Abstract
Methods
The data for this study were obtained from the 2005 and 2008 Health-Related Behaviors Survey. The 2008 survey had a total sample size of 45,800, with 28,546 completed surveys. This study used data from surveys completed by women aged 18–44 years, so the final sample size was 7225 [1]. The 2005 survey had data from 3745 surveys [2]. The primary outcome of interest was an unintended pregnancy in the prior 12 months, measured by the survey question “In the last 12 months did you cause or have an unintended pregnancy?” The survey data were also age adjusted to allow a balanced comparison with the age range of the general US population. Data for the general population were obtained from the US Census Bureau population projection for women in 2006 [101]. Logistic regression was used to test for univariable and multivariable associations between various demographic features and key subgroups.
Results
The authors found the unintended pregnancy rate in 2008 to be 105 per 1000 women, increased from 97 per 1000 women in 2005. The age-adjusted rate was 78 per 1000 women, which is 50% higher than the general US population of 52 per 1000 women. Multivariate logistic regression was used to analyze demographic data, and the authors found that the unintended pregnancy rates were higher among younger women, women with less education, nonwhite women and married/cohabitating women. Women in the Army, Marine Corps and Navy had a higher rate of unintended pregnancies compared with women in the Air Force. Univariable analysis found that increasing pay grade had an inverse relationship with the unintended pregnancy rate. There was no difference between women who were deployed in the previous 12 months and those who were not deployed in their unintended pregnancy rates [1].
Significance of results
The Health-Related Behaviors Surveys used in this study were intended to gauge the military's progress towards achieving the Healthy People 2010 goals to reduce the high rates of unintended pregnancies [102]. The study results show that there have been no improvements in unintended pregnancy rates from 2005 through to 2008, and in fact, the rate has increased slightly. In addition, active-duty women continue to have higher rates of unintended pregnancy when compared with their civilian counterparts. The number of military women surveyed is a strength of this study, and the results highlight an area of concern for the military.
Unintended pregnancies can create a number of challenges. Perhaps the greatest challenge to the military is the impact on military readiness. Pregnant military women are nondeployable during their pregnancy and for 6 months following pregnancy. They are also immediately evacuated from theater if they become pregnant during deployment [3]. These women are also subject to the same potentially poor pregnancy outcomes associated with unintended pregnancy. These may include delayed or inadequate prenatal care, especially if the pregnancy occurs while deployed, substance abuse during pregnancy, premature birth, lack of breastfeeding and poor childcare behavior [4,103]. This is compounded by the fact that even in a garrison status (billeted at home and in a nondeployed status), the work demands on an active-duty female are usually greater than an equivalent civilian job, making childcare more difficult.
It is interesting to note that under the military insurance program (TRICARE), active-duty soldiers have no cost or access restrictions to most healthcare needs, including almost all forms of contraception, and yet they have a higher rate of unintended pregnancy [5,104]. Several reasons were put forth to explain this, including limited options for pregnancy termination, inadequate predeployment counseling on contraception, limited access to contraceptives during deployment, confusion about the legality of sexual intercourse between nonmarried couples and the high prevalence of sexual assault.
Elective abortions are not covered under TRICARE or performed in a military treatment facility with two exceptions – the mother's health or life is at risk or the pregnancy is a result of incest or rape [104]. Active-duty women are not prevented from obtaining an elective abortion outside of a military treatment facility, it is simply not a covered benefit. However, it is clear that if a woman has an unintended pregnancy during a deployment, it can be difficult or impossible for her to obtain a termination, if she so desires [6].
Prior to deployment, all female soldiers go through medical screening and are offered contraception; however, many soldiers choose not to obtain contraception. Many believe they will not need contraception, because they are either single or not planning on engaging in sexual intercourse while deployed, or they are married/cohabitating and will be separated from their partner.
Contraceptives are limited in access and availability during deployment [7,8]. All soldiers on chronic medications, including contraception, are offered the benefit of the TRICARE Mail Order Pharmacy [104], which will deliver refills of chronic medications, at no cost, to the soldier's deployed location.
According to military law, sexual intercourse is prohibited in all instances, except between married couples [9]. Realistically, except in cases of assault, adultery and fraternization (relationships between enlisted and officer personnel), this is rarely prosecuted because it is difficult to prove. However, the fear of prosecution might be a deterrent to obtaining contraception.
Perhaps another deterrent to obtaining contraception is the stigma associated with the military healthcare system. Unfortunately, there are common feelings that have been voiced among some beneficiaries that anything provided for free (i.e., healthcare) may be substandard and not necessarily in their best interest. This perception could make it difficult for a provider to convince a female soldier of the benefits of contraception.
Finally, sexual assault is a real, highly visible problem that is now receiving a lot of attention in the military.
Other factors that may impact the likelihood that an active-duty service member may become pregnant is that during the pregnancy they will receive full medical care at no expense to themselves, they will continue to receive all pay and allowances, and there should be no effect on the career or promotion of the military member. Although this knowledge will not necessarily lead to an unintended pregnancy, the lack of career consequences linked with pregnancy could make active-duty women less vigilant about contraception.
Conclusion & future perspective
This study clearly identifies a need for improvement in the education and provision of contraception for active-duty females. The Department of Defense has taken notice of this from a broader perspective, and a recent publication from the Government Accountability Office highlights these findings and provides recommendations for improvement [8]. Findings from this study will help both the military treatment facility and combat units focus efforts in improving soldiers' education on female health issues.
Another area of interest would be determining why female soldiers do not obtain more effective contraception. As mentioned above, it is unclear why, despite free access to all forms of contraception, many female soldiers do not take advantage of this benefit. Better education, starting with initial entry training soon after recruitment, during basic training and reinforcement at the time of yearly examinations, may possibly help.
Executive summary
The unintended pregnancy rate among active-duty females is approximately 50% greater than the general population of the USA.
The unintended pregnancy rate in the military increased from the 2005 to the 2008 survey.
Unintended pregnancies have a significant impact on military readiness and deployability.
Despite ‘no cost’ access to healthcare and contraception, there are still significant challenges to providing effective contraception to active-duty females.
Footnotes
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.