WASHINGTON -- Active duty women in the U.S. military are more likely to have an unintended pregnancy than civilian women in the U.S. population, according to one military official and some researchers and advocates interviewed by 番茄社区.
Historically, servicewomen have had difficulty accessing birth control due to logistical as well as cultural barriers. In addition, abortions and abortion counseling are not provided by the Department of Defense (DOD) or the Department of Veterans Affairs (VA).
Stakeholders within and outside of these agencies are thus looking to increase access to effective, longer-lasting forms of contraception.
"We need to really do a good job considering contraceptive needs and tailoring them to active duty women,"said Terry Adirim, MD, MPH, MBA, Principal Assistant Secretary of Defense for Health Affairs at the DOD, who spoke at the recent .
"I think we could be doing a better job at ensuring that active duty women get really good [contraception] counseling services," Adirim added, noting that the DOD has a lot to learn from the VA.
VA beneficiaries' rates of unintended pregnancy are similar to those of the general population and they seek abortion as frequently as women in the larger U.S. population, according to a based on the Examining Contraceptive Use and Unmet Need (ECUUN) study.
Adirim said that, personally, she believes in encouraging greater use of long-acting reversible contraception (LARC).
In a phone interview following the meeting, during which a press representative was present, Adirim said the rates of unintended pregnancy were only "slightly higher" than in the general population; she cited a published in Military Medicine among other research.
Kate Grindlay Kelly, MSPH, project director and associate of the Free the Pill project for Ibis Reproductive Health, a nonprofit research and advocacy group, who co-authored the review, said that even a small increase is worrisome given that the rates of unintended pregnancy among the general population are already high.
In a analyzing the 2011 Department of Defense Health Related Behaviors Survey, an estimated 7% of active duty women ages 18 to 44 reported an unintended pregnancy in the prior year, versus 5% in the U.S. general population, she said in a phone call with 番茄社区. (Much of the data on unintended pregnancy in the military are relatively old.)
Additionally, a 2011 paper found that 54% of pregnancies among active-duty women in 2005 were unintended.
Parsing the Data
Adirim stressed, however, that the military "skews younger" within the 18-44 range and that "younger people tend to take more risks."
The review and other studies have suggested that more of these unintended pregnancies involved younger servicewomen -- i.e., those under 30.
Yet in a published in Obstetrics & Gynecology that adjusted for age differences in the military versus the general population, Grindlay Kelly and her colleagues found that the unintended pregnancy rate among servicewomen was still 50% higher (78 unintended pregnancies per 1,000 women versus 52 per 1,000 women in the general U.S. population).
These findings were counter-intuitive, she noted: "Given that the military population has full insurance coverage and access to contraceptive care, you would expect that [unintended pregnancy rates] would be lower than in the overall U.S. population."
Other research has focused on challenges that active duty women have had in accessing birth control, especially while deployed. Among different military branches, contraceptive use ranged from 50% to 88% among women stationed in the U.S., but that number dipped to 39% to 77% during deployment according to several studies cited in the 2011 review paper.
In still , Grindlay Kelly and a colleague also found that, of 281 servicewomen responding to an online survey, one-third reported difficulty accessing their preferred birth control method and 59% had not spoken to a military provider about contraception before being deployed.
But there aren't good data on service members using particular methods of birth control, Grindlay Kelly said.
At the meeting, Adirim described increasing the use of effective birth control as an area where the military "could and must do better."
"By policy, we encourage access to contraceptives," Adirim said during a follow-up phone call. "We stock every brand available, and if we don't have it by some chance, we get it," and this includes LARC.
While a range of contraception options are available for active duty women stateside through the military's TRICARE insurance, Grindlay Kelly said there are real barriers during deployment.
Sex and the Female Soldier
Not only did her research find that routine pre-deployment counseling on birth control was often lacking, some women were prescribed birth control methods that required refills, which weren't always easy to obtain. Additionally, a 2012 study cited other challenges, including "working long shifts across multiple time zones," which can make adherence to a daily contraceptive method difficult.
In more recent surveys, Ellen Haring, director at the Service Women's Action Network, found that 95% of all active-duty servicewomen have access to their preferred method of birth control, but only 74% have access while they are deployed.
Her research included several hundred servicewomen and is due to be published in November.
Among retired servicewomen, however, the percentage who had access to their preferred birth control during deployment was only 34%, she found. In other words, "it seems to be getting better," she said.
Prohibitions around sexual activity may also impact women's access to contraception, Haring added.
Grindlay Kelly said she has seen evidence of women not seeking birth control through the military "for fear of reprimand," although she didn't know if that has changed.
Her 2013 Contraception study highlighted that "implicit or explicit policies" around sexual activity discouraged some servicewomen or their providers from talking about contraception: "We were directed not to have sex, so birth control was not a conversation," said one survey respondent who served in Iraq in 2008.
Haring surveyed respondents across all categories -- active duty, reserve and guard, veteran and retired military -- and cited examples of providers who had told them, "We're not going to give you birth control, because you shouldn't be having sex while you're deployed," she said.
She called that argument "enormously stupid" because most of these women seek hormonal contraception primarily to suppress their periods during deployment.
Neither the DOD nor the VA will pay for servicewomen's abortions, Adirim and Patricia Hayes, PhD, chief consultant for Women's Health Services for the VA, both confirmed at the meeting.
However, the DOD makes exceptions in cases of rape, incest, and endangerment to the mother's life. Emergency contraception is also required to be made available at all military sites, Grindlay Kelly said.
An in-depth survey of 21 servicewomen published in in 2017 shows the financial and personal challenges that result from these policies, including difficulties maintaining confidentiality.
Getting Better?
There are still bright spots in the military's efforts to improve contraception access, Grindlay Kelly said. LARC use appears to have risen "pretty significantly," from 17.2% in 2012 to 21.7% in 2017, according to a study published in in 2017, she noted -- a trend she said she finds "encouraging."
Recent legislative efforts such as the mandate that clinical practice guidelines be established for contraception care and that service members have access to comprehensive contraceptive counseling during annual pre-deployment and deployment visits, she noted.
"It's very possible that access to contraceptive counseling and to a wider range of methods is available now," Grindlay Kelly said, noting that her data precede these policies. She added that she is waiting for new updated data to better understand the impact of such policies.
Another speaker at the meeting, Cara Krulewitch, PhD, CNM, director of women's health, medical ethics, and patient advocacy for the DOD, noted that contraceptive counseling encounters reached 16.3% in 2017, which she said she believes is an under-reported count, since not every provider who prescribes birth control documents the conversation.
Krulewitch also spoke of a new pilot program, a full-service walk-in clinic for contraception known as Operation PINC (Process Improvement for Non-Delayed Contraception) based in San Diego, where as many as 400 servicewomen are seen in a month.
A 2017 study of Operation PINC published in found an increase in long-acting reversible contraception initiation from 12% to 39%, Grindlay Kelly noted.
"I think that this could help to really improve contraceptive care for deployed women."