Committee on Health Care for Underserved Women
This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
Abstract: Military service is associated with unique risks to women’s reproductive health. As increasing numbers of women are serving in the military, and a greater proportion of United States Veterans are women, it is essential that obstetrician–-gynecologists are aware of and well prepared to address the unique health care needs of this demographic group. Obstetrician–-gynecologists should ask about women’s military service, know the Veteran status of their patients, and be aware of high prevalence problems (eg, posttraumatic stress disorder, intimate partner violence, and military sexual trauma) that can threaten the health and well-being of these women. Additional research examining the effect of military and Veteran status on reproductive health is needed to guide the care for this population. Moreover, partnerships between academic departments of obstetrics and gynecology and local branches of the Veterans Health Administration are encouraged as a means of optimizing the provision of comprehensive health care to this unique group of women.
Women have served in every United States military conflict since the American Revolution. Roles for women in the military have diversified over time, and many current female service members are achieving top ranks in all branches of the military 1. Many have undergone prolonged military deployments with war zone exposure, and increasing numbers of women are serving in combat support units 1. At the conclusion of their military service, women transition back into their communities as Veterans. Veterans are men and women who have served on active duty in the U.S. Army, Navy, Air Force, Marine Corps, Coast Guard, National Guard, or Reserves 2. In 2011, 8% (1.8 million) of all U.S. Veterans were women, a proportion expected to increase to 11% (more than 2 million) by 2020 3 4. Women comprise approximately 14.5% of the active duty military force and almost 18% of the National Guard and Reserves 1. In 2009, the age distribution of women Veterans who use services provided by the Veterans Health Administration showed three main peaks in the mid twenties, mid forties, and mid fifties 5. This trimodal distribution indicates the importance of a lifespan approach to providing reproductive health care for women Veterans.
Women in the military and women Veterans may seek primary and reproductive health care at military treatment facilities, through the U.S. Department of Defense’ TRICARE program, at the civilian sector (through Medicaid, Medicare, or private insurance), through the U.S. Department of Veterans Affairs (VA), or some combination thereof 6. It is critical that all health care providers are familiar with the unique health care needs of these women and with the health care resources (eg, Veterans Health Administration) available to address these needs. Connecting women Veterans to VA services may facilitate needed comprehensive health care; VA facilities may be located by consulting a web-based directory www.va.gov/directory or by calling 1-800-827-1000. Women who are honorably discharged from the military may qualify for a variety of VA benefits, including health care benefits. This eligibility is based on multiple criteria (details are available at http://www.va.gov/healthbenefits/apply/veterans.asp. Many mechanisms are in place to support the health needs of women Veterans. Each Veterans Health Administration facility nationwide has a designated Women Veterans Program Manager who advocates for women and provides leadership in establishing, coordinating, and integrating quality health care services for women. Many VA sites have specialized women’s health clinics and services available to provide care for women Veterans either on site or through referrals to non-VA health care providers. For example, the VA covers pregnancy-related care through arrangements with community health care providers.
Research regarding women Veterans has increased significantly over the past two decades 7 8 9 10. Although limited in scope (studies are primarily observational or descriptive, use cross-sectional designs, and study subsets of women Veterans who used Veterans Health Administration facilities for their health care), several studies characterize the greater physical and psychiatric morbidity and diminished social support of these women compared with their civilian counterparts 7 8 9 10.
Roles of Obstetrician–Gynecologists in the Health Care of Women in the Military and Women Veterans
Because obstetrician–gynecologists may be the primary medical providers for women in the military and women Veterans, they are in a position to interact with these women and intervene early and appropriately with their unique reproductive health care needs. Understanding the potential health effects of military service will help health care providers best serve women in the military and women Veterans across the lifespan. This committee opinion highlights unique reproductive health needs and special considerations of this population. A more detailed review is available at www.acog.org/goto/underserved.
Women in the military and women Veterans are serving or have served our country and deserve the best health care. Efforts to undertake the following steps are essential:
1. Assess women for history of military service and inquire about Veteran status
Many women will not volunteer information about military service or readily identify themselves as Veterans. Screening women for military service (current or past) and inquiring about Veteran status at initial health care visits is important and may be accomplished by asking, “Have you ever served in the military (eg, on active duty in the U.S. Armed Forces, Reserves, or National Guard)?” Health care providers also should ensure that all patients who are Veterans are aware of VA-related resources for their physical and mental health care. This information is available at http://www.va.gov/healthbenefits/access/medical_benefits_package.asp. Additional information regarding obtaining a military history can be found at http://www.va.gov/OAA/pocketcard/FactSheet.asp.
2. Understand reproductive health risks of military service
Military deployment to severe environments (eg, the war zone) can result in limited access to acceptable medical services and sanitary equipment and increase the inconvenience and logistic difficulty of hygienic management of menstruation. This may predispose deployed women to greater risk of gynecologic conditions, such as urinary tract infections or bacterial vaginosis 11 12 13. For some women, such deployment may interrupt preventive care (eg, cervical cancer screening) or ongoing treatment or evaluation for conditions, such as menorrhagia, endometriosis, or uterine leiomyomas. Rates of abnormal Pap test results may be elevated among women in active duty military service who are deployed to war zones 13. Timely access to appropriate cervical cancer screening is critical for all women.
Military service, particularly deployment to war zones and combat exposure, can increase the risk of mental health problems, and Veterans (including women Veterans) have significantly elevated rates of psychiatric illness, including depression, posttraumatic stress disorder (PTSD), and substance abuse compared with their civilian counterparts 14. Deployment status is strongly associated with an increased risk of depression during pregnancy and the postpartum period 15. Careful screening, monitoring, and treatment for depression during pregnancy and the postpartum period are warranted for women in active duty military service, women Veterans who have recently returned from a war zone, or women with a deployed partner 15. Connecting women Veterans to VA-related mental health care during pregnancy may be useful in helping to ensure their timely receipt of comprehensive mental health care.
3. Be knowledgeable about family planning and contraceptive considerations for deployed women and women Veterans
Consistent with the applicable Department of Defense regulations, family planning and contraceptive counseling are available to all women in the military who request these services 16. Depending on the location of the deployment, contraceptive methods may need to be altered because some combat areas are not conducive to stocking certain contraceptives, such as depot medroxyprogesterone acetate and the vaginal ring. Indeed, some women report discontinuation of contraceptive use during deployment because long work shifts and rapid travel across multiple time zones can affect adherence to a regular contraceptive schedule 12 13. Also, harsh climate in some deployment areas has been reported to diminish the adhesive integrity of the patch 12 13.
Small studies show varying rates of unintended pregnancy among women in active duty military service. Some estimates reveal that 50% of pregnancies in this population are unintended, which is consistent with the national average. However, other results indicate that as many as 65% of pregnancies in this population are unintended 17 18 19. In a recent study of 3,745 women in active duty military service aged 18–44 years, authors reported that nearly one in five women in this population was pregnant during 2005, and of these pregnancies, 54% were unintended 18. The American College of Obstetricians and Gynecologists (the College) encourages the education of health care providers, women in the military, and women Veterans regarding the use of long-acting reversible contraceptives, namely intrauterine devices and the contraceptive implant, particularly for women facing military deployment. The U.S. Department of Defense has recently begun encouraging widespread provision of the levonorgestrel intrauterine system for deployed women.
The Veterans Health Administration offers a wide range of prescription contraception methods, including combination oral contraceptives, injections, implants, intrauterine devices, emergency contraceptives, and vaginal ring products that are available at little or no cost to eligible women Veterans. Increased efforts to train VA primary care providers regarding a wide range of basic reproductive health and women’s health issues, including contraception, are ongoing in the VA health care system. Health care providers should consistently discuss contraceptive options with women in the military and women Veterans just as with all other women. Connecting women Veterans to VA services may facilitate receipt of comprehensive health care. For women eligible for VA benefits, this may provide more affordable contraceptive services than through other health systems.
Under statute, women in the military and those women Veterans who receive insurance benefits through the Civilian Health and Medical Program of the Department of Veterans Affairs have more limited insurance coverage of abortion than other women who receive health insurance through the federal government (federal employees, and Medicaid or Medicare beneficiaries) because they receive benefits only in the setting of life endangerment 20 21. The College opposes all regulations that limit or delay access to abortion 22. The disparity in insurance coverage of abortion must be eliminated to provide women in the military and women Veterans the same coverage of abortion and related care as other women who are insured through the federal government.
4. Screen for interpersonal violence, including military sexual trauma and posttraumatic stress disorder
Screening for interpersonal violence, including history of sexual assault and intimate partner violence, is critical to the provision of optimal reproductive health care for women. It is particularly important for women in the military and women Veterans who may have significantly increased rates of lifetime exposure to interpersonal violence, including sexual assault or abuse 23 24 and intimate partner violence 25, compared with their civilian counterparts. The physical and psychosocial health sequelae of interpersonal violence exposure, including delay in seeking medical care, are well known 24 25 26 27 28. The College recommends routine screening of all patients for a history of sexual assault and paying particular attention to those who report pelvic pain, dysmenorrhea, or sexual dysfunction 29. Additional information about approaching the patient who has a history of sexual assault can be found in Committee Opinion No. 498, “Adult Manifestations of Childhood Sexual Abuse” 30. The College also recommends screening and counseling for intimate partner violence during preventive health visits and provides guidance on screening questions 31.
Screening for sexual assault should include questions about military sexual trauma, which is the experience of sexual harassment or attempted or completed sexual assault during military service. Military sexual trauma is a unique risk of military service, and perpetrators and survivors can be of either sex. Perpetrators may include military personnel, civilians, commanding officers, subordinates, strangers, friends, or intimate partners 24. Twenty percent of women Veterans who use Veterans Health Administration facilities report a history of military sexual trauma 24. This is a cause for concern because military sexual trauma can have long-term health implications 24 26 32. It is critical that health care providers screen for military sexual trauma so that they may effectively identify and address any associated health concerns.
In the VA, such screening for military sexual trauma, mandated by the VA for all Veterans seen by a VA health care provider, involves two questions that use descriptive, nonjudgmental language 24 and can be used in any office setting:
“While you were in the military,
did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?
did someone ever use force or threat of force to have sexual contact with you against your will?”
Veterans who respond positively to either question are considered to have a positive screening result for military sexual trauma. The College applauds this mandate by the VA and the efforts of the U.S. Department of Defense and encourages the continuation of prioritization of efforts for primary prevention of military sexual trauma. Health care providers also are encouraged to be involved in advocacy in professional, community, military, and educational arenas for primary prevention of sexual trauma.
Women identified as having military sexual trauma should be referred to a Veterans Health Administration facility, if not already receiving care through such a facility. Veterans can receive care related to military sexual trauma at any VA health system where all treatment for mental and physical health problems related to this diagnosis is free of charge and unlimited in length.
The prevalence of PTSD is increased more than twofold in women Veterans compared with their civilian counterparts 33 34. This is commonly attributed to women Veterans’ greater exposure to interpersonal violence, particularly military sexual trauma 35. Posttraumatic stress disorder is linked to diminished physical health 36 and decreased willingness to pursue preventive reproductive health care in women Veterans 37. As such, women Veterans should be screened for PTSD and offered referral to mental health providers or Veterans Health Administration facilities if the screening results warrant intensive treatment. The benefits of universal screening in reproductive care settings also should be considered. Meltzer-Brody and colleagues have developed a PTSD screening instrument specifically designed for use in obstetrics and gynecology 38. The Veterans Health Administration uses a four-item validated screening questionnaire to identify patients who may have PTSD 39; instructions, questions, and scoring rules for use of this screening tool are presented at http://www.ptsd.va.gov/professional/pages/assessments/pc-ptsd.asp. Additional resources for Veterans with traumatic experiences are available at http://www.ptsd.va.gov/public/index.asp and www.vetcenter.va.gov.
5. Promote a research agenda that studies the effect of military status on reproductive health
Research designed to evaluate the association of military service and women’s reproductive health warrants immediate consideration to ensure the development of empirically derived best practices for their reproductive health care. The particular research areas include the following:
Co-occurrence of medical and mental health conditions in women in the military and women Veterans and effect on reproductive health outcomes
The association of military deployment and unintended pregnancy and the effects of military deployment on subsequent pregnancy outcomes
Best practices for the safe pharmacologic management of women Veterans with psychiatric illness (eg, depression or PTSD) who are pregnant or wish to become pregnant
The provision of perinatal care for women Veterans with disabilities, including cognitive or physical impairment that stems from traumatic brain injury, polytrauma, or other injury.
6. Engage with the local Veterans Health Administration facility
It is essential that strong clinical partnerships between public and private health care settings, academic departments of obstetrics and gynecology, and the VA be forged. This will allow all health care providers who treat Veterans to ensure that Veterans in their care are aware of health care resources offered through VA and provide referrals as needed. Such collaboration offers unique opportunities to share best practices, to foster the development and implementation of a robust research agenda regarding the reproductive health care needs of women Veterans, and to enhance delivery and coordination of care.