnam. The Air Force provided a
computer listing of all Air Force women known to have
served in Vietnam, as did the Navy and Marine Corps. A
total of 5,230 names were compiled as potential Vietnam
veteran study subjects. Military personnel records of these
women were retrieved from various locations and their
military service data were extracted. Women Vietnam
veterans for this study were dened as those women in the
U.S. Military whose permanent tour of duty included
service in Vietnam during the period from July 4, 1965
through March 28, 1973, a period of signicant U.S.
military involvement in Vietnam. After the record review,
4,643 women met the eligibility criteria; of these 4,390
women were found alive as of January 1, 1992.
Women non-Vietnam veterans for the study were
dened as those women assigned to a military unit in the
U.S. during the Vietnam War and whose tour of duty did not
include service in Vietnam. Potential control subjects from
each branch of service were selected using the same
procedures as for Vietnam veterans. A pool of 6,657 women
were eligible for controls; of these 4,390 women were
randomly selected among the living members of this pool as
of January 1, 1992 [SAS, 1990].
To determine the feasibility of the present study, we
conducted a pilot study on 500 of these women (250
Vietnam veterans and 250 non-Vietnam controls), leaving
8,280 women (4,140 Vietnam and 4,140 non-Vietnam)
available for the study.
Survey Methods
Instrument
A structured health questionnaire was administered
using a computer-assisted telephone interview software
package to obtain information concerning demographic
background, general health, lifestyle, menstrual history,
pregnancy history, pregnancy outcomes, military experience
including nursing occupation and combat exposure. For
each pregnancy, information such as smoking, drinking,
complications, infections, medications, exposure to x-ray,
occupational history, exposure to anesthetic gases, ethyle-
neoxide, herbicides and pesticides was collected.
Location Strategies
Names and social security numbers of the 8,280
veterans were rst passed through the Internal Revenue
Service records and VA's Beneciary Identication Records
Locator Subsystem. Those not located were also searched
in the Defense Manpower Data Center records. Several
nationwide commercial databases such as Telematch, TRW/
Experian, and Equifax proprietary databases, and national
telephone directory CD-ROMs were searched for new
addresses and telephone numbers. State nursing boards
and nursing associations were also contacted for new
addresses because most women veterans serving during
the Vietnam era were nurses.
Outcome Assessment
To satisfy the basic statistical requirement of indepen-
dence of observations, i.e., one pregnancy per woman, an
index pregnancy was identied for each woman. For the
Vietnam veterans, it was dened as the rst pregnancy after
448 Kang et al.
entrance date to Vietnam service. If the Vietnam experience
did have any effect, it would more likely be manifest in the
rst pregnancy following the exposure (Vietnam service).
For the non-Vietnam veterans, it was dened as the rst
pregnancy after July 4, 1965, the starting date for the U.S.
ground troops involvement in Vietnam, or the entrance date
into military service, whichever was later.
The outcomes studied and their denitions are as
follows: Fetal loss including spontaneous abortion and
stillbirth was dened as any loss of fetus regardless of
gestational age; a low birth weight infant was dened as a
baby born alive and weighing less than 2500 g or 5 pounds 8
ounces; pre-term delivery was dened as a baby born alive
with a gestational age of 37 weeks or less or 8 months or
less, if reported in months; ``likely'' birth defects were
dened as congenital anomalies and included structural,
functional, metabolic or hereditary defects.
For this study in which the index pregnancy would have
occurred as far back as 30 years, the relevant medical records
were very difcult to retrieve. As an alternative method,
maternally reported data on children with any reported
defects were reviewed by a pediatric epidemiologist while
blinded regarding Vietnam service status of mothers. These
data included maternal description of defect(s); birth weight;
gestational length; any history (yes/no) of surgery, medical
treatment, or functional limitations due to defect; age at
diagnosis; and if deceased, age and cause of death.
After the review, the reported birth defects were
grouped hierarchically into one of 11 groups as follows:
likely congenital birth defects, groups 17; unlikely
congenital birth defects, groups 811 (Table I). The
``likely'' congenital birth defects were further restricted to
``moderate-to-severe'' birth defects for analyses of signi-
cant, potentially teratogenic defects. The ``moderate-to-
severe'' birth defects only included conditions characterized
by the serious nature of the diagnosis (if explicitly stated by
the mother), or conditions having any history of surgical or
medical treatment, functional impairment, or death from the
defect or a related cause.
Medical Records Review
In order to document reported incidents of birth defects,
an attempt was made to retrieve records on all likely
congenital birth defects with ``moderate-to-severe'' condi-
tions. The type of medical records sought were further
restricted to hospital records because of the difculty
locating a private physician or clinic in practice as far back
as three decades ago. Women veterans were contacted again
to gain consent for obtaining medical records, and to gather
specic information about health care providers. Upon
receipt of the signed release form from the mother or the
adult child, a request for the records was sent to each
hospital.
Statistical Analysis
As a measure of association for dichotomous outcomes,
the odds ratio (OR) and 95% condence interval (CI) were
calculated using a multivariate logistic regression model
with adjustment for covariates [Selvin, 1991]. Analyses
were based on self-reported interview data. Logistic
TABLEI. Description of Generic Classes of Reported Birth Defects
Group Description
Likely birth defects
1. Chromosomal abnormality Abnormal chromosome number or size
2. Multiple anomalies Two or more defects in different organ systems except identifiable heritable syndromes
3. Isolated anomaly One or more defects within same organ system
4. Congenital neoplasms
a
Early childhoodtumors
5. Heritable genetic diseases/syndromes Identifiable single-allele disorders (dominant, recessive, or sex-linked)
6. Unspecifiedheart abnormality Undescribedisolatedheart defects or mumurs
7. Poorly specifiednon-cardiac defect Defect(s) with inadequate description to classify further
Unlikely birth defects
8. Developmental disorders Learningand attention deficits, or epilepsy diagnosedbeyond infancy
9. Perinatal complications All delivery, newborn, or prematurity relatedconditions
10. Miscellaneous pediatric illnesses Food allergy, asthma, etc
11. Not classifiable No description of defect, or ``unknown''
a
Some neoplasms are genetic defects.
Women Vietnam Veterans' Pregnancy Outcomes 449
modeling was carried out using STATA and SAS [SAS
Windows, 1991; Epi Inf, 1997; STATA, 1997].
RESULTS
Overall, 6,430 women (78% of total; 85% of living and
located veterans) completed a full telephone interview. Of
the remaining 1,850 women (22.3% of total), 370 were
never located (4.5%), 775 refused to participate in the study
(9.4%), 339 were deceased (4.1%) and 366 completed only
a short written questionnaire (4.4%). 8.1% of Vietnam
veterans (or 334 women) and 10.7% of non-Vietnam
veterans (or 441 women) refused to participate in the study.
Demographic and military characteristics of respondents,
including age, branch, military occupation and duration of
service, were not signicantly different from their respective
groups of eligible veterans. The limited health outcome data
collected from 366 women who only completed a short
written questionnaire showed no signicant difference in the
prevalence of selected outcomes in comparison to those who
completed the telephone interview. They were not included
in the analysis. The most important factor associated with
completing the telephone interview was ability to contact
the subject by telephone. Once reached, a high proportion
of eligible women (Vietnam veterans, 87%; non-Vietnam
veterans, 83%) completed the interview.
The denominators of interest by Vietnam service status
of respondents are listed in Table II. Relatively fewer
women Vietnam veterans were ever married (66 vs. 77%);
or became pregnant (52 vs. 66%). The reason for the
relatively smaller number of Vietnam veterans reporting
``ever pregnant'' than non-Vietnam veterans (52 vs. 66%)
was that more of them never tried to become pregnant than
non-Vietnam veterans (43% vs. 30%). Excluding those
women who did not try to become pregnant, the percentages
of women ``ever pregnant'' for Vietnam and non-Vietnam
veterans were 91 and 94%, respectively. The most frequent
reasons for ``never tried to become pregnant'' were ``never
married'' and ``never wanted children.'' The concern about
birth defects among children was very small: Vietnam
veterans,8; non Vietnam veterans, 2.
Among those women who experienced pregnancy, the
average number of pregnancies (2.7 vs. 2.7) and average
number of live births per pregnancy (0.70 vs. 0.73) were not
signicantly different by their Vietnam service status.
Among those who tried to become pregnant for 12 months
or more, 77.4% of Vietnam veterans and 77% of non-
Vietnam veterans eventually became pregnant. An approxi-
mately equal proportion of women trying to become
pregnant sought medical care for their difculty in
becoming pregnant: Vietnam veterans, 66%; non-Vietnam
veterans, 68%.
Table III describes characteristics of women who had
an index pregnancy. In general the two groups were similar.
Relatively small numbers of women had pregnancies
predating the index pregnancy. However, in reection of
women who were selected for the study in each group, there
were relatively more military nurses in the Vietnam group
and more Army veterans in the non-Vietnam group. These
and other differences were used in the multivariate analyses.
The outcomes of the index pregnancies are presented in
Table IV. After adjustment for demographic and military
characteristics of mothers and a number of factors
associated with the pregnancy, no signicant differences
were observed due to Vietnam experience for spontaneous
abortions or stillbirths, low birth weight, pre-term delivery,
and infant death. However, a statistically signicant
difference was observed in the number of ``likely'' birth
defects and more restricted ``moderate-to-severe'' birth
defects among live born babies between Vietnam veterans
and those of non-Vietnam veterans. The odds ratio was
higher for non-nurse Vietnam veterans than nurse Vietnam
veterans when each group was compared to the correspond-
ing non-Vietnam group. Among the non-nurse group,
adjusted ORs (95% CI) for ``likely'' birth defects and
``moderate-to-severe'' birth defects were 3.14 (1.775.57)
and 2.60 (1.384.85), respectively. The distributions of 231
infants with likely birth defects by generic class of defect
(Vietnam; non-Vietnam infants) were chromosomal
abnormality (3;4), multiple anomalies (28;11), isolated
anomaly (81;74) congenital malignancy (1;1), heritable
genetic disease (4;4), undescribed isolated heart ab-
normality (10;7), and other poorly described non-cardiac
defect (2;1).
Spina bida, a condition of particular interest stemming
from studies of male Vietnam veterans, was reported in ve
infants among index children of the Vietnam group and
three infants among non-Vietnam group. Four were children
TABLEII. Reproductive History of WomenVeteran Respondents
Non-Vietnam
Vietnamveterans veterans
Outcomes (N 3392) (N 3038)
Ever married 2225 2351
Ever pregnant 1775 1993
Number of pregnancies 4778 5465
Total live births
a
3347 3992
Total index pregnancies
b
1665 1912
Total index live births 1229 1460
a
For Vietnamveterans, all liveborn babies after Vietnamservice were included and for non-Viet-
namveteransalllivebornbabiesresultingfrompregnanciesafter July4,1965or thestartingdateof
military service, whichever waslater.
b
For Vietnam veterans, the first pregnancy after the entrance date of Vietnam service; for non-
Vietnam veterans, the first pregnancy after July 4, 1965 or the starting date of military service,
whichever waslater.
450 Kang et al.
of Army nurses who served in Vietnam in the years between
1967 and 1972. The fth case was a child of an enlisted
Marine Corps woman who served in 19691970. The
proportions of reported birth defects excluded for lack of
apparent congenital defects are essentially the same
between Vietnam and non-Vietnam groups: 15.7% of
Vietnam and 14.3% of non-Vietnam infants.
Among the covariates, smoking during pregnancy was
shown to be a signicant risk factor for fetal loss
(OR1.66, 95% CI 1.342.05), low birth weight
(OR2.12, 95% CI 1.512.99), and pre-term delivery
(OR1.42, 95% CI 1.031.94). Mother's age at concep-
tion (each year of age) was positively associated with risk of
fetal loss (OR1.05, 95% CI 1.021.07) but not with
low birth weight or pre-term delivery. There was a strong
association between any pregnancy complication and risk of
low birth weight (OR2.96, 95% CI 2.164.08), and
pre-term delivery (OR3.14, 95% CI 2.384.16).
Medical Records Review
Of the 180 children (95 Vietnam: 85 non-Vietnam) with
``moderate-to-severe'' birth defects, 72 (41:31) were
reportedly diagnosed at birth. Sixty-eight (38:30) of the 72
women agreed to release the relevant records; however, only
23 (13:10) women actually returned the signed released
form. The hospital records for the 23 children were sought
and records were received for 14 children (7:7). Of the 14
children with records, birth defects reported by the mother
were documented in the hospital records for 13 children
(6:7). The records could not be obtained for nine children
because the hospital destroyed the records, could not locate
the records, or could not release the record of an adult child
without the child's consent, but the child was dead. There
appears to be no disproportionately higher number of
Vietnam veterans refusing to release the records or agreeing
to release the records but not returning the signed form.
DISCUSSION
There are several important limitations of this study.
First, the extensive effort to document birth defects reported
by mothers was essentially unsuccessful. Some veterans did
not return the signed release form after agreeing to do so on
the phone. Many records were lost because many hospitals
routinely destroyed records after a certain period (1015
years), changed names, were closed or merged with another
facility. Our attempt to use birth certicates for validation
was also largely unsuccessful. Either the information was
not available on the birth certicate or we were denied
access to the certicate. Only in recent years was
information on congenital malformation recorded on birth
certicates in a structured format. The index births for this
study occurred in the early 1970s, a period when the use of
part II was not widely practiced by states. Part II of the
certicate captures information on conditions present during
the pregnancy, obstetric procedures, type and conditions of
labor, method of delivery, congenital malformations, birth
weight, length of gestation, etc. A study using data from the
TABLE III. Percent Distribution of Vietnam Veterans and non-Vietnam
Veterans who had an Index Pregnancy by Selected Demographic and Other
Characteristics Associated with the Pregnancy
Non-Vietnam
Vietnamveterans veterans
Characteristics (N 1665) (N 1912)
Age at pregnancy
<25 27 45
25^29 46 36
30 27 19
Median age (years) (26) (25)
Calendar Year at Pregnancy (P
.25
^P
.75
) (1970^1975) (1969^1975)
Race
White 95 94
Non-White 5 6
Education level
<4 yr college 43 41
4 yr college 30 30
Post graduate 27 29
Branch
Army 84 90
Air Force 11 7
Navy 5 3
Marine Corps <1 <1
Military Occupation
Nursing 86 62
Other 14 38
Smoking duringpregnancy
Yes 28 26
No 72 74
Drinking duringpregnancy
Yes 42 35
No 58 65
Working
Yes 85 83
No 15 17
Birth control use
Yes 13 15
No 87 85
Illegal druguse
Yes 0.5 0.5
No 99.5 99.5
Prior pregnancy
a
Yes 5 8
No 95 92
a
Pregnancies predatingtheindex pregnancy.
Women Vietnam Veterans' Pregnancy Outcomes 451
Metropolitan Atlanta Congenital Defects and birth certi-
cates showed the birth certicates to have a sensitivity of
only 14% for detecting all birth defects [Watkins et al.,
1996]. In view of the limited sensitivity, we stopped trying
to obtain the birth certicates.
Second, information on an individual's pregnancy and
birth outcomes can only be obtained by asking the person.
There is no national central repository of these data from
which a person's reproductive history can be obtained. The
health history information relevant to the study spans almost
30 years with the possibility of selective recall by one or
both groups of veterans. Vietnam veterans may have over-
reported certain health outcomes because of continuing
publicity about the cancer and reproductive health hazards
related to Agent Orange and Vietnam service.
Third, because of the absence of reliable exposure
measures in Vietnam, the study was designed to be a
Vietnam experience study. Women who served in Vietnam
may have been exposed to a wide variety of potential health
hazards that are probably not homogeneous. Studying all
women Vietnam veterans as a group irrespective of their
potential exposure could have reduced the chance for
detecting any adverse health outcome related to a particular
health hazard. In the past, a variety of approaches have been
used to estimate herbicide exposure among Vietnam
veterans: military service in Vietnam, branch of service,
year and length of service in Vietnam, military occupation,
location of unit in relation to aerial spray mission data and/
or ground spraying activity and biological marker such as
dioxin (2,3,7,8-TCDD) in adipose tissue or serum. None of
these approaches has been fully validated, and there is little
consensus on what method should be used for retro-
spectively reconstructing exposure levels for Vietnam
veterans. A model (s) to characterize exposure of veterans
to Agent Orange and other herbicides used in Vietnam is
being developed under a contract with the National
Academy of Science [IOM, 1999]. When a model is
validated, it can be applied to this study in the future.
A strength of the study is that virtually all women
Vietnam veterans were studied and their entire reproductive
period following their entry into Vietnam service was
covered. The roster of 4,643 women veterans, developed
and veried through a review of military personnel records
for the study, is by far the most comprehensive and largest
collection of women who served in Vietnam. Information on
the primary exposure variable of interest, military service in
Vietnam, is documented and is not dependent on self-
reports.
Another strength is the use of a sample of women non-
Vietnam veterans as a comparison group. The health status
of veterans is different from their civilian peers because of
many factors including initial screening for military service,
requirements to maintain a certain standard of physical
well-being, and better access to medical care during and
after military service [Rothberg et al., 1990; Kang and
Bullman, 1996]. Furthermore, unlike their male counter-
parts, all women in the military during Vietnam War
volunteered to serve in the military.
TABLEIV. Outcomes of 3,577Index Pregnancies Among 6,430 WomenVietnamVeterans and Non-VietnamVeterans
Total number of events
Percentage* Odds Ratio (95%C.I.)
z
Vietnam Non-Vietnam
Outcomes (N 1665) (N 1912) Vietnam Non-Vietnam Crude Adjusted
y
Spontaneous
Abortion or Stillbirth
a
278 317 16.7 16.6 1.01 (0.84^1.21) 1.0 (0.82^1.21)
Lowbirth weight ( <2,500 gm)
b
78 97 6.3 6.6 0.95(0.69^1.31) 1.06 (0.76^1.48)
Pre-termdelivery
b
37 weeks or 8 months 112 125 9.1 8.6 1.07 (0.81^1.41) 1.18 (0.88^1.59)
Birth defects
b
Likely 129 102 10.5 7.0 1.56 (1.18^2.07) 1.66(1.24^2.22)
Moderate-to-Severe 95 85 7.7 5.8 1.36 (0.99^1.86) 1.46 (1.06^2.02)
Infant death
( <1year)
b
6 11 0.5 0.8 0.65(0.21^1.89)
a
Percent based ontotal number of index pregnancies by group (1,665 Vietnam,1,912 non-Vietnam).
b
Percent based ontotal number of live index singletonbirthsby group (1,229Vietnam,1,460 non-Vietnam).
y
Adjusted odds ratios (and95%confidence intervals) were derived froma logistic regressionmodel after adjustment for demographic ((age at conception, paternal age at conception (only birthdefect
regression), education, race, marital status)) andmilitary characteristics (branch, rank, military nursing) and a number of factors associated with the pregnancy (smoking, drinking, average number of
hours worked during pregnancy (except for birth defect regression), complications during pregnancy (except miscarriage or stillbirth regression)). Complication during pregnancy included toxemia,
diabetes, highbloodpressure, bleedingor threatenedmiscarriage.
z
95%Confidence interval.
452 Kang et al.
The overall participation rate among the living and
located women in the study (85%) was moderate. However,
non-respondents did not differ signicantly from respon-
dents with respect to demographic and military character-
istics that may be associated with health outcomes. The
limited health outcome data collected by mail from 366 non-
respondents did not differ signicantly from the telephone
interview respondents.
Fetal loss was not found to be associated with Vietnam
service. A separate analysis in this study for military
nurses showed the same results. In several male Vietnam
veterans' health studies, Vietnam veterans reported more
frequently than non-Vietnam veterans that their spouses
had miscarriages [CDC, 1988; Stellman et al., 1988].
Whether the difference in reported miscarriages among
women veterans and spouses of male veterans is due to
gender specic (male-mediated) reproductive outcomes
or simply inaccurate recollection of events by males is
not known.
Vietnam service was signicantly associated with the
risk of ``likely'' birth defects as well as more restricted
``moderate-to-severe'' birth defects. Separate analyses for
nurses and non-nurse veterans showed similar results,
although the magnitude of the risk was higher among non-
nurse Vietnam veterans. The causes of most human
congenital anomalies are unknown. A combination of
genetic and environmental factors may contribute to 20
25% of anomalies [Moore and Persaud, 1998].
Over-reporting by women Vietnam veterans was
considered an unlikely explanation for this nding for the
following reasons. First, there has been widespread
publicity concerning the risk of many types of cancers,
adverse pregnancy outcomes (stillbirth, spontaneous abor-
tion, low birth weight, pre-term births) and birth defects
among offspring of Vietnam veterans. None of the a priori
health outcomes selected for the study was found to be
associated with Vietnam service, except for birth defects. If
women Vietnam veterans were inuenced by publicity,
over-reporting would have been expected for the other
adverse health outcomes as well. Second, the reported rates
of adverse pregnancy outcomes, spontaneous abortions and
low birth weight infants in the Vietnam group are almost
identical to rates in other studies [Armstrong et al., 1992;
McDonald et al., 1992a, 1992b]. The prevalence of
``moderate-to-severe'' birth defects among the index babies
of the non-Vietnam veterans (5.8%) was also consistent with
about 6% prevalence of obvious major anomaly expected in
live born infants within 2 years of birth [Moore and Persaud,
1998]. In this study, about 93% of ``moderate-to-severe''
birth defects was detected within 2 years of birth. The rate at
birth was 2.1% (31 of the 1,460 index births). In a CDC
Vietnam veteran study, the corresponding rate of ``major''
birth defects was 2.4% [Center for Disease Control, 1988].
Third, the effects of covariates (e.g., smoking, drinking) on
adverse pregnancy outcomes observed in the study were in
general agreement with those in other studies [Armstrong
et al., 1992; McDonald et al., 1992a, 1992b]. Fourth, the
medical record retrieval rate was poor; however, based on a
small number of available records, positive documentation
of maternally reported birth defects in babies was about
93%, and the documentation rates do not differ substantially
between Vietnam veterans and non-Vietnam veterans. For
the gynecological cancers, 99% of the self-reported breast
cancer outcomes were documented in 146 medical records
received, which was about 50% of the records requested.
This may suggest that the ability to corroborate self-reported
adverse birth outcomes depended more on the availability of
the records than on Vietnam service status of women
veterans. Finally, the proportions of birth defects reported
by women veterans excluded for lack of apparent congenital
defects are essentially the same between Vietnam and non-
Vietnam veterans: Vietnam veterans, 15.7%; non-Vietnam
veterans, 14.3%.
In summary, women Vietnam veterans did not report
more spontaneous abortions and still births, pre-term and
low birth weight deliveries, and infant deaths in the
structured telephone interview than did women veterans
who did not serve in Vietnam. However, they did experience
a higher prevalence of birth defects among their children.
Over-reporting by women Vietnam veterans was considered
an unlikely explanation for the excess.
ACKNOWLEDGMENTS
We are indebted to the members of the Study Oversight
Committee, which convened nine times in 4 years to review
and monitor the progress of the study. The members were
Shirley Menard, PhD, RN, University of Texas; Rear
Admiral Mary Nielubowicz; William Pratt, PhD, National
Center for Health Statistics, CDC (Retired); John Queenan,
MD, Georgetown University; Steve Selvin, PhD, University
of California, Berkeley; and Paul Stolley, MD, University of
Maryland.
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