The number of women of childbearing age who are active-duty service members or veterans of the US military is increasing. These women may seek reproductive health care at medical facilities operated by the military, in the civilian sector, or through the Department of Veterans Affairs. This article reviews the current data on unintended pregnancy and prevalence of and barriers to contraceptive use among active-duty and veteran women. Active-duty servicewomen have high rates of unintended pregnancy and low contraceptive use, which may be due to official prohibition of sexual activity in the military, logistic difficulties faced by deployed women, and limited patient and provider knowledge of available contraceptives. In comparison, little is known about rates of unintended pregnancy and contraceptive use among women veterans. Based on this review, research recommendations to address these issues are provided.
There are several definitions used in military service duty. One of these is active duty. This includes enlisted personnel and officers providing full-time duty in the active military service of the United States (Army, Navy, Air Force, Coast Guard, and Marine Corps) and active-duty status in the Reserves and the National Guard (other than for training). Another term is deployed personnel. These are active-duty personnel who are relocated to the desired operational areas. Deployment encompasses all activities from the origin or home station through the destination specifically including the intracontinental United States, the intertheater, and the intratheater movement. Another term is a reservist. These are members of the military services who are not in active service but who are subject to call to active duty. The reserve component consists of the Army and Air National Guard and the Army, Navy, Marine Corps, Air Force, and Coast Guard Reserves. Then there are the veterans, who are individuals who have served, but are not currently serving, on active duty in the US Army, Navy, Air Force, Marine Corps, Coast Guard, National Guard, or Reserves or who served in the US Merchant Marine during World War II.
Now, more than ever, the US military relies on the direct participation of women. Currently, 20% of new military recruits, 15% of active-duty military personnel, and 17% of Reserve and National Guard forces are women. More than 400,000 women are active-duty, National Guard, or Reserve members. In comparison, in 1973, women comprised only 2% of the active-duty population. As the number of women in the military has increased, the population of women veterans has also increased. There are presently more than 1.8 million US female veterans, up from 1.1 million in 1980, who comprise 8% of the total veteran population. By 2036, it is projected that the proportion of women veterans will almost double to 15%.
Both the Department of Defense (DOD) and Department of Veterans Affairs (VA) are making concerted efforts to ensure the provision of quality health care to women who are serving or have served in the US military, yet many women also seek care from civilian physicians. As such, health care providers within the community, as well as those in the DOD and VA, need to be aware of the reproductive health needs of this population.
Existing military health care structure
The DOD provides medical benefits for active duty personnel, retirees, Reservists, and National Guard members called to active duty, and certain dependents under the worldwide health care plan called TRICARE. Under TRICARE, most health care is provided by a military treatment facility. Military personnel covered by TRICARE may be referred to a civilian medical provider if care is unavailable at the local military treatment facility or if they live and work more than 50 miles from the nearest treatment facility. Service members may also seek care outside the military treatment facility or referral network, but this may not be reimbursed.
After leaving active military service, women veterans may seek care from a community physician using TRICARE (where accepted), private health insurance, Medicaid, or Medicare. Women veterans who are honorably discharged active-duty service personnel or eligible Reservists or National Guard members may also qualify for cost-free or subsidized health care services through the VA based on the presence of a service-related medical condition (ie, service connection) and/or income-based need at any time after discharge from the military. Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (OEF/OIF) veterans may receive health care services at the VA for 5 years following discharge, regardless of income or service connection.
Women veterans are the fastest growing group of new VA health center users, and eligible women may receive preventive care, gynecological care, and maternity and some infertility care through the VA. However, only 14% of all female veterans sought health care at a VA site in 2008-2009, with the vast majority, 76%, obtaining health care exclusively at non-VA sites. Of those who used VA services, 53% were dual VA and non-VA users. Among all women veterans, greater than 60% of both VA and non-VA health care visits in 2008-2009 were to address specific women’s health care issues. Even though these women are seeking care at a VA medical center more frequently than female veterans from previous eras, a large majority continue to obtain obstetric and gynecological care from non-VA providers.
Reproductive health needs of military women
Active-duty and veteran women are largely of childbearing age. Approximately 75% of new military recruits are younger than 22 years of age. In total, 42% of all female veterans are currently of childbearing age, and more than 90% of female veterans who served after Sept. 11, 2001, are between 18 and 44 years of age. These women have reproductive health issues that may not be typically thought of when considering military and veteran health care.
Because of its potentially high burden for military women, as well as its impact on military operations, prevention of unintended pregnancy is one reproductive health issue of particular importance. Unintended pregnancy among active-duty servicewomen can be problematic for several reasons. Deployed servicewomen with an unintended pregnancy may face significant obstacles in seeking timely prenatal care and even greater barriers to accessing safe abortion services. Furthermore, the military careers of women who become pregnant may be prematurely halted, thus restricting their economic and professional achievements. For the military, unintended pregnancy is costly, limits unit readiness, and results in decreased deployment of military recruits.
In this article we reviewed the existing literature on unintended pregnancy and contraceptive use among women in the military. This review revealed high rates of unintended pregnancy among active-duty servicewomen, which may result from the limited use of effective methods of contraception. The data on unintended pregnancy and contraceptive use are far greater among active-duty servicewomen than women veterans. Yet the risk factors that predispose women to unintended pregnancy may persist as they transition out of active service and become veterans. The gaps in knowledge about these key issues among military and veteran women are highlighted and provide the basis for research recommendations to further enhance the reproductive health care provided to these women.
Reproductive health needs of military women
Active-duty and veteran women are largely of childbearing age. Approximately 75% of new military recruits are younger than 22 years of age. In total, 42% of all female veterans are currently of childbearing age, and more than 90% of female veterans who served after Sept. 11, 2001, are between 18 and 44 years of age. These women have reproductive health issues that may not be typically thought of when considering military and veteran health care.
Because of its potentially high burden for military women, as well as its impact on military operations, prevention of unintended pregnancy is one reproductive health issue of particular importance. Unintended pregnancy among active-duty servicewomen can be problematic for several reasons. Deployed servicewomen with an unintended pregnancy may face significant obstacles in seeking timely prenatal care and even greater barriers to accessing safe abortion services. Furthermore, the military careers of women who become pregnant may be prematurely halted, thus restricting their economic and professional achievements. For the military, unintended pregnancy is costly, limits unit readiness, and results in decreased deployment of military recruits.
In this article we reviewed the existing literature on unintended pregnancy and contraceptive use among women in the military. This review revealed high rates of unintended pregnancy among active-duty servicewomen, which may result from the limited use of effective methods of contraception. The data on unintended pregnancy and contraceptive use are far greater among active-duty servicewomen than women veterans. Yet the risk factors that predispose women to unintended pregnancy may persist as they transition out of active service and become veterans. The gaps in knowledge about these key issues among military and veteran women are highlighted and provide the basis for research recommendations to further enhance the reproductive health care provided to these women.
Active-duty servicewomen
The burden of unintended pregnancy
Although all members of the US armed forces are prohibited from engaging in sexual intercourse outside marriage, when surveyed, unmarried service personnel do endorse sexual activity. The specific context of these sexual encounters is unknown but may occur in violation of military policy, during vacation from active duty, while under the influence of alcohol or drugs, or be forced. Because sexual intercourse is prohibited in most situations, active-duty personnel often forgo condom use to avoid incriminating evidence. Servicewomen may avoid use of other methods of contraception for the same reason, but no studies have addressed this. It is in this scenario of sexual activity without use of contraception that servicewomen are at risk for unintended pregnancy.
Several studies among women serving in the military report rates of unintended pregnancy exceeding the rates seen in the general population. Approximately 50% of US women will have an unintended pregnancy. Studies among women in the Air Force reveal that 54-60% of women reported an unplanned pregnancy, among whom 71% stated they were unhappy to be pregnant. Surveys of women in the Navy demonstrate similarly high rates of unintended pregnancy at approximately 50-60%. Female Army soldiers also have high rates of unwanted or mistimed pregnancies at 55-65%.
In a 2005 survey conducted by the DOD, 16.2% of military women 20 years old or younger reported an unintended pregnancy in the last year. In the general population, the total pregnancy rate, including intended and unintended pregnancies, was 7.1% for similarly aged women in 2005. As in the general population, unintended pregnancy among military women is most commonly associated with younger age, unmarried status, and lower educational levels. Additionally, servicewomen at highest risk for unintended pregnancy typically have lower military rank.
Although there is no established link between unintended pregnancy and military sexual trauma, defined as severe or threatening forms of sexual harassment and sexual assault sustained in military service, victims of sexual violence in the civilian population have been found to be at higher risk for unintended pregnancy. In the US general population, approximately 18% of women surveyed reported that they had been the victim of a completed or attempted rape during their lifetime and 5% of rapes resulted in pregnancy. More than 20% of all women veterans and 15% of OEF/OIF veterans reported being victims of military sexual trauma. A survey of 130 military women with unintended pregnancy revealed that 4% were a result of rape. Further research among victims of military sexual trauma may reveal this to be a significant factor contributing to unintended pregnancy.
Epidemiological data on the outcomes of unintended pregnancy among servicewomen are limited. Specifically, abortion rates among servicewomen are unknown because federal policy restricts DOD funding of abortion to cases in which pregnancy is life threatening to the mother and limits provision of abortion services at DOD facilities to cases of rape or incest or in which pregnancy threatens the life of the mother. As a result of these policies, active-duty servicewomen must seek abortion services outside the military health system and at their own expense. In addition to abortion, there are few data on prenatal care or birth outcomes among servicewomen with an unintended pregnancy.
Contraceptive use
Unintended pregnancy among active-duty servicewomen is largely related to the lack of contraceptive use. In fact, 50-62% of servicewomen presenting with an unintended pregnancy were not using contraception when they conceived. In a survey of 503 sexually active Army women, 67% did not intend to become pregnant within the next year, yet the desire to avoid pregnancy did not translate into contraceptive use.
Similarly, surveys of active-duty military personnel of reproductive age demonstrate that although 70-85% were sexually active, nearly 40% used no contraception. Young and unmarried women, who are generally at greater risk for unintended pregnancy than older, married women, were less likely to use contraception. In studies investigating contraceptive use among deployed women, only 54% filled a prescription for hormonal contraceptives and 43% actually used hormonal contraception while overseas.
Among servicewomen who use contraception, less effective methods are commonly used. Approximately 30% of sexually active female military personnel reported condom use during their last sexual encounter, but consistent condom use during each act of intercourse was uncommon. Oral contraceptive pills (OCPs) were the method most frequently used, although less than 40% of women at risk for unintended pregnancy used this method. The contraceptive injection was used by less than 15% of sexually active Navy personnel. Even smaller proportions of servicewomen used highly effective methods of contraception such as the intrauterine device (IUD), contraceptive implant, or male or female sterilization.
Similar to civilian women, military women may not use contraception because of concerns about side effects including nausea, weight gain, headache, and abnormal bleeding. There are, however, special circumstances faced by servicewomen that limit consistent contraceptive use. For instance, deployed female soldiers working long shifts across multiple time zones reported difficulty adhering to a daily contraceptive schedule. Other servicewomen reported difficulty using the contraceptive patch in harsh deployment climates; 58% of users in one study stated the patch fell off, and problems with patch adhesion resulted in 60% of women discontinuing use.
Many women, upon experiencing unwanted side effects, found it easier to discontinue contraceptive use than overcome multiple hurdles such as the lack of availability of their chosen method in areas of deployment, inability to keep medications in the barracks because of limited space and privacy, and limited military health care provider knowledge of available contraceptives.
Low rates of contraceptive use among servicewomen may also be attributable to limited reproductive health education and knowledge prior to joining the military. A qualitative study of 29 sexually experienced Navy servicewomen found that prior to entering the military, few had used contraception. Furthermore, a survey of 244 Army women revealed that 26%, 44%, and 44% had never heard of the contraceptive implant, IUD, or emergency contraception, respectively. In a study to assess reproductive health knowledge among 69 female Navy personnel, knowledge scores regarding contraceptives (21.2 on a 32 item scale) and IUDs (1.2 on a 4 item scale) was low.
The Army, Navy, and Air Force have implemented family-planning education programs for active-duty and deployed personnel. In 2 separate studies of Navy servicewomen evaluating these programs, those who received contraceptive education had lower pregnancy rates at the end of the study period compared with the control group (0 vs 14%, P < .001, n = 198, and 23% vs 77%, no P value reported, n = 173 ). However, a trial conducted among female Marine Corps recruits showed no difference in unintended pregnancy rates between women who participated in a pregnancy prevention program and women who did not (6.7% vs 7.3%, P = .8, n = 2157).
In a qualitative study of 10 Navy women addressing contraceptive decision making, those who had previous sexual health education were more likely to use contraception, suggesting that reproductive health education while in the military may reduce unintended pregnancy in this population.
Emergency contraception (EC) may also help reduce unplanned pregnancy among active-duty servicewomen. Yet a survey of 302 Air Force personnel demonstrated that awareness of EC was lower among those who were younger than 22 years old (57% vs 71%, P = .01), unmarried (59% vs 71%, P = .02), and had lower education levels (58% vs 69%, P = .03), that is, those at greatest risk for unintended pregnancy. Among the 124 servicewomen surveyed, only 19% could report the proper time interval in which EC should be taken. Among male and female enlisted personnel, 25% stated they were unwilling to use EC, 42% felt its use should be tightly restricted, and 30% had ethical concerns about the medication. Nevertheless, 56% felt EC should be available upon deployment.
Those providing health care to active-duty personnel may also have limited knowledge about EC. A study of 68 military health care providers in 2008 revealed 34% of providers did not know the proper time interval during which EC could be prescribed and 38% incorrectly believed that it could not be prescribed to women who had contraindications to hormonal contraceptive use.
Use of hormonal contraception is beneficial to active-duty servicewomen not only for prevention of unintended pregnancy but also for induction of menstrual suppression. Deployed women reported that menses were difficult to manage because military gear affected self-care and environmental factors including heat, sand, limited restroom facilities, and long work hours without a break prevented changing sanitary products.
Among deployed women, 66% reported a strong desire for hormonally induced amenorrhea during deployment and 57% of those who used hormonal contraception to induce menstrual suppression reported high satisfaction with this method. Compared with conventional OCP users, those who used pills continuously reported greater adherence with daily pill use (53% vs 100%, P = .02, n = 62, and 42% vs 73%, P = .02, n = 500 ), and fewer lost duty days relating to menstrual disturbances (14% vs 0%, n = 62, and 21% vs 12%, n = 500, no P values reported). Given the possibility of menstrual suppression, both sexually active and abstinent servicewomen may benefit from hormonal contraceptive use.
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