FIVE

Reproductive Health

CARA J. KRULEWITCH

A large majority of active duty Servicewomen are of childbearing age. As of November 2012, among the 2.3 million Department of Defense (DoD) active duty military personnel, 14.5% were women and 43.2% were under 26 years old. The average age for Active Duty Officers was 34.7, and the average age for enlisted personnel was 27.4. The largest proportion (46%) of female active duty military personnel are young, lower ranking enlisted personnel, with the ratio of female Officers to enlisted personnel being 1 to 4.4 (Office of the Deputy Under Secretary of Defense [Military Community and Family Policy], 2012).

A female active duty Service member’s ability to balance family and work life has an impact on troop readiness and planning for deployments or other assignments, as women who are pregnant or in the early postpartum period cannot be deployed. Women who are diagnosed as pregnant in theater must be evacuated, which may affect both their career and the status of their troop, as it may be difficult to replace them (Ritchie, 2001). Bucher (1999) noted that the Persian Gulf War shed light on the impact of pregnancy on US Army readiness when there were large-scale deployments of active duty Servicewomen. Additionally, many women face physical challenges that are different from those of their male counterparts, including access to contraception, management of menstruation, and the impact of environmental exposures on reproductive outcomes. This chapter will analyze the epidemiology and research around these issues.

Contraceptive Use and Unintended Pregnancy

Epidemiology

In the United States, among civilian populations, an estimated 62% of women are currently using contraception, with the most common methods being the pill and female sterilization (Jones, Mosher, & Daniels, 2012). Holt, Grindlay, Taskier, and Grossman (2011) noted similar findings among active duty military personnel in a systematic literature review. These authors found the reported contraceptive use to be 50%–88% among active duty military women stationed in the United States and 39%–77% among active duty military women in deployed environments. Other studies had similar findings (Uriell & Burress, 2009; Goyal, Borrero, & Schwarz, 2012; Robbins, Chao, Frost, & Fonseca, 2005; Thomas, Thomas, & Garland, 2001; Clark, Holt, & Miser, 1998).

Enewold et al. (2010) compared oral contraceptive (OC) use among military women (duty status not specified) included in the Military Health System Management Analysis and Reporting Tool (M2) to civilian women included in the National Health and Nutrition Examination Survey (NHANES). The authors found that military women use oral contraceptives at a higher rate compared to civilian women (34% versus 29%, p < 0.05). Although OC use was consistently higher among military women over the age of 20, in women aged 18–19, use was lower among military women (33.2% versus 40.6%). The largest difference between military women and civilians was among Hispanic women, where 32.2% of military and 19.8% of civilian women reported using OCs. Enewold et al. (2010) noted that some OC use might be for menstrual suppression instead of contraception, which is supported by other studies (Powel-Dunford et al., 2009, 2011; Trego, 2007; Powell-Dunford, Deuster, Claybaugh, & Chapin, 2003).

The most recent reported estimate of unintended pregnancies among civilian women aged 15–44 was 57.2% during 2006–2010. The proportion was higher among civilian women aged 20–29 at 69%, or an estimated 105 per 1,000 women (Zolna & Lindberg, 2012; Grindlay & Grossman, 2013). Lindberg (2011) evaluated the extent of unintended pregnancy among female active duty military personnel and found similar results with 54% of pregnancies being unintended. Goyal et al. (2012) also reported similar findings of 50%–62% unintended pregnancies among active duty Servicewomen.

Similar to that observed in civilian populations, studies consistently reported higher proportions of unintended pregnancy related to age. Unintended pregnancy was higher among active duty Servicewomen who were younger and lower ranking enlisted personnel, compared to Officers (Holt et al., 2011; Grindlay & Grossman, 2013). Although some of these studies have suggested that unintended pregnancy may be more common among women in the military, as noted by Lindberg (2011), these studies were hampered by a range of methodological limitations. In addition, as noted above, almost half of the female active duty military personnel are under age 26. The unintended pregnancy rate among civilian women in similar age groups showed the same patterns. In 2006 the unintended pregnancy rate in the civilian population was 107 per 1000 women aged 15-44 (Finer & Zolna, 2011), 102 per 1000 women aged 20–24, and 84 per 1000 for women aged 25–29 in 2008 (Zolna & Lindberg, 2012).

Regardless whether unintended pregnancy rates in Active Duty servicewomen are similar to those within the civilian population, developing a better understanding of circumstances when Active Duty women become unexpectedly pregnant provides information to inform pregnancy prevention activities in the military.

Biggs, Douglas, Boyle, and Rieg (2009) conducted a survey at a military hospital with a large obstetric census, representing more than 4,000 births per year. Forty percent of women delivering at this hospital were active duty personnel. The authors felt they had captured more than 90% of all births to active duty Servicewomen in the local area because their insurance required the use of that hospital for coverage. The study included representation from members of all Services. Respondents were enrolled over a seven-month period in 2005, and 415 of 825 active duty Servicewomen who received surveys responded, producing sufficient power to make inferences about the sample. The sample was predominantly enlisted personnel (94%) with an average age of 25. Sixty percent of pregnancies were unplanned, with 35% the result of contraceptive failure, most often oral contraceptive pills. The proportion of women with an unplanned pregnancy who were single was almost twice that of women who were married (82% versus 45%, p = 0.006); 50% of single women were using no contraceptive method, and 54% became pregnant while assigned to a seagoing or deployable unit. Although 64% of women felt that pregnancy did not change their military plans, the majority planned to leave at the end of their current service obligation.

Although some studies indicated that active duty Servicewomen reported they were not comfortable discussing or getting birth control from an independent duty corpsman (Ritchie, 2001; Ryan-Wenger & Lowe, 2000; Nielson et al., 2009), Uriell and Burress (2009) reported that about three-quarters of Navy enlisted personnel and two-thirds of Navy Officers stated that they would feel comfortable discussing or getting birth control from an independent duty corpsman, regardless of setting (overall, or aboard ship).

In conclusion, unintended pregnancy rates and contraceptive use in active duty Servicewomen are similar to rates found in the civilian population and remain higher than the Healthy People 2010 goal of 30% unintended pregnancies. Healthy People 2020 has set a target that 56% of all pregnancies are intended, a 10% improvement from current rates, increasing the proportion of women who consistently use contraception and decreasing the proportion of contraceptive failures.

Chung-Park (2007) and others (von Sandovsky et al., 2008; Thomas, Thomas, & Garland, 2001) have evaluated contraceptive decision-making among military women; however, there is sparse information on effective training methods to promote consistent contraceptive use or the role that the physical challenges and mental stressors of deployed environments contribute to decision-making. Additional research in these areas may be the key to moving closer to the Healthy People 2020 goal.

Pregnancy Outcomes

DEPLOYMENT AND BIRTH DEFECTS

The Armed Forces Health Surveillance Center (AFHSC, 2011) reported that during 2000–2010 there were more Service members hospitalized for labor and delivery than for any other specific condition, accounting for 58.6% of all hospitalizations of females. In March 2013, the Secretary of Defense lifted the ban on women serving in combat roles. As the number of occupational roles for active duty Servicewomen grows, the potential for environmental exposures may increase. There is sparse current research on deployment and other potential health exposures among Servicewomen and the potential effect on their pregnancy outcomes.

Interest in environmental exposures and pregnancy outcome increased when the US Government Accounting Office (GAO, 1994) published a report that raised concerns that the military did not sufficiently evaluate most forms of reproductive dysfunction, including infertility and miscarriage, and that there was inconclusive evidence regarding a relationship between environmental exposures and birth defects. The report cited a study by Penman, Tarver, and Currier (1996) that evaluated birth defects among Gulf War veterans from Mississippi reserve units deployed to the Persian Gulf War. Penman et al. (1996) found no apparent increases in the rate of defects compared to the Atlanta metropolitan Congenital Defects Monitoring Program. The 1994 GAO report expressed concerns that there were methodological flaws in the study, which limited any conclusions that were drawn.

Eight other studies, described below, have reported mixed findings compared to Penman et al. (1996). These studies evaluated the relationship between deployment and adverse effects on birth outcomes (Hourani & Hilton, 2000; Araneta, Destiche, Schlangen, Merz, Forrester, & Gray, 2000; Araneta et al., 2003; Kang et al., 2001; Bukowinski et al., 2012; Armed Forces Health Surveillance Center [AFHSC], 2010; Ryan et al., 2011; Conlin et al., 2012).

Hourani and Hilton (2000) evaluated the relationship to self-reported exposures and adverse pregnancy outcomes among active duty Navy women who were pregnant between January and October in 1993. The authors also surveyed a comparison group of civilian beneficiaries delivering at the same hospital the following year. The authors grouped respondents by report of an adverse live-birth outcome (small for gestational age, birth defect, fetal distress prior or during delivery, birth less than 37 weeks, or birth weight less than 2,500 grams) or no adverse outcomes and compared the groups based on active duty or civilian status. They collected information on environmental exposures including radiation, heavy metals, pesticides, solvents, petroleum products, other chemicals, shipboard duty, or serving in the Persian Gulf. Active duty Servicewomen were significantly more likely to report exposures compared to civilian respondents; however, final models did not demonstrate significance between maternal exposures and adverse birth outcomes.

Araneta et al. (2000) evaluated births from the Hawaii Birth Defects Program (HBDP) and Hawaii birth certificate records linked to information from the Defense Manpower Data Center (DMDC) and the Defense Enrollment Eligibility Reporting System (DEERS) to identify military status. HBDP is part of the Centers for Disease Control and Prevention’s (CDC) monitoring program and uses specific definitions for 48 major congenital anomalies that are included in the database. Military status was grouped as Gulf War veterans (GWV) and non-deployed veterans (NDV).

The authors identified 17,182 infants born to military personnel (men and women) in Hawaii between 1989 and 1993, with 9,437 determined to have been conceived prior to the war and 3,717 (22%) born to GWV. Among GWV births, 202 (8.1%) had a mother who served in the military. There were 1,854 (50%) postwar conceptions among GWVs and 5,882 (44%) among NDVs. Among GWVs, there were no differences found comparing prewar conceptions to those with postwar conceptions.

There were a total of 165 GWV women who conceived after the war. Among births to mothers who had served in the military, there were no statistical differences between GWV births compared to NDV births, nor were there any statistical differences in the rate of birth defects among GWV if the infant was conceived before the war compared to infants conceived after the war. Although the multiple data linkages and standardized birth defect definitions strengthen this study, the authors stress that the small number of female GWVs, along with the inability to identify stillbirths, miscarriages, or induced abortions due to anomalies, limits the generalizability of this study.

In a larger study using the same methodology, Araneta et al. (2003) evaluated data from six states that report to the CDC’s birth defects monitoring system. In this case, they identified 450 GWV mothers (142 conceived prior to the war) and 3,966 NDV mothers (2007 conceived prior to the war). They found that although there was no difference in the rates of congenital anomalies between GWV and NDV mothers for infants conceived prior to the war, there was a significant difference in the adjusted prevalence of hypospadias among sons born postwar to female GWVs compared to postwar female NDVs (RR 6.3, 1.5–26.3, p = 0.015). None of the infants was also reported to have epispadias. There were no other significant differences in the other 48 reported congenital defects.

Kang et al. (2001) evaluated self-reported birth outcomes, including fetal loss and birth defects, that were included in a 16-page questionnaire sent to a large sample of Service members selected from the DMDC. Their survey methodology included stratified random sampling by gender and unit component to achieve an adequately representative sample of 15,000 GWV and 15,000 active duty Service members who were not deployed to the Gulf War. The survey oversampled for women, Reservists, and National Guardsmen. The study analyzed spontaneous abortions, stillbirths, preterm delivery, birth defects, and infant mortality. Pediatric epidemiologists evaluated the verbatim descriptions of infant birth defects to assess if the birth defect self-reports were accurate by using a 12-group sorting system. The analysis categorized a response as a birth defect only if it was determined to be “likely” and “moderate-to-severe” based upon the sorting scheme.

There were 20, 917 survey respondents with 6,043 (28.9%) who had an index pregnancy during the time period. In both male and female respondents, those who had been deployed to the Gulf War were two to three times as likely to report a “moderate-to-severe” birth defect compared to those who had not deployed (males: 1.78 [1.19–2.66], females: 2.80 [1.26–6.25]). The majority reported isolated anomalies that were one or more anomalies within the same organ system. There were no significant differences for preterm birth or stillbirth. The authors noted that, although the reported spontaneous abortion rate for males was significantly increased, the rate for GWV and non-deployed Service members was still well below the expected range of 10%–15%, and may be an artifactual comparative risk. The authors evaluated the data for self-selection bias in reporting and determined that the data did not suggest this as a plausible reason for the increased reporting rate in birth defects. This population-based study demonstrated adequate power to detect differences; however, data were self-reported, and the identification of birth defects was based upon verbatim data that were categorized for evaluation.

The AFHSC (2010) conducted a retrospective cohort study that included active duty, Reserve, and National Guard personnel of all Services at three USCENTCOM burn pit sites in Iraq: Joint Base Balad (JBB), Contingency Operating Base (COB) Speicher, and Camp Taji, to evaluate pregnancy outcomes following these exposures. The authors included two control groups of active component personnel, one stationed in Korea for more than 30 days and one stationed in the United States during the same time. Among active duty military women who gave birth in the year following possible exposure to a burn pit area (within 5 miles), there was no significant statistical differences in the risk of preterm birth or birth defect compared to those who were not exposed. Compared to men who were not exposed, active duty Servicemen who were exposed to burn pits were 1.31 (1.04–1.64) times more likely to have an infant with birth defects, if the infant was conceived 280 days or more after the exposure.

Bukowinski et al. (2012) linked birth records from Department of Defense Infant Health Registry and the Defense Manpower Data Center to identify active duty Service members who had been deployed within 3 miles of a burn pit and later had a child. The authors evaluated children born in 2004–2007 following one or both of their parents serving in the 1990–1991 Gulf War. The authors found no increased risk for birth defects among deployed active duty Servicewomen; however, among active duty Servicemen who had been deployed 153–200 days, there was a 1.25 (1.05–1.49) times increased risk of birth defects in children compared to active duty Service members who had been deployed 1–92 days. This risk was not present in the group of men who had been deployed 201–485 days. The authors note that among the 178,766 births included in the study, the majority of exposures (152,149) were paternal exposures, 19,320 were maternal exposures, and 7,297 were both parents. In addition, birth defects were identified through ICD9-CM coding, thus requiring them to be identified at birth. The gender disparity may have affected the statistical power to detect differences, and only major congenital birth defects were identified.

Conlin et al. (2012) conducted a similar study using the same methodology as Bukowinski et al. (2012). They identified active duty Servicewomen who had given birth following deployment. There were 1171 women who had been deployed within a 3-mile radius of burn pits and 11,958 women who had not been exposed, but who had other deployments to Iraq or Afghanistan outside the 3-mile radius of a burn pit. The authors compared the risk of having an infant born with birth defects or preterm in relation to burn pit exposure. There were no significant differences in the rate of birth defects in the exposure group compared to the non-exposed group.

In summary, there are a number of studies that have evaluated the relationship of birth defects and exposures associated with deployment, including burn pits. The studies have either conducted retrospective review of existing data registries or data obtained by self-report through mail/phone surveys. Most studies have identified no association between exposures and outcome; however, four studies identified an association.

Kang et al. (2001) identified an increased risk of self-reported “moderate-to-severe” birth defects for both men and women who had been deployed to areas with burn pits. Two studies reported findings of a delayed association between exposure and birth defects with fathers who had been deployed either 153–200 days (Bukowinski et al., 2012) or greater than 280 days (AFHSC, 2010). The birth defects in both studies were self-reported. Finally, Araneta et al. (2000) conducted a retrospective registry study and noted an association in women who had deployed with an increased risk of hypospadias.

Many of the studies had small sample sizes, low response rates, or other methodological concerns that limit the ability to draw conclusions. These concerns may have affected the ability to either confirm a relationship, or may have had insufficient power to detect differences. Additionally, since data collection was 20 years ago, it is possible that current exposures may not produce similar results. A larger scale evaluation, with specific definitions of birth defects, sufficient information about exposure, and that is of sufficient size to detect differences is needed.

VACCINE OR CHEMOPROPHYLAXIS EXPOSURE

Since 2009, there are only a few studies that have evaluated vaccine exposure and pregnancy outcomes among Active Duty Servicewomen. Four studies (Wiesen & Littell, 2002; Conlin, Bukowinski, Sevick, DeScisciolo & Crum-Cianflone, 2013; Ryan, et al., 2008; Ryan, Smith & Sevick, 2008) evaluated vaccine exposure (anthrax, H1N1, smallpox) or chemoprophylaxis (Mefloquine) (Schlagenhauf, et al., 2012) during pregnancy and pregnancy outcomes.

These studies found that neither vaccine nor chemoprophylaxis administration during the prenatal period resulted in adverse effects on pregnancy outcome, but none of these studies evaluated spontaneous abortion or early fetal loss. Smoak, Writer, Keep & Chantelois (1997) noted an increase in spontaneous abortion among women who inadvertently received Mefloquine while pregnant as they prepared to deploy for the Gulf War in 1989–1992. Further research is needed to draw conclusions regarding this exposure risk.

PREGNANCY IN THEATER

There are several reports that evaluated pregnancy following combat deployment and the need for evacuation. Albright et al. (2007) noted that in a study of one Army division in theater during the Persian Gulf War, there were 24 pregnancies out of 458 gynecologic visits. At the Eighth Evacuation Hospital, Hines (1993) found that the 26 pregnancies diagnosed accounted for 16% of the hospital evacuations and 56% of all women evacuated. In a similar study of the 312th Evacuation hospital, Hanna (1992) found that 49 of 577 gynecologic visits were for pregnancy. Hanna (1992) noted that many women stated that they had been told to stop their oral contraceptive pills as they would not need them, nor would they be available. Since then, this policy has changed, and oral contraceptives are offered at pre-deployment physicals, not only for contraception, but also for menstrual suppression during deployment (Christopher & Miller, 2007; Trego, 2007; Powell-Dunford, Cuda, Crago, & Deuster, 2009). Women have access to refills through mail order and local military treatment facilities.

In spite of increased contraceptive access, as discussed above, unintended pregnancies continue at a rate comparable to that for civilian women in the same age group and have an impact on theater operations. Albright et al. (2007) conducted a retrospective chart review of 1,737 gynecology visits presenting to the gynecology clinic in Camp Doha, Kuwait during August 2003–April 2004. They found that 77 (4.4%) of those visits had a positive pregnancy test. Women with positive pregnancy tests had a mean age of 27 (±7), and the most common rank was E-4. Most presented to the clinic with a complaint of amenorrhea or a desire to check for pregnancy. Three of the pregnancies were second trimester (two greater than 20 weeks), and one ectopic pregnancy was identified. Information on arrival date to theater was available for 43 of the 77 women. Among those with an arrival date, 33 had become pregnant after arrival in theater. Although pregnancy in theater can have an impact on troop readiness, these estimates are consistent with the expected rate of pregnancy in a given population. Mosher, Martinez, Chandra, Abma, and Wilson (2004) estimated that approximately 5% of women in a childbearing population would be pregnant at any given time.

Ectopic pregnancy has a reported incidence of 1.5 cases per 1,000 women of reproductive age and is an obstetric emergency. It usually is asymptomatic and thus undetected until intervention is critically necessary. It is estimated that the death rate is 4 per 1,000 cases (Stamilio, McReynolds, Endrizzi, & Lyons, 2004). In the Active Component of the US Armed Forces, among the approximately 35,000–50,000 women who have been deployed to combat zones, this translates to the potential for 53–75 cases per year (Stamilio et al., 2004; Albright, et al., 2007). If ectopic pregnancy is undetected before deployment, this could present a life-threatening emergency for the Service member and may affect troop readiness.

The AFHSC (2012) evaluated the incidence of ectopic pregnancy among Active Component US Armed Forces and found that among active component women younger than 49, there were 1,245 cases in 1,216 women (some women had more than one ectopic pregnancy) in 2002–2011. Rivera-Alsina and Crisan (2008) and Stamillo et al. (2004) present case reports of the challenges and successes of the treatment of ectopic pregnancy during deployment and stress the importance of available portable ultrasound machines. The annual number of ectopic pregnancies ranged from 91 to 151. The proportion of pregnancies that were ectopic remained stable at 0.70 during 2002–2005 and then declined to 0.49% in 2005–2011. These findings were similar to rates in the civilian population. In both the active component and civilian populations, the diagnosis of ectopic pregnancy was preceded by either a diagnosis of a genital infection with chlamydia or gonococci, or pelvic inflammatory disease (PID). In summary, ectopic pregnancy is a rare and life-threatening condition. Adequate resources in theater, including portable ultrasound machines, are critical assessment tools to perform life-saving assessments in austere environments.

The participation by active duty women in military operations has expanded, and large-scale deployments to theaters of operation commenced in the Persian Gulf War. Today, women may serve in combat roles. The challenges of achieving a work-life balance are even greater than they were 20 years ago; however, the same challenges exist in the area of reproductive health. Women who choose to enlist are of similar ages to their civilian counterparts who have chosen to go to college.

In these early adult years, contraception use may not be consistent, leading to higher rates of unintended pregnancy. In a college setting, this may delay graduation, but does not always require the student to leave her studies. In the military, the scenario may be quite different, and it can affect troop readiness. Women who become pregnant after deployment will need to be evacuated from theater. Complications in pregnancy that require immediate intervention, such as ectopic pregnancy, may be more difficult to diagnose and manage if far away from echelon 3 Services. Environmental exposures may affect the pregnancy outcome, or may produce delayed responses for future childbearing.

Many of these issues have not been fully studied, sample sizes are small, or methodological flaws exist in the analysis, limiting conclusions that can be drawn. Additional research with greater rigor, larger sample sizes, and careful design are needed to address many of these questions. Innovative approaches to contraception education are also needed to provide necessary information on contraceptive decision-making.

These findings are important for clinical providers who care for both military women and veterans. The American College of Obstetricians and Gynecologists (ACOG, 2012b) has stressed the need for healthcare providers to familiarize themselves with the unique needs of women in the military and military veterans. Although most active duty women have a primary care provider, often their primary contact with the medical system is for annual gynecologic examinations. The same is true for healthy women Reservists and veterans. Standard care for both military and veteran women should include questions about current service status; a discussion of the potential reproductive health risks due to environmental exposures during military service; family planning and contraceptive considerations for deployed women, other military women, and veterans; and other potential exposures, such as vaccines or chemoprophylaxis.

ACOG (2009) and others have noted that countries with higher usage of long-acting reversible contraceptive (LARC) methods such as intrauterine devices and contraceptive implants have lower rates of unintended pregnancy (Trussell & Wynn, 2008; Winner et al., 2012), and that these methods are safe in both women and adolescents (ACOG, 2012a). In addition to pregnancy prevention, hormonal contraception has been used in theater for menstrual suppression (Holt et al., 2011). Pre-deployment physicals should include discussion of the desire for menstrual suppression as well as contraception.

As part of preconception planning, ACOG (2013) recommends that healthcare providers become knowledgeable about toxic environmental agents that are endemic to specific geographic areas. As discussed in this chapter, military women can be exposed to environmental agents as part of deployment or duty station. Providers should consider taking an environmental exposure history as part of an initial health history for both active duty and veteran women. Results of the exposure history can be used for teaching, counseling, and further testing if necessary.

Ectopic pregnancy can be a life-threatening emergency, and when it occurs away from areas with echelon 3 or greater diagnostic capabilities, it has the potential to be deadly. Healthcare providers in deployed environments should consider portable handheld ultrasound equipment as part of the standard setup. Their utility in austere environments has been demonstrated in both military and civilian settings (Nelson, Melnick, & Li, 2011; Shorter & Macias, 2012; Harcke & Rooks, 2012). In conclusion, there are many similarities among civilian, military, and veteran women related to rates of unintended pregnancy and reproductive healthcare needs; however, there are additional unique reproductive healthcare needs that should be considered when providing or planning care to military and veteran women. Midwives, gynecologists, family practice physicians, and other healthcare providers should review and consider the ACOG Committee Opinions referenced in this chapter (ACOG 2009, 2012a, 2012b, 2013) when caring for military and veteran women.

The views expressed by the authors in this book are their own, and do not necessarily reflect the view of the United States Government or the Department of Defense.

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