ORIGINAL ARTICLES Authors alone are responsible for opinions expressed in the contribution and for its clearance through their federal health agency, if required.
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Reproductive Health Access Among Deployed U.S. Servicewomen: A Qualitative Study Ruth Manski, BA*; Kate Grindlay, MSPH*; Bridgit Burns, MPH*; Kelsey Holt, MAf; Daniel Grossman, MDt ABSTRACT Servicewomen"s reproductive health experiences during deployment are itnportant given that the tnajority of women in the U.S. military are of reproductive age and that this population experiences a disproportionately high rate of unintended pregnancy. Few studies have explored women's reproductive health experiences and their perceived barriers and facilitators to health care access during deploytnent. From May 2011 to January 2012, we conducted 22 in-depth interviews with women in the U.S. military about their reproductive health experiences during deployment, including their access to health services. Participants identified a range of barriers to accessing medical care in deployment settings, including confidentiality concerns, lack of female providers, and health-seeking stigma, which were reported to disproportionately impact reproductive health access. Some participants experienced challenges obtaining contraceptive refills and specific contraceptive methods during deployment, and only a few participants received predeployment counseling on contraception, despite interest in both menstruation suppression and pregnancy prevention. These findings highlight several policy and practice changes that could be impletnented to increase contraceptive access and reduce unintended pregnancy during deployment, including mandated screening for servicewomen's contraceptive needs before operational duty atid at least annually, and increasing the number of female providers in deployed settings.
INTRODUCTION Women in the U.S. military, who make up 15,8% of the Department of Defense's Active Duty, Reserve, and Guard forces,' are playing an increasing role in deployment settings. Between September 11, 2001 and Eebruary 28, 2013, a total of 299,548 women were deployed to Afghanistan and Iraq in Operation Enduring Ereedom and Operation Iraqi Ereedom." Additionally, recent legislation rescinding the 1994 Direct Ground Combat Definition and Assignment Rule that restricted women from serving in ground combat units will expand female participation and job roles in the military.^ Servicewomen deployed overseas are often stationed in harsh environments with limited access to health care, particularly preventive and specialized care. Most preventive care is typically addressed before deploying. The Department of Defense requires active duty and reserve military personnel *Ibis Reproductive Health. 17 Dunster Street, Suite 201, Cambridge, MA 02138. tDepartment of Social and Behavioral Sciences, Harvard School of Public Health, 677 Huntington Avenue, SPH 3, Floor 7, Boston, MA 02115. 1:Ibis Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612. doi; 10.7205/MILMED-D-13-00302
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to have annual periodic health assessments, which include a medical record review, risk factor counseling, preventive screening exams, assessment of occupational risks, immunizations, and assessment of deployment readiness,'^"'' Required reproductive health screenings for servicewomen include breast exams and mammograms for women >40 years and annual cervical cancer screening.** Within 60 days before deployment, all service members are required to have a predeployment health assessment, which includes a self-evaluation form to record physical and tnental health information for surveillance purposes and to identify health issues that may need to be addressed before deployment; service members may be referred for further evaluation of issues that could affect deployability. Service members are given a minimum 90-day supply of prescription medications before deploying.^ Other annual and predeployment health activities, such as immunizations, pregnancy testing, contraceptive counseling, and HIV testing, are based on .service branch policies, health risk assessments specific to the deployment location, the deployment type, or commander's decision.^ Once deployed, health encounters are primarily incident-driven or based on health threats specific to the deployment*" and preventive care is not
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typically provided. Most contraceptive methods are covered by TRICARE, the militaiy's health insurance program.^ However, once overseas, a more limited array of contraceptive options may be available. The Basic Core Fonnulary, a list of medications required at full-service military treatment facilities, only includes certain oral contraceptive formulations and Next Choice levonorgestrel emergency contraception; additionally, in August 2013, the Assistant Secretaiy of Defense issued a memorandum requiring that Plan B OneStep emergency contraception (Teva Pharmaceuticals, North Wales, Pennsylvania) also be available at military treatment facilities at no cost and without prescription.^** Availability of other contraceptive methods is at the discretion of the military treatment facilities and may differ by branch and location. Research on women's health care experiences during deployment focuses primarily on mental health and posttraumatic stress disorder, and to a lesser extent on menstruation, hygiene, and genitourinary experiences. These latter studies highlight unique challenges of deployment that impact women's health access, including limited running water and bathroom facilities, and lack of adequate pritnary health care facilities.'^"'^ Women's reproductive health needs and experiences during deployment are particularly important given that 97% of active duty women in the U.S. military are of reproductive age"; however, these issues are not well documented. Estimates of contraceptive use among women in the U.S. military range from 50 to 88% among women stationed in the United States and from 39 to 77% during deployment."* Studies suggest that the unique circumstances of deployment may impact contraceptive accessibility. In a survey of 281 servicewomen who had been deployed overseas between 2001 and 2010, one-third of women reported they could not access a contraceptive method that they wanted for deployment, and 41% of women using a method that required refills had difficulty obtaining them.''' Further, a 2005-2006 study of 397 servicewomen presenting at an outpatient facility in Iraq found that 42% of women using contraception during deployment changed their method during deployment because it was unavailable."" Access to contraception is critical to women's ability to prevent unintended pregnancy and is an important issue among active duty women, who experience higher rates of unintended pregnancy than women in the general U.S. population.''' Unintended pregnancy remains a concern during deployment: a longitudinal analysis of an Anny Brigade Combat Team in Iraq found that 10.8% of women were medically evacuated for pregnancy-related reasons over a 15-month period.^' Although the above studies provide a useful starting point for understanding servicewomen's reproductive health care needs and experiences during deployment, there is little qualitative exploration of women's experiences to provide greater depth on their perceived barriers and facilitators to health care access during deployment. To fill this gap, we conducted in-depth interviews with servicewomen who had been deployed
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overseas between 2001 and 2011 about their experiences with reproductive health care during deployment, including barriers and facilitators to care. METHODS From May 2011 to January 2012, we conducted in-depth interviews with women who had served in the U.S. military about their reproductive health experiences during deployment, including their access to health services. The data for this analysis were collected as part of a larger study that also included questions on U.S. servicewomen's experiences with sexual violence during deployment.^^ Participants were recruited via Facebook advertisements, postings on Craigslist in cities near large military bases, e-mail communication, and postings to military- and veteran-related websites and Facebook pages. Further, some participants were recruited after completing an online survey on contraception access and use during deployment.'^ Women of any military status, who had been deployed overseas anytime from 2001 or later, and were >18 years of age were eligible to participate. Participants were recruited until thematic saturation was reached. Two research team members trained in qualitative data collection techniques conducted the interviews in English via telephone. All study participants gave oral informed consent to participate and have their interview audio recorded, and received a $25 gift card remuneration. The study was approved by Allendale Investigational Review Board. Participants were asked open-ended questions about their military background and deployment experiences; their overall health care experience during deployment, including where health services were available, facilitators and barriers to care, and personal health experiences; contraceptive counseling, access, and use during deployment; and experiences with pregnancy and abortion during deployment. Whenever possible, interviewers solicited information about women's personal experiences; however, participants also shared information related to their knowledge of others' experiences with health care services during deployment, and this information is also included in the analysis. All interviews were digitally recorded and transcribed verbatim. Data were analyzed thematically in ATLAS.ti 6.2 (ATLAS.ti GmbH, Berlin, Germany) using modified grounded theory methods.^'' Grounded theory methodology was chosen because little qualitative research has been conducted on this topic, and we therefore desired to obtain emerging themes rooted in the data. Each transcript was coded by 2 research members to ensure inter-coder reliability. Initial codes were developed a priori based on the above interview questions, and subsequent revisions were made to the codebook as new inductive themes surfaced. Codes were summarized and organized thematically with representative quotes extracted, and provisional findings were cross-validated among the research team. Quotations are identified by participant's country and year of last deployment.
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Reproductive Health Access Among Deployed U.S. Servicewomen TABLE I.
Background Characteristics {N = 22)
Characteristic Age at Last Deployment (Years)" 18-24 25-29 30+ Education Level at Last Deployment" High School Some College Bachelor's Degree Master's Degree Marital Status at Last Deployment" Single Married Separated/Divorced Race/Ethnicity" White, Non-Hispanic Hispanic Time in Military. Current (Years) 1-5 6-10 11-15 16-20 21-25 Service Branch at Last Deployment Army Navy National Guard Marine Corps Rank/Rate at Last Deployment E-1 toE-3 E-4 to E-6 E-7 to E-9 O-l toO-3 Number of Deployments, Current 0 1 2 3+ Country of Last Deployment" Afghanistan Bahrain Cuba (Guantanamo Bay) Djibouti Iraq Kuwait Pakistan Romania At sea Contraceptive Use at Last Deployment (More Than 1 Method Possible) Otal Contraception Injectable Female Sterilization Patch Condom IUD None
RESULTS
Demographics
/;
%
7
7 7
31.8 31.8 31.8
2 8 9 2
9.1 36.4 40.9 9.1
14 5 2
63.6 22.7 9.1
Twenty-two women completed in-depth interviews. Two additional participants were screened but found ineligible because of their last deployment being before 2001, Most participants self-identified as White, and the majority were in the military for 6 to 15 years and had been deployed one time. At the time of their last deployment, one-third were 18 to 24 years old, one-third were 25 to 29 years old, and one-third were 30 years or older. Most participants had at least some college, were single, and were lower enlisted rank/rate (E-1 to E-6) at the time of their last deployment. Slightly more than half had served in the Army (Table I),
t9 2
86.4 9.1
Health Care Service Availability
4
1 2
18.2 40.9 27.3 4.5 9.1
12 4 4 2
54.5 18.2 18.2 9.1
3 13 1 5
13.6 59.1 4.5 22.7
1 14 6 1
4.5 63.6 27.3 4.5
2 1 1 1 11 2 1 1 1
9.1 4.5 4.5 4.5 50.0 9.1 4.5 4.5 4.5
11 3 2 1 1 1 5
50.0 13.6 9.1 4.5 4.5 4.5 22.7
9 6
Participants described a variety of health care services that were available during deployment. These services tended to focus on curative care and were wide ranging in scope. Few women reported preventive service availability during deployment, including both female-specific and general health care, and most noted that service members were encouraged to receive preventive services before deployment.
Facilitators and Barriers to Health Care
"Percents do not total 100 because of missing data.
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Participants reported that health care access was dependent on a variety of factors, explored below. Chain of Command and Confidentiality
The majority of participants reported having to inform their chain of command when they needed to access health care and described a variety of processes for obtaining permission, which ranged from formal to informal. In addition, some reported having to tell their chain of command why they were seeking health care. For example, one respondent recounted, "I needed to take the day off to go to the appointment. And my chief was like, 'Well, what are you going for?'.... 'Well, I'm going, because I have an appointment,' 'Well, for what?'"(At sea, 2011), Several servicewomen reported that the low proportion of women in the military could make them uncomfortable or embarrassed when discussing their health needs with male commanders, as illustrated by this participant last deployed to an unknown location in 2004: "If you have other women that you work with, I think it makes it a little ... easier at least to ask, whereas if you're in a chain of command with mostly men and no other women, or all men, I can't say that even as an officer I'm gonna approach my department head or the XO and be like, 'Hey, Sir, I'm having this female issue.'" However, other participants stated that they did not have to disclose any details related to their health visit, particularly if it was female-specific: "If you say, 'It's a woman issue,' they [the chain of command] would just be like, 'I don't wanna hear it, go!'" (Iraq, 2003-2004).
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Regardless of whether women disclosed health issues to their chain of command, participants reported challenges maintaining confidentiality because of "gossip" and the close quarters of the military base. One respondent who had been deployed to Iraq in 2003-2004 said, "Because you're living in such close quarters, everybody knows everybody's business." Another participant discussed the conflict and breach of confidentiality that could arise when a health care provider is a colleague: "I don't wanna go out for beer with the same person that just gave me a gynecological exam" (At sea, 2011), However, a small number of participants reported that rank could facilitate access to confidential health care services. One participant explained:
a deterrent to seeking care, particularly when individuals feared negative consequences to their careers. For example, seeking health care for certain conditions, like depression or substance abuse, could raise questions about the suitability of the solider and potentially damage one's career:
"I was an officer I needed birth control, so I was able to go to the airport to get it, because I could run my own convoy over. But I didn't tell anybody in my chain of command, because I didn't want to them to know But my soldiers never would've been able to do that—if my soldiers had an issue, they would have to run it all the way up the chain of command and get approval" (Iraq, 2004-2005).
Logistical challenges to seeking medical care during deployment were discussed in most interviews. The most common logistical challenge mentioned was in relation to participants' job responsibilities and difficulties finding time to seek medical care. As one servicewomen reported, "You kinda had to work around schedules and things like that. So it was kind of like if you had time to go do it, you could go get it done. If not, you're just gonna have to suck it up till you do have time" (Afghanistan 2006-2007). Other logistical challenges included limitations in providers' availability and difficulties arranging transportation when seeking medical care off-base or within large bases. One participant stationed in Iraq in 2007-2008 explained, "You had to set up a convoy to get you and you needed to go at set times. And so there was a lot of preparation that had to go into it in order to figure out how you were gonna get there. And, you know, if you were allowed to go, that sorta thing," A few participants discussed the implications that these logistical challenges had on confidentiality. For instance, the chain of command may not be willing to arrange transportation for a soldier to receive care off-base without knowing the reason they need to seek care. One participant described, "In some cases, travel is dangerous.... You can't just say, 'I wanna go to the Level 3 facility that's ten miles away.' You have to explain yourself (Iraq, 2004-2005).
Eemale Providers
Several participants reported limited or no availability of female providers during deployment. The majority of these participants stated that they felt embarrassed going to male providers, particularly for reproductive health services. As one servicewoman remarked, "I don't recall even on the big bases seeing any women providers. So if you do have a women's health care issue, it can be kind of daunting or intimidating" (Afghanistan, 2006-2007). In some cases, discomfort with male providers led to forgoing care. For instance, one participant, who had a history of abnormal Pap test results and had been advised to have more frequent exams explained, "When we were under way, I didn't have one done, because we only had male gynecologists. And I felt very uncomfortable with that" (At sea, 2011). Health Care Seeking Stigma
Many participants reported stigma associated with seeking medical care within the military. Reasons for this included perceptions that soldiers who seek care are shirking their responsibilities or are weak, and that health issues are not as important as the mission. As one woman recounted, "Basically [the chain of command] were always thinking you were scheming, trying to get out of deployment. So they were thinking that whatever your 'issue' is, it's not legit" (Djibouti, 2003-2004). Several participants felt that women are disproportionately impacted by this stigma and that they are more reluctant to seek care for fear of exacerbating the perception that women are weak. One participant explained, "In the military in general, it's kind of—looked down on to go to sick call,... So as a woman, you already have that kind of perception that you're weak, so you don't wanna—kind of exacerbate it" (Iraq, 2004-2005). This stigma was reported as
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"Some things in the military records are careerenders Um, counseling. Unit counseling. That could be career-ending. It doesn't matter what it's for, they see that you've been in there for mental health and they'll re-evaluate you—are you really stable enough to be a solider?" (Djibouti, 2003-2004). Logistics
Lack of Orientation
A handful of participants described a lack of orientation to health services available during deploytnent, with several expressing a desire for more information about reproductive health services, including contraception. In addition, one participant recounted moving between bases and often not knowing where general medical services were located. Another participant, who was deployed to a new base that was still being developed, explained that her base did not have an established location for medical facilities and was unsure where the medics were located. Resources
Some participants described lack of medical supplies and providers as barriers to accessing health services. In some
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cases, shortages of supplies and providers meant having to wait a long time for appointments, or having to forgo certain medical services. One participant explained, "When you go overseas or are deployed, it's harder to get that medical care, because there might not be a trained professional deployed with you or they rnay not have the things that they need" (Iraq, 2003-2004). A few participants noted that personal connections to health care personnel could help mitigate these challenges. For some participants, having personal connections meant they had greater access to health care services or appointments, or could obtain medical care without having to go through the formal channels, such as sick call. As one participant remarked, "On the ship, a lot of the times it's real hard to get into medical unless you know people" (At sea, 2011). Another respondent needed a pregnancy test after a sexual assault, and reported she was able to discretely obtain a pregnancy test because she was friends with the staff at the medical station. She stated, "I made friends with them I was like, 'hey,' you know, it's a little back door swap. Til bring you an extra package of, you know, cookies or something, and we'll just swap out the back.' Instead of going in—cause you have to sign in and tell your reason why you're actually here and stuff like that" (Djibouti, 2003-2004). Base Size
Many of the above barriers and facilitators to care were reported to vary depending on the participant's base size. Compared to participants on large bases, those on smaller bases noted greater confidentiality coticems and less access to medical supplies, services, and facilities. In addition, some participants reported that obtaining medical care on a small base could be challenging because there were fewer people to cover shifts. However, the ability to walk to a medical facility and easily navigate one's base was described as an asset to accessing health care on small bases. One participant explained: "On the larger bases it's harder to find [medical services], harder to navigate. It's also a little harder to get to sometimes Small bases it's hard to do anything without everybody knowing your business" (Djibouti, 2003-2004),
Contraceptive Use Most participants reported using contraception during their last deployment, including oral contraceptives (n = 9), tubal ligation (n = 2), injectable contraceptives (« = 1), the patch (« = 1), condoms (n - 1), and an intrauterine device (n = 1), Two additional participants switched from oral contraceptives to injectable contraceptives during deployment. The main reason reported for contraceptive use was menstrual suppression, including reducing heavy cramping and bleeding, increasing regularity, and reducing the frequency of menstruation. One woman explained, "When I got to Iraq, I remember hearing
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from somebody that they were giving the Depo shot. And so I wanted it not for contraceptive use, but for the having no period, 'cause that's a lot of planning when you're in a deployment situation where it's a hundred and thirty degrees" (Pakistan, 2005). Two women reported that, in addition to wanting to manage their menses, they wanted contraception for pregnancy prevention in case they were sexually active during deployment. Most participants who used contraception were satisfied with their method, though some indicated having minor challenges, such as excessive bleeding, forgetting pills, or patches not sticking well because of clitnate conditions. Among women who did not use contraception during their last deployment, the primary reason for nonuse was not being sexually active.
Contraceptive Counseling Most participants reported that they did not receive counseling on contraception for either pregnancy prevention or menstrual regulation as part of their predeployment medical check. Only a small minority of participants reported having a conversation about contraception beyond a general inquiry about prescription medications they were already taking. One woman explained, "They didn't really ask or brief you on those kinda things or have any kind of, really, discussions on it prior to going" (Iraq, 2007-2008), Some participants attributed the lack of discussion to rules prohibiting sexual activity during deployment, such as one participant who was deployed to Djibouti in 2003-2004 who stated, "They don't talk about [birth control] on, you know, on base. You're getting deployed, you're not supposed to be doing that stuff,"
Contraceptive Access Most contraceptive users obtained their initial supply through military providers before deployment. About half brought a supply for the entire deployment, whereas half brought a lesser amount and required refills. Use of nonmilitary sources for contraceptives was uncommon, with only two participants repotting they accessed their initial supply from a nonmilitary source: one had condoms shipped from home, and the other was a member of the Reserves who already had a supply of oral contraceptives before being activated. Participants generally felt it was easy to access contraception for deployment through the military, although some experienced challenges obtaining a sufficient supply of oral contraceptives to last throughout their deployment. One woman noted: "They actually said bring enough [oral contraceptives] with you for six months I was like, 'Where am I gonna get six months worth?' So yeah, you had to figure out a way to get a six months supply" (unknown location, 2004). Participants described a variety of processes for obtaining contraceptive refills during deployment. Some repotted on-base availability of prescription contraceptives, whereas others
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reported needing to order their birth control (either through the mail or on-base medical providers) or travel to a different base to obtain it. The selection of oral contraceptives available through on-ba.se pharmacies tended to be limited, and some participants encountered difficulty accessing their preferred brand. One participant commented, "The only issue I had was that originally, my civilian provider had given me a certain prescription and of course the Army medical system didn't carry that brand. So I was on a generic, and I had a reaction to the generics" (Iraq, 2007-2008). Some participants described medical staff who were proactive in checking whether they needed medication refills whereas others reported experiencing difficulties because of mail delays or problems with a contracted mail-order service. One woman who traveled extensively during deployment reported discontinuing her oral contraceptive because she was unable to return to base to refill her prescription on time. Several participants reported condoms were available either through medical services, where they were sometimes freely available in a basket, or through the Post Exchange (i.e., military retail store), though participants expressed that people may be reluctant to purchase condoms at the Post Exchange. A condom user who had all her condoms shipped from home noted, "It was extremely embari'assing to buy [condoms] (laughs). I mean, you stand in line with twenty other dudes" (Iraq, 2005-2006). Participants overwhelmingly felt that accessing contraception off-base during deployment was not an option, citing logistical challenges, inability to travel, and safety concerns. However, respondents did consider getting contraception through the mail as an option, either ordering online or having someone back home send it to them.
Pregnancy Tests Pregnancy tests were commonly reported as being included in participants' predeployment medical checks and several participants joked about how often they were given such tests. One participant explained: "Every time you walked back in the medical building they gave you a pregnancy test.... They give you your shots and vaccinations and everything, but every time you step out and then you come back in—they haven't seen you for ten minutes, they give you another pregnancy test" (Djibouti, 2003-2004). Most participants stated that during deployment pregnancy tests were not required or routine. Only two participants reported taking or receiving a pregnancy test during deployment, but several noted that they were available at the Post Exchange or a medical station.
Experiences With and Perceptions of Pregnancy During Deployment The majority of participants had some type of experience with pregnancy during deployment, either with themselves
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becoming pregnant (/; = 2) or other women in their unit {n = 16). The two participants who personally experienced an unintended pregnancy during deployment both subsequently accessed abortion back in the United States through nonmilitary health services. Both reported receiving support from most of their immediate chain of command and from medical staff; however, 1 received a formal letter of reprimand from a brigade commander who attempted to bar her from re-enlistment for the pregnancy. The perception of pregnancy as an intentional way to avoid deployment was fairly widespread among respondents. This was illustrated by a woman in the Navy who remarked, "I'm not a fan of people that get pregnant when we're underway. It's unfair that they should be able to use their reproduction system in order to get out of doing what they signed a contract to do" (At sea, 2011). In some cases, the notion that women intentionally become pregnant was reported to be caused and perpetuated by a "rumor mill" in which women could be stereotyped as being promiscuous or trying to avoid duty. One participant attributed this tendency among women to blame other women as a means of self-protection and a way to differentiate themselves and defect blame. This woman had gotten pregnant before deploying but only found out once overseas. She described: "It was really important to me that people know that [the conception] wasn't there [during deployment]. So I think that my instinct was to really judge the girl who had gotten pregnant in country 'cause to me that was so much the stereotype that I was trying to fight against. I think in retrospect I see it a little bit differently but at the time, you know, I was kind of like, 'You're the person that everybody tbinks I am'" (Iraq 2006-2007). Participants explained that women experiencing pregnancy during deployment were immediately sent back home and could make a personal decision whether to continue their pregnancy or have an abortion, as well as whether to stay in the military or separate. One participant noted, "You get sent home to deal with it Yeah, they don't mess around with that. You turn up pregnant, you go home and figure out what your options are" (Kuwait, 2009-2010).
Impact of Pregnancy Most participants perceived negative repercussions for pregnancy during deployment including discrimination and social isolation and in some cases loss of rank, pay, or other career impacts. Participants noted that consequences may depend on the woman's chain of command, her marital status and rank, whether the conception occurred during deployment, and her year and place of service. Some participants also reported that pregnancy can have a negative impact on troop readiness. One participant explained, "It tnakes the job harder for everybody else because you're down—you lose manpower and so then everybody else has to do that person's job" (Iraq, 2004-2005).
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Reproductive Health Access Among Deployed U.S. Servicewomen
DISCUSSION This study sheds light on women's experiences accessing health services generally, and contraception and pregnancyrelated services in particular, during deployment. Although the harsh environment of deployment settings inherently presents challenges to health care access, knowledge about servicewomen's reproductive health needs and experiences, and supportive attitudes among officers and health care providers, are critical to promoting servicewomen's health. In this study, participants identified a range of barriers to accessing medical care in deployment settings, which were often reported to disproportionately impact reproductive health access. The findings from this study highlight several policy and practice changes that could be implemented to better meet women's needs during deployment. First, respondents underscored the desire for expanded availability and accessibility of female providers in deployed .settings to provide more comfortable spaces for women to access care. Although this may not be possible in all settings, particularly in more austere environments, increasing the number of female providers may improve women's likelihood of seeking needed care. Additionally, both male and female providers should become more sensitive and educated about providing women's health services in the deployed environment. Second, participants emphasized confidentiality concerns surrounding health care access. Although resource limitations, such as temporary health stations, may limit the ability to ensure privacy in some settings, greater efforts are needed to reinforce patient confidentiality. Third, there is a common perception that women become pregnant during deployment to avoid military service; however, this was not substantiated in this study or in prior literature.'" These misperceptions highlight the challenges women may face with a pregnancy during deployment, and the critical need to provide more comprehensive prevention services. Related to this is the need to mitigate health care seeking stigma for service members more broadly, and among women in particular. Health care seeking stigma could be addressed through trainings with military troops and commanders to ensure that health needs are perceived as important to maintaining the well-being and readiness of troops, and to promote an environment where service members feel supported if they have a health issue for which they must seek care. This study also identified several avenues for increasing contraceptive access and reducing unintended pregnancy during deployment. Although the majority of participants reported using contraception during deployment, few received predeployment counseling on contraception, and may therefore not have known the full range of methods available to them. Lack of contraceptive counseling during predeployment screening has also been identified in previous research: in a 2005-2006 survey of deployed servicewomen, only one-third of women received information on contraception and menstrual cycle suppression before deployment."" Given participants' interest in both menstrual suppression and pregnancy
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prevention, routine predeployment contraceptive counseling is especially important. Further, some women reported being unable to access methods that they wanted while overseas. Resource limitations may pose more acute challenges to providing comprehensive care in some locations, particularly new outposts or temporary installments, which further reinforce the need for enhanced contraceptive counseling predeployment. All service branches should screen women for contraceptive needs before operational duty and at least annually. Further, to better understand the factors related to unintended pregnancy and assess progress toward its prevention, the Department of Defense should collect representative data on contraceptive use among active duty military personnel. Several studies, including the online survey conducted in conjunction with this study, have shown that servicewomen experience challenges obtaining contraceptive refills and specific methods during deployment. 10,19,20 findings supported by women in this study. Women should be offered the full range of contraceptive options, including long-acting rnethods, and those choosing shorter-acting methods should be given a sufficient supply for the duration of deployment, obviating the need for refills. Long-acting reversible contraceptive methods could be particularly beneficial for women in deployed settings and they can be used discretely and dependably. Although long-acting reversible contraceptive methods are more than 99% effective at preventing pregnancy,^'* research shows limited use among servicewomen.'^ Levonorgestrel intrauterine devices may be of particular interest to active duty women because of their added menstrual suppressing benefits. Balancing health care concerns and unintended pregnancy prevention with military regulations prohibiting sexual activity in certain circumstances^^ may be a source of tension for some commanders and military health care providers. These regulations may also cause confusion, as the policies have fluctuated over time. During Operation Iraqi Freedom/Operation Enduring Freedom, sexual relationships between unmarried people, unmarried members of the opposite sex spending the night in the same living quarters, and pregnancy itself were at varying times and locations punishable offenses under General Order Number One. ' ^ Additionally, sexual relationships are a chargeable offence under the Utiiform Code of Military Justice in a number of circumstances.^^ Information for service members and providers should emphasize the available services to prevent unintended pregnancy, and policies should be clearly communicated. There are several limitations to this study. First, caution should be used in generalizing these findings because of the small size, nonrepresentative nature of the study population, and self-selection of participants. Second, participants were recalling experiences from 2002 to 2011 and some responses are therefore subject to recall bias. Additionally, serviees and facilities matured as the war progressed, and policy and practice have changed during the time since some participants' last deployment. For example, in 2009, Next Choice levonorgestrel emergency contraception was added to the Basic Core
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Formulary,^^ which expanded access to this method during the study period, and in 2006, the Department of Defense revised the requirement for periodic health assessments for active duty and reserve military personnel from occurring every 5 years to annually.^ Policies related to sexual activity also fluctuated throughout the period, and some participants' experiences with and perceptions of regulations related to sexual activity may be based on regulations and policies that are no longer in place. Despite these limitations, our study contributes new data on ban"iers and facilitators to reproductive health care and can help guide efforts to improve contraceptive access and reduce unintended pregnancy in deployment settings. Attention to servicewomen's reproductive health among policy makers and military health system administrators and providers is particularly important given the disproportionate rates of unintended pregnancy among military women'^ and the impact of unintended pregnancy on troop readiness, deployment, and military health care costs. As women's presence continues to grow in the U.S, military, understanding servicewomen's reproductive health care needs and experiences during deployment becomes even more critical.
ACKNOWLEDGMENTS The authors thank Meredith Nicholson and Dawn Huckelbridge for their help with transcription. This research was supported by grants from The William and Elora Hewlett Foundation (Grant no. 2011-7098) and the Wallace A. Gerbode Eoundation (Grant #11-0068).
REFERENCES 1. U.S. Department of Defense; 2011 Demographics; profile of the military community. Available at http;//www.militaryonesource.mil/12038/MOS/ Reports/201 l_Demographics_Report.pdf; accessed December 17, 2013. 2. Burrelli DE: Women in combat: issues for Congress. Available at http:// www.fas.org/sgp/crs/natsec/R42075.pdf; accessed December 17. 2013. 3. U.S. Department of Defense: Defense Department rescinds direct combat exclusion rule; services to expand integration of women into previously restricted occupations and units. Available at http://www.defense.gov/ releases/release.aspx?releaseid=15784; accessed December 17, 2013. 4. Department of Defense: DD Form 2766: Adult prevention and chronic care fiowsheet. Available at http://www.med.navy.mil/sites/nmcphc/ Documents/health-promotion-wellness/Healthy_Living/Clinical_Health_ Services/PHA/DD_2766.pdf; accessed December 17, 2013. 5. Assistant Secretary of Defense; Periodic health assessment policy for active duty and selected reserve members. Available at http://www .health.mi1/~/media/MHS/Policy%20Files/Impon/06-006.ashx; accessed December 17,2013. 6. Department of Defense (DoD); DoD Instruction 6490.03: deployment health. Available at http://www.dtic.mil/whs/directives/corres/pdf/ 649003p.pdf; acces.sed December 17, 2013.
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7. Department of Defense Phaimacoeconomic Center; TRICARE formulary search tool. Available at http;//pec.ha.osd.mil/fonnulary_search.php; accessed December 17, 2013. 8. Assistant Secretary of Defense; Coverage of over-the-counter Plan B One-Step emergency contraceptive at military treatment facilities. Available at http;//www.ncdsv.org/images/DOD_Coverage-of-over-thecounter-Plan-B-one-step-emergency-contraceptive-at-miitary-treatmentfacilities_8-14-2013.pdf; accessed December 17, 2013. 9. Doherty ME, Scannell-Desch E; Women's health and hygiene experiences during deployment to the Iraq and Afghanistan wars, 2003 through 2010. J Midwifery Womens Health 2012; 57; 172-7. 10. Wilson C, Nelson JP; Exploring the patterns, practices, and experiences of military women who managed genitourinary symptoms in deployed settings. J Obstet Gynecol Neonatal Nurs 2012; 41; 293-302. 11. Trego LL: Prevention is the key to maintaining gynecologic health during deployment. J Obstet Gynecol Neonatal Nurs 2012; 41; 283-91. 12. Powell-Dunford NC, Cuda AS, Moore JL, Crago MS, Kelly AM, Deuster PA; Menstrual suppression for combat operations; advantages of oral contraceptive pills. Womens Health Issues 2011; 21; 86-91. 13. Powell-Dunford N, Cuda AS, Moore JL, Crago MS, Deuster PA: Menstrual suppression using oral contraceptives: survey of deployed female aviation personnel. Aviat Space Environ Med 2009; 80: 971-5. 14. Lowe NK, Ryan-Wenger NA: Military women's risk factors for and symptoms of genitourinary infections during deployment. Mil Med 2003; 168; 569-74. 15. Trego LL; Military women's menstrual experiences and interest in menstrual suppression during deployment. J Obstet Gynecol Neonatal Nurs 2007; 36: 342-7. 16. Czerwinski BS. Wardell DW, Yoder LH, et al: Variations in feminine hygiene practices of military women in deployed and noncombat environments. Mil Med 2001; 166: 152-8. 17. Grindlay K. Yanow S, Jelinska K. Gomperts R, Grossman D: Abortion restrictions in the U.S. military: voices from women deployed overseas. Womens Health Issues 2011; 21: 259-64. 18. Holt K. Grindlay K, Taskier M, Grossman D: Unintended pregnancy and contraceptive use among women in the U.S. military: a systematic literature review. Mil Med 2011; 176; 1056-64. 19. Grindlay K, Grossman D: Unintended pregnancy among active-duty women in the United States military. 2008. Obstet Gynecol 2013; 121: 241-6. 20. Nielsen PE, Murphy CS, Schulz J, et al: Female soldiers' gynecologic healthcare in Operation Iraqi Freedom: a survey of camps with echelon three facilities. Mil Med 2009; 174: 1172-6. 21. Belmont PJ, Goodman GP, Waterman B, DeZee K, Burks R, Owens BD; Disease and nonbattle injuries sustained by a U.S. Army brigade combat team during Operation Iraqi Freedom. Mil Med 2010; 175: 469-76. 22. Bums B. Grindlay K, Holt K, Manski R. Grossman D: Military sexual trauma among US servicewomen during deployment: a qualitative study. Am J Public Health 2014; 104; 345-9. 23. Charmaz K: Constructing Grounded Theory: A Practical Guide Through Qualitative Analysis. Thousand Oaks, CA, Sage Publications, 2006. 24. Hatcher RA. Trussell J, Nelson AL, Cates W, Stewart FH, Kowal D: Contraceptive efficacy. In: Contraceptive Technology, 18th rev, p 226. Edited by Trussell. New York, Ardent Media, 2004. 25. Library of Congress, Federal Research Division: Manual for courtsmartial United States (2012 edition). Available at http://www.loc.gov/ rr/frd/Military_Law/CM-manuals.html; accessed December 17, 2013. 26. Kolbi-Molinas A; Military lifts ban on emergency contraception. Available at http;//www.aclu.org/blog/reproductive-freedom/military-lifts-banemergency-contraception; accessed December 17, 2013.
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Reproductive Health Access Among Deployed U.S. Servicewomen: A Qualitative Study Ruth Manski, BA*; Kate Grindlay, MSPH*; Bridgit Burns, MPH*; Kelsey Holt, MAf; Daniel Grossman, MDt ABSTRACT Servicewomen"s reproductive health experiences during deployment are itnportant given that the tnajority of women in the U.S. military are of reproductive age and that this population experiences a disproportionately high rate of unintended pregnancy. Few studies have explored women's reproductive health experiences and their perceived barriers and facilitators to health care access during deploytnent. From May 2011 to January 2012, we conducted 22 in-depth interviews with women in the U.S. military about their reproductive health experiences during deployment, including their access to health services. Participants identified a range of barriers to accessing medical care in deployment settings, including confidentiality concerns, lack of female providers, and health-seeking stigma, which were reported to disproportionately impact reproductive health access. Some participants experienced challenges obtaining contraceptive refills and specific contraceptive methods during deployment, and only a few participants received predeployment counseling on contraception, despite interest in both menstruation suppression and pregnancy prevention. These findings highlight several policy and practice changes that could be impletnented to increase contraceptive access and reduce unintended pregnancy during deployment, including mandated screening for servicewomen's contraceptive needs before operational duty atid at least annually, and increasing the number of female providers in deployed settings.
INTRODUCTION Women in the U.S. military, who make up 15,8% of the Department of Defense's Active Duty, Reserve, and Guard forces,' are playing an increasing role in deployment settings. Between September 11, 2001 and Eebruary 28, 2013, a total of 299,548 women were deployed to Afghanistan and Iraq in Operation Enduring Ereedom and Operation Iraqi Ereedom." Additionally, recent legislation rescinding the 1994 Direct Ground Combat Definition and Assignment Rule that restricted women from serving in ground combat units will expand female participation and job roles in the military.^ Servicewomen deployed overseas are often stationed in harsh environments with limited access to health care, particularly preventive and specialized care. Most preventive care is typically addressed before deploying. The Department of Defense requires active duty and reserve military personnel *Ibis Reproductive Health. 17 Dunster Street, Suite 201, Cambridge, MA 02138. tDepartment of Social and Behavioral Sciences, Harvard School of Public Health, 677 Huntington Avenue, SPH 3, Floor 7, Boston, MA 02115. 1:Ibis Reproductive Health, 1330 Broadway, Suite 1100, Oakland, CA 94612. doi; 10.7205/MILMED-D-13-00302
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to have annual periodic health assessments, which include a medical record review, risk factor counseling, preventive screening exams, assessment of occupational risks, immunizations, and assessment of deployment readiness,'^"'' Required reproductive health screenings for servicewomen include breast exams and mammograms for women >40 years and annual cervical cancer screening.** Within 60 days before deployment, all service members are required to have a predeployment health assessment, which includes a self-evaluation form to record physical and tnental health information for surveillance purposes and to identify health issues that may need to be addressed before deployment; service members may be referred for further evaluation of issues that could affect deployability. Service members are given a minimum 90-day supply of prescription medications before deploying.^ Other annual and predeployment health activities, such as immunizations, pregnancy testing, contraceptive counseling, and HIV testing, are based on .service branch policies, health risk assessments specific to the deployment location, the deployment type, or commander's decision.^ Once deployed, health encounters are primarily incident-driven or based on health threats specific to the deployment*" and preventive care is not
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typically provided. Most contraceptive methods are covered by TRICARE, the militaiy's health insurance program.^ However, once overseas, a more limited array of contraceptive options may be available. The Basic Core Fonnulary, a list of medications required at full-service military treatment facilities, only includes certain oral contraceptive formulations and Next Choice levonorgestrel emergency contraception; additionally, in August 2013, the Assistant Secretaiy of Defense issued a memorandum requiring that Plan B OneStep emergency contraception (Teva Pharmaceuticals, North Wales, Pennsylvania) also be available at military treatment facilities at no cost and without prescription.^** Availability of other contraceptive methods is at the discretion of the military treatment facilities and may differ by branch and location. Research on women's health care experiences during deployment focuses primarily on mental health and posttraumatic stress disorder, and to a lesser extent on menstruation, hygiene, and genitourinary experiences. These latter studies highlight unique challenges of deployment that impact women's health access, including limited running water and bathroom facilities, and lack of adequate pritnary health care facilities.'^"'^ Women's reproductive health needs and experiences during deployment are particularly important given that 97% of active duty women in the U.S. military are of reproductive age"; however, these issues are not well documented. Estimates of contraceptive use among women in the U.S. military range from 50 to 88% among women stationed in the United States and from 39 to 77% during deployment."* Studies suggest that the unique circumstances of deployment may impact contraceptive accessibility. In a survey of 281 servicewomen who had been deployed overseas between 2001 and 2010, one-third of women reported they could not access a contraceptive method that they wanted for deployment, and 41% of women using a method that required refills had difficulty obtaining them.''' Further, a 2005-2006 study of 397 servicewomen presenting at an outpatient facility in Iraq found that 42% of women using contraception during deployment changed their method during deployment because it was unavailable."" Access to contraception is critical to women's ability to prevent unintended pregnancy and is an important issue among active duty women, who experience higher rates of unintended pregnancy than women in the general U.S. population.''' Unintended pregnancy remains a concern during deployment: a longitudinal analysis of an Anny Brigade Combat Team in Iraq found that 10.8% of women were medically evacuated for pregnancy-related reasons over a 15-month period.^' Although the above studies provide a useful starting point for understanding servicewomen's reproductive health care needs and experiences during deployment, there is little qualitative exploration of women's experiences to provide greater depth on their perceived barriers and facilitators to health care access during deployment. To fill this gap, we conducted in-depth interviews with servicewomen who had been deployed
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overseas between 2001 and 2011 about their experiences with reproductive health care during deployment, including barriers and facilitators to care. METHODS From May 2011 to January 2012, we conducted in-depth interviews with women who had served in the U.S. military about their reproductive health experiences during deployment, including their access to health services. The data for this analysis were collected as part of a larger study that also included questions on U.S. servicewomen's experiences with sexual violence during deployment.^^ Participants were recruited via Facebook advertisements, postings on Craigslist in cities near large military bases, e-mail communication, and postings to military- and veteran-related websites and Facebook pages. Further, some participants were recruited after completing an online survey on contraception access and use during deployment.'^ Women of any military status, who had been deployed overseas anytime from 2001 or later, and were >18 years of age were eligible to participate. Participants were recruited until thematic saturation was reached. Two research team members trained in qualitative data collection techniques conducted the interviews in English via telephone. All study participants gave oral informed consent to participate and have their interview audio recorded, and received a $25 gift card remuneration. The study was approved by Allendale Investigational Review Board. Participants were asked open-ended questions about their military background and deployment experiences; their overall health care experience during deployment, including where health services were available, facilitators and barriers to care, and personal health experiences; contraceptive counseling, access, and use during deployment; and experiences with pregnancy and abortion during deployment. Whenever possible, interviewers solicited information about women's personal experiences; however, participants also shared information related to their knowledge of others' experiences with health care services during deployment, and this information is also included in the analysis. All interviews were digitally recorded and transcribed verbatim. Data were analyzed thematically in ATLAS.ti 6.2 (ATLAS.ti GmbH, Berlin, Germany) using modified grounded theory methods.^'' Grounded theory methodology was chosen because little qualitative research has been conducted on this topic, and we therefore desired to obtain emerging themes rooted in the data. Each transcript was coded by 2 research members to ensure inter-coder reliability. Initial codes were developed a priori based on the above interview questions, and subsequent revisions were made to the codebook as new inductive themes surfaced. Codes were summarized and organized thematically with representative quotes extracted, and provisional findings were cross-validated among the research team. Quotations are identified by participant's country and year of last deployment.
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Reproductive Health Access Among Deployed U.S. Servicewomen TABLE I.
Background Characteristics {N = 22)
Characteristic Age at Last Deployment (Years)" 18-24 25-29 30+ Education Level at Last Deployment" High School Some College Bachelor's Degree Master's Degree Marital Status at Last Deployment" Single Married Separated/Divorced Race/Ethnicity" White, Non-Hispanic Hispanic Time in Military. Current (Years) 1-5 6-10 11-15 16-20 21-25 Service Branch at Last Deployment Army Navy National Guard Marine Corps Rank/Rate at Last Deployment E-1 toE-3 E-4 to E-6 E-7 to E-9 O-l toO-3 Number of Deployments, Current 0 1 2 3+ Country of Last Deployment" Afghanistan Bahrain Cuba (Guantanamo Bay) Djibouti Iraq Kuwait Pakistan Romania At sea Contraceptive Use at Last Deployment (More Than 1 Method Possible) Otal Contraception Injectable Female Sterilization Patch Condom IUD None
RESULTS
Demographics
/;
%
7
7 7
31.8 31.8 31.8
2 8 9 2
9.1 36.4 40.9 9.1
14 5 2
63.6 22.7 9.1
Twenty-two women completed in-depth interviews. Two additional participants were screened but found ineligible because of their last deployment being before 2001, Most participants self-identified as White, and the majority were in the military for 6 to 15 years and had been deployed one time. At the time of their last deployment, one-third were 18 to 24 years old, one-third were 25 to 29 years old, and one-third were 30 years or older. Most participants had at least some college, were single, and were lower enlisted rank/rate (E-1 to E-6) at the time of their last deployment. Slightly more than half had served in the Army (Table I),
t9 2
86.4 9.1
Health Care Service Availability
4
1 2
18.2 40.9 27.3 4.5 9.1
12 4 4 2
54.5 18.2 18.2 9.1
3 13 1 5
13.6 59.1 4.5 22.7
1 14 6 1
4.5 63.6 27.3 4.5
2 1 1 1 11 2 1 1 1
9.1 4.5 4.5 4.5 50.0 9.1 4.5 4.5 4.5
11 3 2 1 1 1 5
50.0 13.6 9.1 4.5 4.5 4.5 22.7
9 6
Participants described a variety of health care services that were available during deployment. These services tended to focus on curative care and were wide ranging in scope. Few women reported preventive service availability during deployment, including both female-specific and general health care, and most noted that service members were encouraged to receive preventive services before deployment.
Facilitators and Barriers to Health Care
"Percents do not total 100 because of missing data.
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Participants reported that health care access was dependent on a variety of factors, explored below. Chain of Command and Confidentiality
The majority of participants reported having to inform their chain of command when they needed to access health care and described a variety of processes for obtaining permission, which ranged from formal to informal. In addition, some reported having to tell their chain of command why they were seeking health care. For example, one respondent recounted, "I needed to take the day off to go to the appointment. And my chief was like, 'Well, what are you going for?'.... 'Well, I'm going, because I have an appointment,' 'Well, for what?'"(At sea, 2011), Several servicewomen reported that the low proportion of women in the military could make them uncomfortable or embarrassed when discussing their health needs with male commanders, as illustrated by this participant last deployed to an unknown location in 2004: "If you have other women that you work with, I think it makes it a little ... easier at least to ask, whereas if you're in a chain of command with mostly men and no other women, or all men, I can't say that even as an officer I'm gonna approach my department head or the XO and be like, 'Hey, Sir, I'm having this female issue.'" However, other participants stated that they did not have to disclose any details related to their health visit, particularly if it was female-specific: "If you say, 'It's a woman issue,' they [the chain of command] would just be like, 'I don't wanna hear it, go!'" (Iraq, 2003-2004).
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Regardless of whether women disclosed health issues to their chain of command, participants reported challenges maintaining confidentiality because of "gossip" and the close quarters of the military base. One respondent who had been deployed to Iraq in 2003-2004 said, "Because you're living in such close quarters, everybody knows everybody's business." Another participant discussed the conflict and breach of confidentiality that could arise when a health care provider is a colleague: "I don't wanna go out for beer with the same person that just gave me a gynecological exam" (At sea, 2011), However, a small number of participants reported that rank could facilitate access to confidential health care services. One participant explained:
a deterrent to seeking care, particularly when individuals feared negative consequences to their careers. For example, seeking health care for certain conditions, like depression or substance abuse, could raise questions about the suitability of the solider and potentially damage one's career:
"I was an officer I needed birth control, so I was able to go to the airport to get it, because I could run my own convoy over. But I didn't tell anybody in my chain of command, because I didn't want to them to know But my soldiers never would've been able to do that—if my soldiers had an issue, they would have to run it all the way up the chain of command and get approval" (Iraq, 2004-2005).
Logistical challenges to seeking medical care during deployment were discussed in most interviews. The most common logistical challenge mentioned was in relation to participants' job responsibilities and difficulties finding time to seek medical care. As one servicewomen reported, "You kinda had to work around schedules and things like that. So it was kind of like if you had time to go do it, you could go get it done. If not, you're just gonna have to suck it up till you do have time" (Afghanistan 2006-2007). Other logistical challenges included limitations in providers' availability and difficulties arranging transportation when seeking medical care off-base or within large bases. One participant stationed in Iraq in 2007-2008 explained, "You had to set up a convoy to get you and you needed to go at set times. And so there was a lot of preparation that had to go into it in order to figure out how you were gonna get there. And, you know, if you were allowed to go, that sorta thing," A few participants discussed the implications that these logistical challenges had on confidentiality. For instance, the chain of command may not be willing to arrange transportation for a soldier to receive care off-base without knowing the reason they need to seek care. One participant described, "In some cases, travel is dangerous.... You can't just say, 'I wanna go to the Level 3 facility that's ten miles away.' You have to explain yourself (Iraq, 2004-2005).
Eemale Providers
Several participants reported limited or no availability of female providers during deployment. The majority of these participants stated that they felt embarrassed going to male providers, particularly for reproductive health services. As one servicewoman remarked, "I don't recall even on the big bases seeing any women providers. So if you do have a women's health care issue, it can be kind of daunting or intimidating" (Afghanistan, 2006-2007). In some cases, discomfort with male providers led to forgoing care. For instance, one participant, who had a history of abnormal Pap test results and had been advised to have more frequent exams explained, "When we were under way, I didn't have one done, because we only had male gynecologists. And I felt very uncomfortable with that" (At sea, 2011). Health Care Seeking Stigma
Many participants reported stigma associated with seeking medical care within the military. Reasons for this included perceptions that soldiers who seek care are shirking their responsibilities or are weak, and that health issues are not as important as the mission. As one woman recounted, "Basically [the chain of command] were always thinking you were scheming, trying to get out of deployment. So they were thinking that whatever your 'issue' is, it's not legit" (Djibouti, 2003-2004). Several participants felt that women are disproportionately impacted by this stigma and that they are more reluctant to seek care for fear of exacerbating the perception that women are weak. One participant explained, "In the military in general, it's kind of—looked down on to go to sick call,... So as a woman, you already have that kind of perception that you're weak, so you don't wanna—kind of exacerbate it" (Iraq, 2004-2005). This stigma was reported as
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"Some things in the military records are careerenders Um, counseling. Unit counseling. That could be career-ending. It doesn't matter what it's for, they see that you've been in there for mental health and they'll re-evaluate you—are you really stable enough to be a solider?" (Djibouti, 2003-2004). Logistics
Lack of Orientation
A handful of participants described a lack of orientation to health services available during deploytnent, with several expressing a desire for more information about reproductive health services, including contraception. In addition, one participant recounted moving between bases and often not knowing where general medical services were located. Another participant, who was deployed to a new base that was still being developed, explained that her base did not have an established location for medical facilities and was unsure where the medics were located. Resources
Some participants described lack of medical supplies and providers as barriers to accessing health services. In some
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Reproductive Health Access Among Deployed U.S. Servicewomen
cases, shortages of supplies and providers meant having to wait a long time for appointments, or having to forgo certain medical services. One participant explained, "When you go overseas or are deployed, it's harder to get that medical care, because there might not be a trained professional deployed with you or they rnay not have the things that they need" (Iraq, 2003-2004). A few participants noted that personal connections to health care personnel could help mitigate these challenges. For some participants, having personal connections meant they had greater access to health care services or appointments, or could obtain medical care without having to go through the formal channels, such as sick call. As one participant remarked, "On the ship, a lot of the times it's real hard to get into medical unless you know people" (At sea, 2011). Another respondent needed a pregnancy test after a sexual assault, and reported she was able to discretely obtain a pregnancy test because she was friends with the staff at the medical station. She stated, "I made friends with them I was like, 'hey,' you know, it's a little back door swap. Til bring you an extra package of, you know, cookies or something, and we'll just swap out the back.' Instead of going in—cause you have to sign in and tell your reason why you're actually here and stuff like that" (Djibouti, 2003-2004). Base Size
Many of the above barriers and facilitators to care were reported to vary depending on the participant's base size. Compared to participants on large bases, those on smaller bases noted greater confidentiality coticems and less access to medical supplies, services, and facilities. In addition, some participants reported that obtaining medical care on a small base could be challenging because there were fewer people to cover shifts. However, the ability to walk to a medical facility and easily navigate one's base was described as an asset to accessing health care on small bases. One participant explained: "On the larger bases it's harder to find [medical services], harder to navigate. It's also a little harder to get to sometimes Small bases it's hard to do anything without everybody knowing your business" (Djibouti, 2003-2004),
Contraceptive Use Most participants reported using contraception during their last deployment, including oral contraceptives (n = 9), tubal ligation (n = 2), injectable contraceptives (« = 1), the patch (« = 1), condoms (n - 1), and an intrauterine device (n = 1), Two additional participants switched from oral contraceptives to injectable contraceptives during deployment. The main reason reported for contraceptive use was menstrual suppression, including reducing heavy cramping and bleeding, increasing regularity, and reducing the frequency of menstruation. One woman explained, "When I got to Iraq, I remember hearing
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from somebody that they were giving the Depo shot. And so I wanted it not for contraceptive use, but for the having no period, 'cause that's a lot of planning when you're in a deployment situation where it's a hundred and thirty degrees" (Pakistan, 2005). Two women reported that, in addition to wanting to manage their menses, they wanted contraception for pregnancy prevention in case they were sexually active during deployment. Most participants who used contraception were satisfied with their method, though some indicated having minor challenges, such as excessive bleeding, forgetting pills, or patches not sticking well because of clitnate conditions. Among women who did not use contraception during their last deployment, the primary reason for nonuse was not being sexually active.
Contraceptive Counseling Most participants reported that they did not receive counseling on contraception for either pregnancy prevention or menstrual regulation as part of their predeployment medical check. Only a small minority of participants reported having a conversation about contraception beyond a general inquiry about prescription medications they were already taking. One woman explained, "They didn't really ask or brief you on those kinda things or have any kind of, really, discussions on it prior to going" (Iraq, 2007-2008), Some participants attributed the lack of discussion to rules prohibiting sexual activity during deployment, such as one participant who was deployed to Djibouti in 2003-2004 who stated, "They don't talk about [birth control] on, you know, on base. You're getting deployed, you're not supposed to be doing that stuff,"
Contraceptive Access Most contraceptive users obtained their initial supply through military providers before deployment. About half brought a supply for the entire deployment, whereas half brought a lesser amount and required refills. Use of nonmilitary sources for contraceptives was uncommon, with only two participants repotting they accessed their initial supply from a nonmilitary source: one had condoms shipped from home, and the other was a member of the Reserves who already had a supply of oral contraceptives before being activated. Participants generally felt it was easy to access contraception for deployment through the military, although some experienced challenges obtaining a sufficient supply of oral contraceptives to last throughout their deployment. One woman noted: "They actually said bring enough [oral contraceptives] with you for six months I was like, 'Where am I gonna get six months worth?' So yeah, you had to figure out a way to get a six months supply" (unknown location, 2004). Participants described a variety of processes for obtaining contraceptive refills during deployment. Some repotted on-base availability of prescription contraceptives, whereas others
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reported needing to order their birth control (either through the mail or on-base medical providers) or travel to a different base to obtain it. The selection of oral contraceptives available through on-ba.se pharmacies tended to be limited, and some participants encountered difficulty accessing their preferred brand. One participant commented, "The only issue I had was that originally, my civilian provider had given me a certain prescription and of course the Army medical system didn't carry that brand. So I was on a generic, and I had a reaction to the generics" (Iraq, 2007-2008). Some participants described medical staff who were proactive in checking whether they needed medication refills whereas others reported experiencing difficulties because of mail delays or problems with a contracted mail-order service. One woman who traveled extensively during deployment reported discontinuing her oral contraceptive because she was unable to return to base to refill her prescription on time. Several participants reported condoms were available either through medical services, where they were sometimes freely available in a basket, or through the Post Exchange (i.e., military retail store), though participants expressed that people may be reluctant to purchase condoms at the Post Exchange. A condom user who had all her condoms shipped from home noted, "It was extremely embari'assing to buy [condoms] (laughs). I mean, you stand in line with twenty other dudes" (Iraq, 2005-2006). Participants overwhelmingly felt that accessing contraception off-base during deployment was not an option, citing logistical challenges, inability to travel, and safety concerns. However, respondents did consider getting contraception through the mail as an option, either ordering online or having someone back home send it to them.
Pregnancy Tests Pregnancy tests were commonly reported as being included in participants' predeployment medical checks and several participants joked about how often they were given such tests. One participant explained: "Every time you walked back in the medical building they gave you a pregnancy test.... They give you your shots and vaccinations and everything, but every time you step out and then you come back in—they haven't seen you for ten minutes, they give you another pregnancy test" (Djibouti, 2003-2004). Most participants stated that during deployment pregnancy tests were not required or routine. Only two participants reported taking or receiving a pregnancy test during deployment, but several noted that they were available at the Post Exchange or a medical station.
Experiences With and Perceptions of Pregnancy During Deployment The majority of participants had some type of experience with pregnancy during deployment, either with themselves
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becoming pregnant (/; = 2) or other women in their unit {n = 16). The two participants who personally experienced an unintended pregnancy during deployment both subsequently accessed abortion back in the United States through nonmilitary health services. Both reported receiving support from most of their immediate chain of command and from medical staff; however, 1 received a formal letter of reprimand from a brigade commander who attempted to bar her from re-enlistment for the pregnancy. The perception of pregnancy as an intentional way to avoid deployment was fairly widespread among respondents. This was illustrated by a woman in the Navy who remarked, "I'm not a fan of people that get pregnant when we're underway. It's unfair that they should be able to use their reproduction system in order to get out of doing what they signed a contract to do" (At sea, 2011). In some cases, the notion that women intentionally become pregnant was reported to be caused and perpetuated by a "rumor mill" in which women could be stereotyped as being promiscuous or trying to avoid duty. One participant attributed this tendency among women to blame other women as a means of self-protection and a way to differentiate themselves and defect blame. This woman had gotten pregnant before deploying but only found out once overseas. She described: "It was really important to me that people know that [the conception] wasn't there [during deployment]. So I think that my instinct was to really judge the girl who had gotten pregnant in country 'cause to me that was so much the stereotype that I was trying to fight against. I think in retrospect I see it a little bit differently but at the time, you know, I was kind of like, 'You're the person that everybody tbinks I am'" (Iraq 2006-2007). Participants explained that women experiencing pregnancy during deployment were immediately sent back home and could make a personal decision whether to continue their pregnancy or have an abortion, as well as whether to stay in the military or separate. One participant noted, "You get sent home to deal with it Yeah, they don't mess around with that. You turn up pregnant, you go home and figure out what your options are" (Kuwait, 2009-2010).
Impact of Pregnancy Most participants perceived negative repercussions for pregnancy during deployment including discrimination and social isolation and in some cases loss of rank, pay, or other career impacts. Participants noted that consequences may depend on the woman's chain of command, her marital status and rank, whether the conception occurred during deployment, and her year and place of service. Some participants also reported that pregnancy can have a negative impact on troop readiness. One participant explained, "It tnakes the job harder for everybody else because you're down—you lose manpower and so then everybody else has to do that person's job" (Iraq, 2004-2005).
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Reproductive Health Access Among Deployed U.S. Servicewomen
DISCUSSION This study sheds light on women's experiences accessing health services generally, and contraception and pregnancyrelated services in particular, during deployment. Although the harsh environment of deployment settings inherently presents challenges to health care access, knowledge about servicewomen's reproductive health needs and experiences, and supportive attitudes among officers and health care providers, are critical to promoting servicewomen's health. In this study, participants identified a range of barriers to accessing medical care in deployment settings, which were often reported to disproportionately impact reproductive health access. The findings from this study highlight several policy and practice changes that could be implemented to better meet women's needs during deployment. First, respondents underscored the desire for expanded availability and accessibility of female providers in deployed .settings to provide more comfortable spaces for women to access care. Although this may not be possible in all settings, particularly in more austere environments, increasing the number of female providers may improve women's likelihood of seeking needed care. Additionally, both male and female providers should become more sensitive and educated about providing women's health services in the deployed environment. Second, participants emphasized confidentiality concerns surrounding health care access. Although resource limitations, such as temporary health stations, may limit the ability to ensure privacy in some settings, greater efforts are needed to reinforce patient confidentiality. Third, there is a common perception that women become pregnant during deployment to avoid military service; however, this was not substantiated in this study or in prior literature.'" These misperceptions highlight the challenges women may face with a pregnancy during deployment, and the critical need to provide more comprehensive prevention services. Related to this is the need to mitigate health care seeking stigma for service members more broadly, and among women in particular. Health care seeking stigma could be addressed through trainings with military troops and commanders to ensure that health needs are perceived as important to maintaining the well-being and readiness of troops, and to promote an environment where service members feel supported if they have a health issue for which they must seek care. This study also identified several avenues for increasing contraceptive access and reducing unintended pregnancy during deployment. Although the majority of participants reported using contraception during deployment, few received predeployment counseling on contraception, and may therefore not have known the full range of methods available to them. Lack of contraceptive counseling during predeployment screening has also been identified in previous research: in a 2005-2006 survey of deployed servicewomen, only one-third of women received information on contraception and menstrual cycle suppression before deployment."" Given participants' interest in both menstrual suppression and pregnancy
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prevention, routine predeployment contraceptive counseling is especially important. Further, some women reported being unable to access methods that they wanted while overseas. Resource limitations may pose more acute challenges to providing comprehensive care in some locations, particularly new outposts or temporary installments, which further reinforce the need for enhanced contraceptive counseling predeployment. All service branches should screen women for contraceptive needs before operational duty and at least annually. Further, to better understand the factors related to unintended pregnancy and assess progress toward its prevention, the Department of Defense should collect representative data on contraceptive use among active duty military personnel. Several studies, including the online survey conducted in conjunction with this study, have shown that servicewomen experience challenges obtaining contraceptive refills and specific methods during deployment. 10,19,20 findings supported by women in this study. Women should be offered the full range of contraceptive options, including long-acting rnethods, and those choosing shorter-acting methods should be given a sufficient supply for the duration of deployment, obviating the need for refills. Long-acting reversible contraceptive methods could be particularly beneficial for women in deployed settings and they can be used discretely and dependably. Although long-acting reversible contraceptive methods are more than 99% effective at preventing pregnancy,^'* research shows limited use among servicewomen.'^ Levonorgestrel intrauterine devices may be of particular interest to active duty women because of their added menstrual suppressing benefits. Balancing health care concerns and unintended pregnancy prevention with military regulations prohibiting sexual activity in certain circumstances^^ may be a source of tension for some commanders and military health care providers. These regulations may also cause confusion, as the policies have fluctuated over time. During Operation Iraqi Freedom/Operation Enduring Freedom, sexual relationships between unmarried people, unmarried members of the opposite sex spending the night in the same living quarters, and pregnancy itself were at varying times and locations punishable offenses under General Order Number One. ' ^ Additionally, sexual relationships are a chargeable offence under the Utiiform Code of Military Justice in a number of circumstances.^^ Information for service members and providers should emphasize the available services to prevent unintended pregnancy, and policies should be clearly communicated. There are several limitations to this study. First, caution should be used in generalizing these findings because of the small size, nonrepresentative nature of the study population, and self-selection of participants. Second, participants were recalling experiences from 2002 to 2011 and some responses are therefore subject to recall bias. Additionally, serviees and facilities matured as the war progressed, and policy and practice have changed during the time since some participants' last deployment. For example, in 2009, Next Choice levonorgestrel emergency contraception was added to the Basic Core
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Reproductive Health Access Among Deployed U.S. Servicewomen
Formulary,^^ which expanded access to this method during the study period, and in 2006, the Department of Defense revised the requirement for periodic health assessments for active duty and reserve military personnel from occurring every 5 years to annually.^ Policies related to sexual activity also fluctuated throughout the period, and some participants' experiences with and perceptions of regulations related to sexual activity may be based on regulations and policies that are no longer in place. Despite these limitations, our study contributes new data on ban"iers and facilitators to reproductive health care and can help guide efforts to improve contraceptive access and reduce unintended pregnancy in deployment settings. Attention to servicewomen's reproductive health among policy makers and military health system administrators and providers is particularly important given the disproportionate rates of unintended pregnancy among military women'^ and the impact of unintended pregnancy on troop readiness, deployment, and military health care costs. As women's presence continues to grow in the U.S, military, understanding servicewomen's reproductive health care needs and experiences during deployment becomes even more critical.
ACKNOWLEDGMENTS The authors thank Meredith Nicholson and Dawn Huckelbridge for their help with transcription. This research was supported by grants from The William and Elora Hewlett Foundation (Grant no. 2011-7098) and the Wallace A. Gerbode Eoundation (Grant #11-0068).
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