Other challenges identified

Lindberg discussed other challenges specific to women in the military — for example, where they are stationed. “We do not have information on the impact of where women are stationed and the kind of units they’re in, but certain settings make contraceptive use much more challenging — such as being shipboard or facing very inconsistent or extended hours,” she observes.

For example, she explains, with a low-dose contraceptive pill, it is important that it be taken at the same time every day. “If you’re not in your bunk at the same time every day, how do you do that?” She poses. “The way to address that is using long-acting contraception. That would be my No. 1 medical policy; this population should be primed for long-acting contraceptive methods.” Lindberg recommends this be addressed not just through education and counseling, but also as an integral part of medical visits.

Long-Acting Reversible Contraception (LARC) offers several options. They include intrauterine devices (IUD); subdermal contraceptive implants; and oral and injectable contraceptives.

“Providers can play an important role here,” Lindberg notes. “Nationally, in the civilian population, we know that IUD use is very low, although it has been rising. Women have concerns that relate to myths and perception of health status that do not address the current reality — this is not your mother’s IUD.”

Because many women have very little information about contraception, Lindberg says, “providers should not assume because the patient is a woman and doesn’t ask specific questions, that they have the answers.” Such issues, she adds, should certainly be raised in the course of a general gynecological visit, “And more than that, the military should want to create a strong line between gynecological care and overall health care, because you do not only want to talk to women about these issues if they come in once a year for their pap smear.”

Another challenge Lindberg sees is cultural. “The issue of unintended pregnancy influences how all women in the military are perceived,” she asserts. “As long as there’s a perception that ‘a woman can just get pregnant to get out of this,’ it engenders resentment and disrespect, or it can lead to less opportunity for a woman; it certainly must impact the culture and morale.” (Please see the box below for more details on military policies concerning pregnancy.)

A ‘strong foundation’

Lindberg says that, while the DoD has what she calls “a strong foundation” of women’s health care programs in place, more can be done to address the challenge of unintended pregnancy.

“[DoD provides] high-quality universal health care and a strong system; they’ve recently added emergency contraception to their list of provided pharmaceuticals, and the DoD over the past decades has been a leader in the prevention of STIs, which include HIV and AIDs,” she notes.

In addition, she says, DoD provides prenatal care and a substantial amount of care to spouses of military personnel, “So much of the care actually covers partners of men in the military.”

One of her frustrations, she continues, has to do with the health data set. “It’s a great health data set, but I had to use 2005 data because in 2008 they dropped the question of unintended pregnancy; they no longer ask it,” she says. “The need for better monitoring is paramount, but you can’t address a problem if you do not know the statistics.”

Cover the bases

Based on her experience, what are the key elements of successful education program to prevent unintended pregnancies? “It has to have multiple components,” says Lindberg. “The first has to do with encouraging women to develop specific pregnancy plans — is this a time you want to be pregnant, and if not now, when? If you say you’re not sure, how will you make the decision?”

Another key question to be addressed, she continues, is how a woman's duties change if she is pregnant or a parent. “I would try to highlight how unplanned pregnancies can make all of this more challenging  . . . and has implications for troop readiness,” she says. “Certainly, for example, [you should try not to become pregnant if you are] in combat or at sea. The Navy has developed some programs around preventing unintended pregnancy, but there’s this whole issue that sex while in a combat unit is discouraged; what does that mean in terms of access to contraception?”

General Order No. 1, which covers prohibited activities for soldiers, includes “Cohabiting, residing, or spending the night with members of the opposite sex within any building or living quarters.” It makes no specific mention of contraceptives.

In 2008, Maj. Gen. Jeffrey Schloesser, commander of Combined Joint Task Force-101, in Jalalabad, Afghanistan, lifted the ban on sexual relations between unmarried men and women in the combat zone, although his order warned that sex in a combat zone "can have an adverse impact on unit cohesion, morale, good order and discipline" and was “highly discouraged.”

Lindberg adds that, while she was not able to do a similar analysis for men, “We recognize that unintended pregnancy also places a burden on men, and including men in these types of counseling and education is important.”

Finally, says Lindberg, the military provides a positive environment for such programs. “Lack of clear goals can lead to unintended pregnancy; having clear goals fits well into the military culture,” she concludes. References