Background
Unplanned pregnancy is a common problem among United States servicewomen. Variation among service branches in contraceptive education and access during initial training is associated with differences in contraceptive use and childbirth rates despite access to a uniform health benefit including no-cost reproductive healthcare and contraception. However, it is unclear whether changes in branch-specific contraceptive policies can influence reproductive outcomes among junior enlisted women in that service branch.
Objective
To assess the longitudinal effect of contraceptive policy changes on contraception use and childbirth rates among military recruits.
Materials and Methods
Secondary analysis was performed of insurance records from 70,852 servicewomen who started basic training between October 2013 and December 2016, assessing the longitudinal impact of a Navy policy change expanding contraceptive access during basic training implemented in January 2015, and a Marine Corps policy change restricting contraceptive access during basic training implemented in January 2016 on the following: contraception use (pills, patches, rings, injectable, implantable, and intrauterine) at 6 months, long-acting reversible contraception use at 6 months, and childbirth prior to 24 months after service entry. We used logistic and Cox regression models, adjusted for age group, to compare outcomes of women in the Navy and Marine Corps who started basic training before and after their service branch’s policy change with outcomes among women in the Army and Air Force.
Results
Compared to the longitudinal difference observed among women attending Army or Air Force basic training, changing policies to increase contraceptive access during Navy basic training in January 2015 increased contraception use from 33.1% of sailors to 39.2% of sailors before and after the policy change (interaction term odds ratio, 1.31; 95% confidence interval, 1.22−1.41) and long-acting reversible contraception use 11.0% to 22.7% (odds ratio, 1.78; 95% confidence interval, 1.50−2.08). However, this policy change was not associated with a decline in childbirth rates among sailors (7.5% versus 6.1%) relative to the change among women in the Army and Air Force over the same time period (interaction term hazard ratio, 0.90; 95% confidence interval, 0.79−1.03). The January 2016 Marine Corps policy change decreased contraception use (29.6% to 24.4%; odds ratio, 0.78; 95% confidence interval, 0.70−0.88), long-acting reversible contraception use 14.6% to 7.3% (odds ratio, 0.39; 95% confidence interval, 0.31−0.48), and increased childbirth rates (8.0% to 9.6%; hazard ratio, 1.26; 95% confidence interval, 1.03−1.55) among Marines compared to outcomes in the Army and Air Force over the same time period.
Conclusion
Basic training contraceptive policy influences contraception use among junior enlisted servicewomen. Implementing best practices across the military may increase contraception use and decrease childbirth rates among junior enlisted servicewomen.
Servicewomen in the United States military, especially junior enlisted servicewomen, experience a higher frequency of unintended pregnancy than do women in the general population. These pregnancies are associated with multiple negative medical and socioeconomic consequences for the mother and infant, and degrade military readiness. ,
Why was this study conducted?
Despite access to no-cost reproductive healthcare and contraception, unplanned pregnancy rates are high among junior enlisted servicewomen across the United States military. This study assessed the impact of changes in branch-specific basic training contraceptive education and access policy on contraception use at 6 months and childbirth rates prior to 24 months of military service.
Key findings
Policy changes that limit contraceptive education and access to long-acting reversible contraception during initial training reduce contraception use and may increase childbirth rates, whereas changes facilitating access have the opposite effect.
What does this add to what is known?
Among women with no financial barriers to contraceptive care, changes in contraceptive education and access are associated with changes in hormonal contraceptive use and method selection, and may influence childbirth rates.
Previous studies have shown wide variability in contraceptive use and pregnancy rates among servicewomen by rank and service-branch, with the lowest rates of contraception use and highest pregnancy rates among junior enlisted. , , The Navy, Air Force, and Marines each have a single location for basic training of all recruits, whereas the Army has three different locations that share a common curriculum and policies. Each service branch offers some form of contraceptive education during basic training, with access to contraceptive pills, patches, rings, and injections, without any cost to the servicewoman. However, the format and content of the education provided and the guidelines on LARC use vary by service branch. In a cross-sectional study, these differences in reproductive health outcomes among service branches were associated with differences in policies addressing contraceptive education and access during basic training. It is unclear whether changes in contraceptive education and access during basic training will improve reproductive health outcomes among junior enlisted servicewomen in the US military.
This study examined the longitudinal association of changes in service branch contraceptive policy with use of contraception (pills, patches, rings, injectable, implantable, and intrauterine) at 6 months on active duty; LARC use (implantable and intrauterine contraception) at 6 months; childbirth in the first 24 months on active duty; and days of pregnancy-related reduced work availability among female recruits in the US military. We hypothesized that implementation of policies that facilitate contraceptive initiation during basic training would be associated with increased use of contraception at 6 months of service and would decrease childbirth rates in the first 24 months of service.
Materials and Methods
We conducted a secondary analysis of military insurance records contained in the Military Health System Management Analysis and Reporting Tool (M2) to assess the longitudinal impact of changes in branch-specific contraceptive education and access policy on reproductive health outcomes among active-duty US servicewomen who started basic training between October 2013 and December 2016. We identified 70,852 individuals who met the following inclusion and exclusion criteria: female sex, age 17−34 years (reflecting the age limits on military enlistment in place at the time); Beneficiary Category of Active Duty; Ambulatory Care Value of Reliant (beneficiaries assigned to an operational unit for primary care); Sponsor Rank of Junior Enlisted (the lowest 3 of 10 enlisted military ranks); no active duty service in the previous 12 months; and >6 months of continuous active duty service after study entry (to exclude women who enlisted in the Reserve forces).
We collected the following demographic information for each subject: age at the beginning of basic training (ages 17−19, 20−24, 25−29, and 30−34 years), service branch, and date that the subject began basic training. Approximately 98% of military recruits have at least a high school diploma. Starting salary is $20,172 plus allowances for housing, food, uniforms, and job-specific bonuses, many of which are not taxed. Approximately 11.2% of new female recruits are married at the time of accession into the military.
We determined the timing and content of any changes in contraceptive policy that occurred between October 2013 and December 2016 through discussions with providers who prescribe contraception at the basic training locations in each of the services. We identified admissions for childbirth during the first 24 months of active duty service using inpatient insurance records. Data collection for childbirth follow-up ended in April 2018.We used pharmacy records and clinical procedure codes to identify whether the woman was using a contraceptive pill, patch, ring, shot, implant, or intrauterine device method at 6 months of active duty service. The specific codes used to search the database are listed in Appendix 1 . The specific type of contraception prescribed was identified by Food and Drug Administration National Drug Code. We assumed that women who had a visit for removal of a long-acting reversible contraception (LARC) method between 7 and 12 months of active duty service without a previous medical visit for insertion had the method in place prior to joining the military, and they were recorded as being on a LARC method at 6 months. We assumed that women used all contraceptive pill, patch, and vaginal ring prescriptions as directed unless that prescription was subsequently replaced by a different method. We assessed contraceptive use at 6 months on active duty because this generally coincides with the time that new enlistees complete initial and advanced training before being transferred to their first duty station, and branch-specific policies on contraceptive education and access would have the greatest impact on contraceptive uptake during this timeframe. We believed that the impact of these branch-specific, basic-training, contraceptive policies would diminish over time as subjects obtained more freedom at their first duty stations, and we limited our analysis of childbirth rates to the first 24 months on active duty.
We used χ 2 analyses and analysis of variance to assess the association of service branch with age at the beginning of basic training, contraceptive use in general, and LARC use specifically at 6 months on active duty. The Navy and Marine Corps made changes to basic training contraceptive education and access policy during our study period. In January 2015, the Navy changed contraceptive education to emphasize LARC methods, implemented walk-in contraceptive clinics, and created group appointments for LARC placement during the third or fourth week of basic training for all women in a training group who wanted to start using a LARC method. In January 2016, the Marines restricted the opportunity for LARC initiation from all 12 weeks basic training to the last 2 weeks only, and modified the optional weekly contraceptive education program to emphasize use of depot medroxyprogesterone for contraception and menstrual suppression. We used recruits in the Army and Air Force as the control group for our analyses, as basic training contraceptive policies in these services did not change during our study period. Details of the service-specific policies and any changes that occurred are listed in Table 1 .
| Service | Prechange policy | Implementation date | Policy changes implemented |
|---|---|---|---|
| Army | Group contraceptive education offered to all soldiers as part of basic training curriculum. Contraceptive pills, patches, rings and injection offered at sick-call appointments. LARC methods available via consultation to base hospital. | No changes implemented during study interval | None |
| Air Force | Group contraceptive education was not offered during basic training. Contraceptive pills, patches, rings, and shots available through once-a-week contraception-only clinic. LARC methods were not available during basic training. | No changes implemented during study interval | None |
| Navy | Group contraceptive education offered to all sailors as part of basic training curriculum. All forms of contraception, including LARC, offered at sick-call appointments. | January 2015 | Education revised to emphasize the most effective methods. Group contraceptive education provided to women during initial orientation and then all sailors from a training group requesting a LARC are brought in as a group during the third or fourth week of basic training. Walk-in, contraception-only clinics offered outside of sick call hours as well. |
| Marines | Optional group contraceptive education offered once a week, outside of regular training hours, to female Marines interested obtaining contraception. Contraceptive pills, patches, rings, and shots available through sick call. LARC methods available 2 mornings per week throughout basic training. | January 2016 | Optional education revised to emphasize DMPA for menstrual suppression. LARC access restricted to 2 days per week during the last 2 weeks of basic training (weeks 11 and 12). |
We used Kaplan−Meier analyses to estimate the effect of our policy change and service variables on delivery rates among military recruits. We used Cox proportional hazards analysis, adjusting for service member age at the beginning of basic training, to assess the hazard of a female recruit in the Navy or Marines giving birth during the first 24 months on active duty relative to recruits in the Army and Air Force (Navy and Marine Corps Service variables) both before and after the service-specific policy change (Navy and Marine Policy variables). We also assessed the change in childbirth rates among Navy or Marine Corps recruits associated with their service branch’s policy change compared to the change among women in the Army and Air Force over the same time period, using a Cox proportional hazards regression model containing the variables age group, service, and policy change, and a service × policy change interaction term.
Finally, to assess the impact of policy changes on future military readiness, we multiplied the preintervention delivery rate in the Army and Air Force with the interaction term hazard ratio to estimate the change in delivery rate accounted for by the policy change. Then we multiplied this change in delivery rate by the time authorized for postpartum leave in the military (12 weeks) to calculate the impact of changes in contraceptive policy during basic training in terms of days of postpartum leave per servicewoman. We also used the change in delivery rate to calculate the impact of changes in contraceptive policy during basic training in terms of days of pregnancy-related nondeployable days per servicewoman trained. Servicewomen are not allowed to deploy into operational environments while pregnant and for an interval after delivery (Marines, 6 months; Navy, 12 months).
All analyses were conducted using SPSS version 24 software. This study was approved by the institutional review board of the 59 th Medical Wing, Lackland Air Force Base and by the Defense Health Agency Data Review Board.
Results
The average age at the beginning of basic training of the 70,852 active duty servicewomen in our sample was 20.3 ± 3.0 years. The mean follow-up time in our study was 21.8 ± 3.8 months. The age profile, contraceptive types selected, and childbirth rates for women in each service branch are listed in Table 2 .
| Characteristic | Army (n = 25,689) | Air Force (n = 15,552) | Navy (n = 21,526) | Marines (n = 8084) | P |
|---|---|---|---|---|---|
| Mean age at basic training, y | 20.8 ± 3.5 | 20.3 ± 2.6 | 20.4 ± 3.0 | 19.2 ± 1.9 | <.001 |
| Age group, y | <.001 | ||||
| 17−19 | 50.1% | 51.4% | 52.8% | 71.9% | |
| 20−24 | 35.6% | 40.5% | 37.2% | 25.1% | |
| 25−29 | 11.1% | 7.5% | 8.3% | 3.0% | |
| 30−34 | 3.2% | 0.6% | 1.7% | <0.1% | |
| LARC method in place at beginning of basic training a | 1.1% | 1.6% | 0.9% | 0.6% | <.001 |
| Contraceptive use at after 6 mo on active duty | <.001 | ||||
| None | 81.6% | 72.3% | 63.1% | 72.1% | |
| Pill/patch/ring | 15.8% | 23.3% | 17.7% | 13.6% | |
| DMPA | 0.7% | 1.2% | 1.0% | 2.1% | |
| IUD | 0.4% | 0.8% | 4.7% | 0.4% | |
| Implant | 1.5% | 2.4% | 13.5% | 11.8% | |
| Kaplan−Meier estimate of childbirth rates prior to 24 mo on active duty | 11.1% ± 0.2% | 5.9% ± 0.2% | 6.7% ± 0.2% | 8.4% ± 0.3% | <.001 |
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