Maj. Audrey Atwell is an active-duty Army officer and mother of four with over 19 years of service.
As women have become a larger part of the military force over the decades, policies to address their unique health care needs have adapted and changed dramatically. However, there remain critical gaps in essential health care services that significantly impact the reproductive health and psychological well-being of female service members.
Policies that address the specific needs of women have strategic implications affecting the military's ability to achieve manpower requirements and mission readiness. With women now representing roughly 16% of the force, it is critical for military leaders and policymakers to identify and address issues that may be hurting the services' ability to recruit and retain women.
In the 1970s, as the military transitioned to an all-volunteer force, women comprised only 5% of the Army, and were being involuntarily separated at high rates due to pregnancy and motherhood. The high separation rates of women had a detrimental effect on the Army's ability to meet manpower requirements. In 1975, leaders were forced to contend with the increased presence of women in the service and repealed the involuntary separation policy, Executive Order 10240, which authorized involuntary discharge of women due to pregnancy or motherhood.
Although the inclusion of women brought about a greater pool of talent, it also brought new policy challenges that remain unsolved.
In May 2020, the Government Accountability Office published a report to congressional committees on "Female Active-Duty Personnel-Guidance and Plans Needed for Recruitment and Retention Efforts." This report emphasizes that, despite incremental increases in the population of military women over the past 15 years, female service members are 28 percent more likely to separate than their male active-duty counterparts. The report further identified six categories of "other factors" that influence a woman's decision to separate from the military, including work schedules, deployments, organizational culture, family planning, sexual assault and dependent care.
For the first time in almost 30 years, the Department of Defense conducted in August a DoD-wide Women's Reproductive Health Survey (WRHS) created to assess the health care needs of women in uniform. The survey will be used to formulate policies going forward to address inadequacies in care or lack of services. I am excited and hopeful to see how the DoD responds to the survey and moves forward to address inadequate services for women in ways that potentially impact readiness and retention.
However, after taking the survey, there are deeper, more prominent issues affecting women within the military health care system that the DoD leaves unexplored. Most markedly, the survey did not assess a woman's experience with sexual trauma or sexual assault or obstetric care, or how any of these topics affect a woman's mental and overall sexual health and well-being.
It is important to capture women's experiences navigating health care in a bureaucratic system bogged down and overtaxed to the point that it is struggling to provide basic gynecological and sexual health preventative care resources for its active-duty population.
The Military Medicine Journal in 2016 concluded "that women in the military have an age-standardized rate of unintended pregnancy up to 50% higher than the general population with higher rates among less educated, nonwhite, and married or cohabiting women." The study determined a correlation between higher rates of unintended pregnancies and access to preventative health care services such as reliable, effective contraception.
Women of all ages serve in the military, and the health care system should be capable of providing adequate services for the populations they serve. Adolescent women, young adults and women of childbearing age and beyond all have differing needs and require distinctly different solutions to their health care challenges. It is difficult to assess adequately the broad spectrum of women's specific health care needs, as they change dramatically throughout a woman's life.
Many women who serve are of childbearing age, and fertility issues, as well as prenatal, perinatal and postnatal obstetric care, are of great concern. When you look at obstetric outcomes based on race, the health care gap further divides. A 2019 report to the House and Senate Armed Services Committees states, "Risk of death can vary by race, ethnicity, and age, suggesting that further analysis of demographics can be done to better understand and reduce pregnancy-related deaths."
Within the military health care system, there are known obstetric discrepancies resulting from systematic inequalities due to race.
In April 2020, Maternal and Child Health Journal published a study concluding that "non-Hispanic Black military women had consistently worse outcomes than their non-Hispanic White counterparts. This suggests that equal access to health care does not eliminate racial disparities in outcomes or utilization; additional research is needed to elucidate the underlying etiology of these disparities."
Lack of access to gynecological care and sexual health resources for women is a huge issue, and it has second- and third-order effects, including reduced readiness, unintended pregnancies and the spread of sexually transmitted illnesses -- as well as a degradation of overall health for women. These problems spill over into larger issues that affect more than recruitment and retention.
Women are the fastest-growing veteran demographic and, like the active-duty military, the Department of Veterans Affairs is struggling to meet the health care needs of this new population of veterans. Less-than-desirable gynecological and obstetric outcomes affect not only the current system, but also the VA as women conclude their service. A 2018 report from Disabled American Veterans outlines the diagnoses faced by VA patients that specifically create challenges during pregnancy, including anxiety, post-traumatic stress disorder, depression, musculoskeletal problems and endocrine dysfunction, among others.
"PTSD, for instance, has been associated with a higher risk of spontaneous pre-term births, more antenatal complications and extended length of stay in the hospital postpartum," it found. "Overall, women who receive VA-sponsored maternity care have a higher-than expected incidence of pre-eclampsia, fetal growth restriction and placental abruption."
It could be argued that the lack of preventative care and lack of adequate access to gynecological, obstetric, or other types of care while on active-duty are contributing to an increased need for specialty services when women become veterans. At the very least, there is a perception among female veterans that their service was detrimental to their physical and mental health. The Service Women's Action Network found in 2018 that "60 percent of women who served thought their time in the military had negatively impacted both their physical and mental health."
Another point of contention is that some women experience discriminatory Tricare policies. Civilian dependents have more Tricare-covered authorized birthing options than active-duty women, resulting in more control and say in their obstetric care. For example, home births are an authorized birthing option for civilian dependents, but are not authorized for active-duty women. Active-duty soldiers should be afforded the same flexibility and birthing options that Tricare covers for dependent spouses.
With women integrated into units of all types, it is critical to examine these policy concerns. The implication of these policy issues, lack of adequate care, discrepancies in care and lack of a comprehensive plan to address current problems will certainly affect the services' ability to retain talented women in the force. Three of the six identified "other factors" that influence a woman's decision to separate from the military can be addressed in part through the revision of women's health care policies and formal examination of women's needs during their childbearing years. Family planning, sexual assault and dependent care are all deeply personal and influential experiences that affect a woman's decision to continue to serve.
With the increase of diversity and inclusion studies throughout the DoD, the services can conduct more research and target their policies to address and reevaluate imbalanced policies.
Going forward, implementation of Women’s Health Centers on each installation would significantly reduce the bureaucratic processes that limit women’s access to specialty care. It is also critical that additional research is conducted to understand and eradicate the underlying racial disparities experienced within the military healthcare system. Understanding the complexities of some of these issues can be done through the expansion of the DoD’s Women's Reproductive Health Survey to understand the broad spectrum of women's specific health care needs, as they change dramatically throughout a woman's life. Women of all ages serve in the military, and the health care system should be capable of providing adequate services for the populations they serve.
Inadequate or insufficient gynecological or obstetric care in the military should no longer be considered a "female-only issue." Lack of adequate health care is a soldier's issue, a leadership issue and a talent management issue. As a readiness issue that directly affects the deployability of 16% of our active-duty force at any given time, it's a problem leaders simply cannot afford to ignore.
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