Contraceptive use and access among deployed US servicewomen: findings from an online survey

Abortion access for U.S. active-duty servicewomen: A scoping review

OBJECTIVES

U.S. active-duty servicewomen experience barriers to abortion care that civilian women do not experience due to military regulations and federal law. This scoping review aims to address this gap in knowledge by evaluating the research in this area.

STUDY DESIGN

A scoping review protocol based on Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was used to search PubMed, Embase, and CINAHL for peer-reviewed publications and gray literature. Inclusion criteria included (1) abortion access for active-duty servicewomen; (2) knowledge, attitudes, or beliefs regarding abortion for active-duty servicewomen; or (3) the prevalence of abortion among active-duty servicewomen. Quality appraisal was completed according to Let Evidence Guide Every New Decision criteria.

RESULTS

The search yielded 811 articles, of which 15 met the criteria for inclusion in this review. Nine were empirical research articles, and six were nonempirical. Overall, 66% (n = 10) had abortion coverage or access as the primary outcome of interest; 73% (n = 11) cited relevant legislation; 80% (n = 12) made policy recommendations; and 40% (n = 6) made future research recommendations. Three themes emerged (1) prevalence estimates, (2) barriers to care, and (3) lack of knowledge and training on military abortion policies.

IMPLICATIONS

More studies with abortion coverage and access for active-duty servicewomen as the primary outcome of interest should be conducted to better understand the scope of the issue and the impact on military readiness and to inform policy makers and future interventions to mitigate barriers to care.

Racial Disparities in Highly Effective Contraceptive Use Among U.S. Active Duty Servicewomen, Fiscal Years 2016-2019

Background: Previous studies have found that unintended pregnancy rates are higher among racial minorities and active duty servicewomen (ADSW), correlating with lower rates of effective contraceptive use. The Military Health System (MHS) provides universal health care benefit coverage for all ADSW, including access to all highly effective contraceptive (HEC) methods. This study investigated the association between race and HEC use among ADSW. Materials and Methods: We conducted a cross-sectional study using fiscal year 2016-2019 data from the MHS Data Repository for all ADSW ages 18-45 years. Statistical analyses included descriptive statistics and logistic regression models, adjusted and unadjusted, determining the odds of HEC use, overall and by method. Results: Of the 729,722 ADSW included in the study, 59.7% used at least one HEC during the study period. The highest proportions of users were aged 20-24 years, White, single, Junior Enlisted, and serving in the Army. Lower odds of HEC use were demonstrated in Black (odds ratio [OR] = 0.94, 95% confidence interval [CI] = 0.92-0.95), American Indian/Alaska Native (OR = 0.85, 95% CI = 0.82-0.89), Asian/Pacific Islander (OR = 0.81, 95% CI = 0.80-0.83), and Other (OR = 0.97, 95% CI = 0.94-0.99) ADSW compared with White ADSW. Conclusions: Universal coverage of this optional preventive service did not guarantee its use. The MHS can serve as a model for monitoring racial disparities in HEC use.

Physical Health and Well-being: Updates and the Way Ahead

INTRODUCTION

The Women in Combat Summit 2021 "Forging the Future: How Women Enhance the Fighting Force" took place during February 9-11, 2021, via a virtual conference platform. The third and final day of the Summit regarded the physical health and well-being of military women and included the topics of urogenital health, nutrition and iron-deficiency anemia, unintended pregnancy and contraception, and traumatic brain injury.

MATERIALS AND METHODS

After presentations on the topics earlier, interested conference attendees were invited to participate in focus groups to discuss and review policy recommendations for physical health and well-being in military women. Discussions centered around the topics discussed during the presentations, and suggestions for future Women in Combat Summits were noted. Specifics of the methods of the Summit are presented elsewhere in this supplement.

RESULTS

We formulated research and policy recommendations for urogenital health, nutrition and iron-deficiency anemia, contraception and unintended pregnancy, and traumatic brain injury.

CONCLUSIONS

In order to continue to develop the future health of military women, health care providers, researchers, and policymakers should consider the recommendations made in this supplement as they continue to build on the state of the science and forge the future.

Unintended pregnancy among U.S. military active duty servicemembers: Estimates for 2018 and trends since 2005

OBJECTIVES

To evaluate the prevalence of and factors associated with unintended pregnancy in the past 12 months among women and men in the United States (U.S.) military in 2018, as well as trends in unintended pregnancy between 2005 and 2018.

STUDY DESIGN

This was a cross-sectional study using the 2018 Department of Defense Health Related Behaviors Survey of active duty servicemembers. We selected a stratified random sample from members of all military service branches and used weighted logistic regression models to identify associated independent factors. A 9.6% weighted response rate to the online survey resulted in 16,806 active duty servicemembers analyzed; 4993 women aged 17 to 44 years and 11,813 men aged 17 to 45+ years. We used data from five independent surveys: 2005, 2008, 2011, 2015, and 2018 to examine trends over time.

RESULTS

A total of 5.6% (95% CI: 4.5%-6.7%) of servicewomen reported unintended pregnancy and 2.4% (95% CI: 1.9%-2.9%) of servicemen reported to have caused unintended pregnancy. Unintended pregnancy was associated with contraception nonuse, younger age, and being either married or cohabiting.

CONCLUSION

The decrease in prevalence of unintended pregnancy among U.S. servicemembers since 2005 mirrors the general U.S.

POPULATION

Differing contraception policies during basic training across military services may influence rates of unintended pregnancy. Unintended pregnancies place a large burden on the military healthcare system, as the majority of women serving in the military are of reproductive age, and thus require care before, during, and for years after giving birth.

IMPLICATIONS

Unintended pregnancy among U.S. military servicewomen relatively mirrors that seen in the U.S.

POPULATION

Contraceptive policies affect unintended pregnancy throughout servicemembers' duration of service. As they are more likely to live in states which restrict access to abortion services, servicewomen with unintended pregnancy may face increased obstacles to care.

Sexually Transmitted Infections in the U.S. Military: A Sexual Health Paradigm to Address Risk Behaviors, Unintended Pregnancy, Alcohol Use, and Sexual Trauma

To address the ongoing epidemic of sexually transmitted infections (STIs) in the United States, the National Academies of Sciences, Engineering, and Medicine (National Academies) conducted a consensus study on STI control and prevention in the United States to provide recommendations to the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. The culminating report identified military personnel as one of the priority groups that require special consideration given the high prevalence of STIs and their associated behaviors (e.g., concurrent sexual partners and infrequent condom use) that occur during active duty service. Universal health care access, the relative ease and frequency of STI screening, and the educational opportunities within the military are all assets in STI control and prevention. The report offers a comprehensive framework on multiple and interrelated influences on STI risk, prevention, health care access, delivery, and treatment. It also provides an overview of the multilevel risk and protective factors associated with STIs that could be applied using a sexual health paradigm. The military context must integrate the multilevel domains of influences to guide the effort to fill current gaps and research needs. The Department of Defense, with its large clinical and preventive medicine workforce and its well-established universal health care system, is well positioned to enact changes to shift its current approach to STI prevention, treatment, and control. STI control based on highlighting behavioral, social, cultural, and environmental influences on service members' sexual health and wellness may well drive better STI care and prevention outcomes.

Women's Health Care in the Deployed Setting 2013-2020: A Health Services Research Approach

INTRODUCTION

With the management and oversight of MTFs moving under the authority of the Defense Health Agency, coupled with a careful examination of the composition of uniformed medical personnel, it is imperative to ensure that active duty servicewomen who are in deployed settings receive timely, appropriate, and quality health care. This study sought to examine the amount and types of gynecological and obstetric care provided in the deployed setting and to examine that data by the socioeconomic and demographic characteristics of the women receiving that care.

MATERIALS AND METHODS

Using the Military Health System's Theater Medical Data Store, we identified women aged 15 to 54 years old who received care at a theater-based MTF between 2013 and 2020. Within our study population, we subsequently identified obstetric and gynecologic (OBGYN) health services during the study period, and ran descriptive statistics on patient demographics (age group, race, rank, and U.S. military branch of service) and OBGYN health services. Patient age was assessed at the time of data extraction and race was categorized as Black, White, Other, and Unknown. The military branch of service was categorized as Army, Navy/Marines, Air Force, and Other. Rank was used as a proxy for socioeconomic status and categorized as Junior Enlisted, Senior Enlisted, Junior Officer, Senior Officer, Warrant Officer, and Other. Multivariable logistic regressions were also conducted and used to assess the odds of OBGYN health service utilization, with all patient demographics included as predictor variables.

RESULTS

A total of 490,482 women were identified and received OBGYN health services at theater-based MTFs between 2013 and 2020. The majority of our population consisted of women aged 25 to 34 years (56.98%), associated with a Junior Enlisted rank (39.27%) and with the Navy/Marines (37.27%). Race was severely underreported, with 51.58% associated with an unknown race; however, 20.88% of our population were White women, 16.81% were Black women, and 10.72% of women identified their race as Other. The top five diagnoses for women seen in the deployed environment were for a contraceptive prescription (12.13%), followed by sexually transmitted infection (STI) screening (8.14%), breast disorder (7.89%), GYN exam (6.86%), and menstrual abnormalities (6.35%). Compared to White women, Black women had higher odds of seeking the contraceptive prescription (3.03 OR, 2.91-3.17 95% CI), obtaining STI screening (5.34 OR, 5.16-5.54 95% CI), being seen for a breast disorder (4.88 OR, 4.71-5.06 95% CI), GYN exam (3.21 OR, 3.10-3.32 95% CI), and menstrual abnormalities (3.71 OR, 3.58-3.85 95% CI).

CONCLUSIONS

Almost consistently, senior officers were more likely to receive OBGYN services during deployment. Policymakers and health-care providers need to identify interventions to close this care gap, particularly in preventive OBGYN services (contraception, GYN exams, STI screenings). Fully implementing the Comprehensive Contraceptive Counseling and Access to the Full Range of Methods of Contraception policy and developing one standard Defense Health Affairs policy on pre-deployment evaluation standards and deployment follow-up care for women's health care may also assist in closing care gaps.

The Rise of the Female Warfighter: Physiology, Performance, and Future Directions

ABSTRACT

Since 1948, the United States military has been open to both men and women as permanent party service members. However, in the majority of the time since, there have been a subset of military occupational specialties (MOS), or job descriptions, open only to men. In particular, jobs requiring more intense physical and/or environmental strain were considered to be beyond the physiological capabilities of women. In the present analysis, we review the literature regarding neuromuscular, physical performance, and environmental physiology in women, to highlight that women have no inherent limitation in their capacity to participate in relevant roles and jobs within the military, within accepted guidelines to promote risk mitigation across sexes. First, we discuss performance and injury risk: both neuromuscular function and physical capabilities. Second, physiological responses to environmental stress. Third, we discuss risk as it relates to reproductive health and nutritional considerations. We conclude with a summary of current physiological, performance and injury risk data in men and women that support our overarching purpose, as well as suggestions for future directions.

Decide + Be Ready: A Contraceptive Decision-Making Mobile Application for Servicewomen

Women in the military have a high rate of unintended pregnancies, which is an issue both personally and with respect to the warfighting mission. One strategy to help servicewomen achieve family planning goals includes increasing education about and access to contraception. Research suggests that preference-sensitive decisions about contraceptives benefit from shared decision-making, and decision aids have been shown to facilitate this patient-centered approach. In this article, we describe the process by which we enhanced an existing evidence-based tool to meet the needs of military servicewomen and created Decide + Be Ready, a contraceptive decision-making mobile application. After extensive research into challenges faced by servicewomen with respect to contraceptive knowledge and access, we developed content for the decision aid and determined that a mobile app format would provide the privacy and convenience needed. Our team developed a prototype that, in collaboration with the Defense Health Agency Connected Health Branch, was tested with servicewomen and providers. User feedback shaped the final version, which can be accessed free from the App Store and Google Play. Early implementation has demonstrated patient and provider satisfaction. Obstacles to full implementation of Decide + Be Ready remain within the Military Health System. We lay out a roadmap for dissemination, implementation, and evaluation and explore the applications of the decision aid for health professions education in the realm of shared decision-making. Finally, we recommend consideration of decision aids for other health care decisions as a way to achieve patient-centered care, improve health outcomes, and potentially reduce costs.