January 26, 2012 — Summary of "Unintended Pregnancy and Contraception Among Active Duty Servicewomen and Veterans," Vinita Goyal et al., American Journal of Obstetrics and Gynecology, December 2, 2011.
As the U.S. military is relying more than ever on the participation of women, the number of active duty and veteran women continues to grow, according to Vinita Goyal of the Women and Infants' Hospital in Rhode Island and Sonya Borrero and Eleanor Bimla Schwarz of the University of Pittsburgh. They wrote, "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." The authors reviewed existing literature on unintended pregnancy and contraceptive use among women in the military.
Unintended pregnancy among women in the military "can be problematic for several reasons," the authors wrote. They added, "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."
Although all members of the U.S. armed forces are prohibited from engaging in sexual intercourse outside of marriage, most unmarried service personnel endorse sexual activity when surveyed. The authors wrote, "Since sexual intercourse is prohibited in most situations, active duty personnel often forgo condom use to avoid incriminating evidence."
The authors' review found "high rates of unintended pregnancy among active duty servicewomen." Rates of unintended pregnancy among servicewomen are significantly higher than among the general population. Similar to the general population, unintended pregnancy among military women is associated with younger age, unmarried status and lower educational levels. The authors noted that women at the highest risk for unintended pregnancy tend to have lower military ranks. Additionally, sexual assault rates in the military are very high. Other studies have shown an increased unintended pregnancy rate associated with sexual violence.
Outcomes of Unintended Pregnancy
According to the authors, there is a shortage of epidemiologic data on the outcomes of unintended pregnancy for servicewomen. They noted, "Specifically, abortion rates among servicewomen are unknown because federal policy restricts [Department of Defense] 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, incest or in which pregnancy threatens the life of the mother." Because of these policies, "active duty servicewomen must seek abortion services outside the military health system and at their own expense," the authors wrote. There also is little data on prenatal care or birth outcomes among military women with unintended pregnancies.
"Unintended pregnancy among active duty servicewomen is largely related to lack of contraceptive use," the authors wrote. They found that 50% to 62% of servicewomen with an unintended pregnancy did not use contraception. Moreover, women who use contraception often rely on less-effective methods. Consistent condom use was uncommon, and oral contraceptive pills were used by less than 40% of women at risk of unintended pregnancy.
Although military and civilian women both cite similar concerns about side effects as reasons for not using contraception, military women face "special circumstances" that can hinder use, according to the authors. "For instance, deployed female soldiers working long shifts across multiple times zones reported difficulty adhering to a daily contraceptive schedule," they wrote. Military women also face a lack of availability of their preferred contraceptive while deployed, an inability to store medications in barracks because of privacy and space shortages, and limited knowledge about available contraceptives from military health providers. Low rates of contraceptive use may also be a result of limited reproductive health education prior to military service.
The authors noted that the Air Force, Army and Navy have started family planning education programs for active duty and deployed members. Some studies have shown that these programs decrease unintended pregnancy rates and that education about sexual health raises rates of contraception use. However, a recent study of female Marines found no difference in unintended pregnancy rates among women who participated in the programs and those who did not. Studies around emergency contraception have shown that both service members and military health providers lack knowledge about the method.
According to Goyal and colleagues, there are no published data on unintended pregnancy rates among female veterans. However, female veterans share "many of the risk factors for unintended pregnancy found among active duty servicewomen and civilian women." In addition, female veterans are "more likely to have experienced intimate partner violence than non-veteran women, and intimate partner violence is associated with higher unintended pregnancy rates," the authors wrote. There have been attempts in recent years to facilitate contraceptive access for veterans, but issues such as lack of access and provider knowledge persist.
Military women might have an elevated risk for unintended pregnancy compared with civilian women because servicewomen "are predominately young, unmarried, have lower educational achievement and lower socioeconomic status, and are more likely to be members of racial and ethnic minority groups than the general population," according to the authors. They continued, "Each of these demographic characteristics are associated with higher rates of unintended pregnancy." However, there are some factors that impact servicewomen uniquely. For instance, access to effective methods is limited. Because of the prohibition on sexual activity, service members avoid condom use and may avoid use of other contraceptive methods as well. Additionally, women in the military experience high levels of sexual violence.
Goyal and colleagues wrote that while servicewomen generally are satisfied with the health care provided by DOD, "deployed servicewomen, in particular, reported facing limitations in the range of reproductive health care services and supplies available overseas." The authors acknowledged that although "it may not be feasible to stock overseas military treatment facilities with a variety of daily, weekly and monthly contraceptives, deployed servicewomen may benefit from use of long-acting reversible methods of contraception like the IUD and contraceptive implant." Education of military health care providers and servicewomen "may also result in greater use of contraception."
The authors also discussed a lack of data on contraceptive use among female veterans. They noted, "The magnitude of unintended pregnancy, subpopulations of women veterans at greatest risk for unintended pregnancy, prevalence of contraceptive use, barriers to contraceptive use, levels of contraceptive knowledge among providers and patients, system variations on contraceptive availability and effect of reproductive health education are all unknown."
Goyal and colleagues concluded, "Understanding and addressing the needs of [military women] will give health care providers an opportunity to improve reproductive health care as well as pregnancy outcomes for this population."