Faculty and Student Perceptions of Unauthorized Collaborations in the Preclinical Curriculum: Student or System Failure?

PURPOSE: Unauthorized collaboration among medical students, including the unauthorized provision of assistance and sharing of curricular and assessment materials, is a reported problem. While many faculty view such sharing as academic dishonesty, students do not always perceive these behaviors as problematic. With the trend toward more small-group and team-based learning and the proliferation of resource-sharing and online study aids, collaboration and sharing may have become a student norm. This multi-institutional, qualitative study examined faculty and student perceptions of and student motivations for unauthorized collaboration. METHOD: Using a constructivist approach, the authors conducted scenario-prompted semistructured interviews with faculty and students in the preclinical curriculum. Participants were asked to reflect on scenarios of unauthorized collaboration and discuss their perceptions of student motivation and the influence of personal or environmental factors. The authors performed inductive thematic analysis of the interview transcripts using open and axial coding followed by abstraction and synthesis of themes. RESULTS: Twenty-one faculty and 16 students across 3 institutions were interviewed in 2021. There was variation in perceptions among faculty and among students, but little variation between faculty and students. Both participant groups identified the same 3 areas of tension/themes: faculty/curriculum goals vs student goals, inherent character traits vs modifiable behavioral states, and student relationships with their peer group vs their relationships with the medical education system. Student behaviors were perceived to be influenced by their environment and motivated by the desire to help peers. Participants suggested cultivating trust between students and the education system, environmental interventions, and educating students about acceptable and unacceptable behaviors to prevent unauthorized collaboration. CONCLUSIONS: Given the various tensions and positive motivations behind unauthorized collaborations, institutions should consider explicitly preparing students to make thoughtful decisions when faced with competing priorities in addition to developing mitigation strategies that address the environment and its interactions with students.

Physical Health and Well-being: Updates and the Way Ahead.

INTRODUCTION: The Women in Combat Summit 2021 "Forging the Future: How Women Enhance the Fighting Force" took place during February 9-11, 2021, via a virtual conference platform. The third and final day of the Summit regarded the physical health and well-being of military women and included the topics of urogenital health, nutrition and iron-deficiency anemia, unintended pregnancy and contraception, and traumatic brain injury. MATERIALS AND METHODS: After presentations on the topics earlier, interested conference attendees were invited to participate in focus groups to discuss and review policy recommendations for physical health and well-being in military women. Discussions centered around the topics discussed during the presentations, and suggestions for future Women in Combat Summits were noted. Specifics of the methods of the Summit are presented elsewhere in this supplement. RESULTS: We formulated research and policy recommendations for urogenital health, nutrition and iron-deficiency anemia, contraception and unintended pregnancy, and traumatic brain injury. CONCLUSIONS: In order to continue to develop the future health of military women, health care providers, researchers, and policymakers should consider the recommendations made in this supplement as they continue to build on the state of the science and forge the future.

Shorter and Stronger: Revision of a Resident Performance Evaluation Survey.

INTRODUCTION: In order to evaluate the outcomes of a USU School of Medicine (SOM) education, a program director (PD) evaluation survey was developed in 2005 and is completed annually by PDs regarding trainees who graduated from USU and are in their first post-graduate training year (PGY-1) and their third post-graduate training year (PGY-3). The survey was last reviewed and revised in 2010 to better align with the competencies established by the Accreditation Council for Graduate Medical Education but has not been further evaluated or revised. The objective of the study was to utilize 12 years of aggregated data to improve the psychometric properties of the survey, with an emphasis on shortening the survey. A secondary objective was to refine the verbiage of the existing questions and add new items to assess health systems science competencies. METHODS: The survey was sent out to PDs who supervised USU SOM graduates in the classes of 2008 to 2019 (n = 1,958) with 997 responses for the PGY-1 PD survey and 706 responses to the PGY-3 PD survey. Exploratory factor analysis (EFA) was conducted on 334 complete responses of the PGY-1 survey and 327 responses of the PGY-3 survey. A working group of PDs, USU Deans, and health professions education scholars reviewed the results from the EFA and from a survey of experienced PDs and, in an iterative process, developed a proposed revised survey. RESULTS: The EFA for both the PGY-1 data and the PGY-3 data yielded three factors, and a total of 17 items were identified with cross-loading across the factors in the PGY-1 and/or PGY-3 surveys. Items without clean loadings or that were determined to be unclear, redundant, or difficult to assess by PDs were revised or removed. Items were revised or added to address needs within the SOM curriculum, including the new health systems science competencies. The proposed revised survey had 36 items in place of the original 55 items and contained at least four items for each of the six competency domains (patient care, communication and interpersonal skills, medical knowledge, professionalism, system-based practice and practice-based learning and improvement, and military-unique practice, deployment, and humanitarian missions). CONCLUSIONS: The USU SOM has benefited from over 15 years of results from the PD surveys. We identified those questions that performed well, and these were refined and augmented in order to optimize the performance of the survey and fill gaps in our knowledge of graduates' performance. To determine how well the revised set of questions performs, efforts will be made to increase the response rate and completion of 100% of items on the survey, and the EFA should be repeated after about 2-4 years. Furthermore, the USU graduates should continue to be tracked longitudinally past residency to determine if PGY-1 and PGY-3 survey measures predict long-term performance and patient outcomes.

Assuring TRICARE Coverage of Preventive Health Services for Women Beneficiaries of the Military Health System.

WHY DEFENSE HEALTH HORIZONS PERFORMED THIS STUDY: The primary role of the Military Health System is to assure readiness by protecting the health of the force by providing expert care to wounded, ill, and injured service members. In addition to this mission, the Military Health System (both directly through its own personnel and indirectly, through TRICARE) provides health services to millions of military family members, retirees, and their dependents. Women's preventive health services are an important part of comprehensive health care to reduce rates of disease and premature death and were included in the 2010 Patient Protection and Affordable Care Act's (ACA) expanded coverage of women's preventive health services, based on the best available evidence and guidelines. These guidelines were updated by the Health Resources and Services Administrations and the American College of Obstetrics and Gynecology in 2016. However, TRICARE is not subject to the ACA, and therefore, TRICARE's provisions or the access of TRICARE's female beneficiaries to women's preventive health services was not directly changed by the ACA. This report compares women's reproductive health care coverage under TRICARE with coverage available to women enrolled in civilian health insurance plans subject to the 2010 ACA. WHAT DEFENSE HEALTH HORIZONS RECOMMENDS: Three recommendations are proposed to ensure that women who are TRICARE beneficiaries have access to and receive preventive reproductive health services that are consistent with Health Resources and Services Administration recommendations as implemented in the ACA. Each recommendation has strengths and weaknesses that are described in detail in the body of this paper. WHAT DEFENSE HEALTH HORIZONS FOUND: In covering contraceptive drugs and devices, TRICARE appears to reflect the scope of coverage found in ACA-compliant plans but, by not incorporating the term "all FDA-approved methods" of contraception, TRICARE leaves open the possibility that a narrower definition could be adopted at a future date. There are important differences in how TRICARE and ACA-compliant plans address reproductive counseling and health screening, including TRICARE's more restrictive counseling benefit and some limits to preventive screening. By not aligning with policies related to the provision of clinical preventive services established under the ACA, TRICARE allows health care providers in purchased care to diverge from evidence-based guidelines. Although the ACA respects medical judgment when providing women's preventive services, standards restrict the extent to which health care systems and providers can depart from evidence-based screening and prevention guidelines essential to optimizing quality, cost, and patient outcomes.

Improving the Health and Readiness of Military Women.

WHY THE DEFENSE HEALTH HORIZONS DID THIS STUDY: Women comprise approximately one-fifth of the total force in the U.S. Military. Gynecologic and reproductive health issues not only affect the health and wellness of individual servicewomen but may also impact the mission of the DoD. Unintended pregnancies can result in adverse maternal and infant outcomes and can negatively impact the careers of military women and mission readiness. Gynecologic conditions such as abnormal uterine bleeding, fibroids, and endometriosis can also limit women's optimal health and performance, and a significant proportion of military women have indicated their desire to manage and/or suppress menstrual cycles, especially when deployed. Access to the full range of contraceptive methods is an important strategy to allow women to achieve their reproductive goals and address other health concerns. This report reviews rates of unintended pregnancy and contraceptive utilization among servicewomen and examines factors that influence these measures of health. WHAT DEFENSE HEALTH HORIZONS FOUND: Overall rates of unintended pregnancy are higher among servicewomen than the general population and rates of contraceptive use among servicewomen are lower than the general population. Congress mandates that servicewomen have access to contraceptive options, but the DoD has not established target measures for contraceptive access and use, unlike that present for the civilian population. WHAT DEFENSE HEALTH HORIZONS RECOMMENDS: Four potential courses of action are proposed to improve the health and readiness of military women.Recommendation 1: The Military Health System (MHS) should develop and maintain reliable sources of data to assess the gynecologic health of servicewomen, including rates of unintended pregnancy.Recommendation 2: When menstrual suppression, treatment for a medical condition, or contraception is desired, servicewomen should have ready access to the information they need to select the option that is best suited for their personal preferences and situation.Recommendation 3: In order to ensure that servicewomen have optimal access to the full range of contraceptive methods, the MHS should determine true access at all their facilities and identify actions to address any barriers.Recommendation 4: The MHS should establish service delivery targets for use of women's preventive health services, particularly contraception, to prevent unintended pregnancies.

Unintended pregnancy among U.S. military active duty servicemembers: Estimates for 2018 and trends since 2005.

OBJECTIVES: To evaluate the prevalence of and factors associated with unintended pregnancy in the past 12 months among women and men in the United States (U.S.) military in 2018, as well as trends in unintended pregnancy between 2005 and 2018. STUDY DESIGN: This was a cross-sectional study using the 2018 Department of Defense Health Related Behaviors Survey of active duty servicemembers. We selected a stratified random sample from members of all military service branches and used weighted logistic regression models to identify associated independent factors. A 9.6% weighted response rate to the online survey resulted in 16,806 active duty servicemembers analyzed; 4993 women aged 17 to 44 years and 11,813 men aged 17 to 45+ years. We used data from five independent surveys: 2005, 2008, 2011, 2015, and 2018 to examine trends over time. RESULTS: A total of 5.6% (95% CI: 4.5%-6.7%) of servicewomen reported unintended pregnancy and 2.4% (95% CI: 1.9%-2.9%) of servicemen reported to have caused unintended pregnancy. Unintended pregnancy was associated with contraception nonuse, younger age, and being either married or cohabiting. CONCLUSION: The decrease in prevalence of unintended pregnancy among U.S. servicemembers since 2005 mirrors the general U.S. POPULATION: Differing contraception policies during basic training across military services may influence rates of unintended pregnancy. Unintended pregnancies place a large burden on the military healthcare system, as the majority of women serving in the military are of reproductive age, and thus require care before, during, and for years after giving birth. IMPLICATIONS: Unintended pregnancy among U.S. military servicewomen relatively mirrors that seen in the U.S. POPULATION: Contraceptive policies affect unintended pregnancy throughout servicemembers' duration of service. As they are more likely to live in states which restrict access to abortion services, servicewomen with unintended pregnancy may face increased obstacles to care.

Influence of "Decide + Be Ready" Contraceptive Decision Aid on Pre-deployment Health Decisions.

INTRODUCTION: The number of active duty servicewomen and the career opportunities available to them continue to increase. Of the approximately 350,000 women in uniform, 97% are estimated to be of reproductive age, underscoring the importance of reproductive health care. This study aimed to explore the influence of the Decide + Be Ready (DABR) contraceptive decision aid on providing contraceptive knowledge, facilitating a servicewoman's contraceptive choice before and during deployment, and enabling understanding of individual preferences around contraception in a population of active duty women most at risk for unintended pregnancy. MATERIALS AND METHODS: We conducted a qualitative study, recruiting active duty women between the ages of 17 and 24 with at least one prior deployment who were stationed at Naval Station Norfolk and presented for evaluation at a primary care clinic. Participants downloaded and reviewed the DABR application. A semi-structured interview was conducted and audio-recorded. Interviews were transcribed and underwent thematic analysis. RESULTS: Twenty women participated in the study over 2 weeks. Analysis revealed three overarching themes: perceived utility of and attitudes toward DABR, knowledge of and comfort with contraceptive options, and challenges specific to active duty women. In total, eight subthemes were also identified and explored. CONCLUSIONS: The DABR app provided study participants with new information about contraception. Participants reported improved knowledge of gynecologic and reproductive health options available during deployment. Other findings raise interest for future studies exploring incorporation of peer validation in counseling and decision-making tools, challenges with the deployed environment for obstetric/gynecologic health, and medical support on naval deployments.

Decide + Be Ready: A Contraceptive Decision-Making Mobile Application for Servicewomen.

Women in the military have a high rate of unintended pregnancies, which is an issue both personally and with respect to the warfighting mission. One strategy to help servicewomen achieve family planning goals includes increasing education about and access to contraception. Research suggests that preference-sensitive decisions about contraceptives benefit from shared decision-making, and decision aids have been shown to facilitate this patient-centered approach. In this article, we describe the process by which we enhanced an existing evidence-based tool to meet the needs of military servicewomen and created Decide + Be Ready, a contraceptive decision-making mobile application. After extensive research into challenges faced by servicewomen with respect to contraceptive knowledge and access, we developed content for the decision aid and determined that a mobile app format would provide the privacy and convenience needed. Our team developed a prototype that, in collaboration with the Defense Health Agency Connected Health Branch, was tested with servicewomen and providers. User feedback shaped the final version, which can be accessed free from the App Store and Google Play. Early implementation has demonstrated patient and provider satisfaction. Obstacles to full implementation of Decide + Be Ready remain within the Military Health System. We lay out a roadmap for dissemination, implementation, and evaluation and explore the applications of the decision aid for health professions education in the realm of shared decision-making. Finally, we recommend consideration of decision aids for other health care decisions as a way to achieve patient-centered care, improve health outcomes, and potentially reduce costs.

Seeing Complexity: Cultural Historical Activity Theory (CHAT) As a Lens for Shared Decision Making.

Shared decision making, a collaborative approach between patient and provider that considers the patient's values and preferences in addition to the scientific evidence, is a complex clinical activity that has not realized its full potential. Gaps in education and training have been cited as barriers to shared decision making, and evidence is inconsistent on effective educational interventions. Because individual agents with their own social and behavioral contexts co-construct a shared decision, the educational approach may need to consider the role of patient agency and sociocultural influences. To address the inherent complexity in shared decision making, the authors identified cultural historical activity theory (CHAT) as a framework for analysis. Although certainly not the only relevant theory, CHAT offers an appropriate lens through which the multivoiced nature of shared decision making can be more clearly appreciated. In this article, the authors demonstrate the application of CHAT as a lens for researchers and educators to examine the complexity of shared decision making. The fictitious case presented in this article describes the use of CHAT with a patient who experiences 2 clinical encounters; during the second, shared decision making takes place. Elements of the case are threaded through the article, demonstrating a sample analysis of the interacting activity systems of the patient and physician and highlighting inherent tensions and contradictions. The authors propose CHAT as a tool for future research around the role of agency in shared decision making and other complex topics and as a framework for design of novel instructional strategies. Although not applicable to all topics and settings, CHAT has significant potential within health professions education.

Curricular Change and Resiliency in the Era of Coronavirus (COVID-19): The Uniformed Services University of the Health Sciences (USU) Experience.

INTRODUCTION: The Coronavirus (COVID-19) pandemic has presented a myriad of organizational and institutional challenges. The Uniformed Services University of the Health Sciences, like many other front line hospitals and clinics, encountered a myriad of challenges in fostering and sustaining the education of students enrolled at the nation's only military medical school. Critical to the function of any academic medical institution, but particularly one devoted to the training of future physicians for the Military Health System, was the ability to rapidly adapt, modify, and create new means of keeping medical students engaged in their core curricula and progressing toward full and timely attainment of established educational goals and objectives. METHODS: This article highlights some of the particular challenges faced by faculty and students during the first 6 months of the COVID-19 pandemic and describes how they were managed and/or mitigated. RESULTS: Six key "lessons learned" were identified and summarized in this manuscript. These lessons may be applicable to other academic institutions both within and outside of the Military Health System. CONCLUSIONS: Recognizing and embracing these key tenets of academic change management can accelerate the generation of a cohesive, organizational response to the next pandemic or public health crisis.

The Impact of Mammography Screening Guideline Changes Among Women Serving in the U.S. Military.

INTRODUCTION: The U.S. Preventive Services Task Force (USPSTF) modified their screening guidelines for breast cancer in November 2009. Previous studies evaluated the impact of these guideline changes among privately and Medicare insured populations. Women in the military form a unique population exposed to many social, environmental, and occupational hazards that may increase breast cancer incidence. By evaluating mammography screening rates among women in the military before and after the USPSTF guideline changes, this study evaluated the impact of the USPSTF breast cancer guideline change on screening mammography use within the military population and determined whether current guidelines were followed for this high-risk population with universal health care access. MATERIALS AND METHODS: This study evaluated the impact of the 2009 guideline changes among the population of universally insured military servicewomen, comparing the proportion of active duty women aged 40 to 64 receiving mammograms from fiscal years 2006 to 2015 using an interrupted time series analysis. Stratified analyses evaluated differences by age (aged 40-49, 50-64), race, military branch, and rank. This research is considered exempt by the Uniformed Services University Institutional Review Board. RESULTS: The proportion of insured military servicewomen receiving mammograms increased from October 2005 through September 2009. A significant decrease occurred in the first quarter of 2010 following the publication of the screening guideline update. From this new baseline, the proportion of women screened increased again through September 2015. Comparative analyses showed more pronounced effects both immediately and over time among the women aged 50 to 64 compared to those aged 40 to 49 years and among older enlisted women compared with their officer counterparts. The patterns were near identical in all subgroups; however, no changes in rate were evident among Air Force and black servicewomen aged 50 to 64 and Army and Navy/Marine Corps servicewomen aged 40 to 49 years. No racial disparities in screening or impact were noted. CONCLUSIONS: The USPSTF guidelines had differential impacts among some subpopulations. While older women, aged 50 to 64 years, had a greater temporary reduction immediately after the guideline change, younger women aged 40 to 49 years had a longer-term reduction in screening following the guideline changes. No racial disparities in the proportion screened or in the impact of the guideline change were noted in this population with universal health coverage. The lack of Department of Defense standard breast cancer screening guidelines was evident from the different patterns of mammography utilization observed among military branches. To completely understand the impact of the updated screening guidelines, future studies must incorporate research focusing on changes in breast cancer morbidity and mortality as well as updated cost-benefit analyses.

Impact of Altitude-based Hemoglobin Modification on Pediatric Iron Deficiency Anemia Screening.

OBJECTIVE: To determine if additional children attending primary care clinics in moderate-altitude areas would screen positive for anemia if the hemoglobin cutoff were modified for altitude. STUDY DESIGN: This cross-sectional study evaluated children aged 11-19 months of age who had a screening hemoglobin conducted between January 2011 and December 2017 at 4 moderate-altitude (1726-2212 m) and 8 low-altitude (1-20 m) US military clinics. The primary outcome was anemia prevalence (hemoglobin <11 g/dL) in moderate-altitude and low-altitude groups, before and after applying the current World Health Organization model for altitude-based hemoglobin modification. Groups were compared with prevalence ORs adjusted for age, sex, weight-for-length percentile, and parental military rank, and the false-negative proportion was calculated for children with anemia at moderate altitude. RESULTS: Before altitude modification, anemia prevalence was 4.4% in the moderate-altitude group (n = 1488) and 16.8% in the low-altitude group (n = 7090) (prevalence OR, 0.23; 95% CI, 0.17-0.29). After applying the World Health Organization model, anemia prevalence in the moderate-altitude group increased to 14.7% (prevalence OR, 0.82; 95% CI, 0.70-0.97). Nonapplication of the model at moderate altitude resulted in a false-negative proportion of 0.70 (95% CI, 0.63-0.76). CONCLUSIONS: Nonuse of the World Health Organization altitude-based modification model for hemoglobin may result in a large percentage of US children with anemia at moderate altitude screening falsely negative for anemia. Although ancestry disparities in altitude acclimatization may limit universal application of the current World Health Organization model, the existing standard of care may leave children at moderate altitude at risk for complications from iron deficiency anemia.

Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes: A Systematic Review.

OBJECTIVE: To systematically review the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes. DATA SOURCES: We conducted a comprehensive search for primary literature in ClinicalTrials.gov, Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. METHODS OF STUDY SELECTION: Qualifying primary studies had a comparison group, were conducted in countries ranked very high on the United Nations Human Development Index, published in English, and evaluated obstetric and gynecologic health outcomes. Cochrane Collaboration's tool and ROBINS-I tool were used for assessing risk of bias. Summary of evidence tables were created using the United States Preventive Services Task Force Summary of Evidence Table for Evidence Reviews. TABULATION, INTEGRATION, RESULTS: Of the 3,926 published abstracts identified, 47 met criteria for inclusion and included 31,967 participants. Telehealth interventions overall improved obstetric outcomes related to smoking cessation and breastfeeding. Telehealth interventions decreased the need for high-risk obstetric monitoring office visits while maintaining maternal and fetal outcomes. One study found reductions in diagnosed preeclampsia among women with gestational hypertension. Telehealth interventions were effective for continuation of oral and injectable contraception; one text-based study found increased oral contraception rates at 6 months. Telehealth provision of medication abortion services had similar clinical outcomes compared with in-person care and improved access to early abortion. Few studies suggested utility for telehealth to improve notification of sexually transmitted infection test results and app-based intervention to improve urinary incontinence symptoms. CONCLUSION: Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics. Further well-designed studies are needed to examine these interventions and others to generate evidence that can inform decisions about implementation of newer telehealth technologies into obstetrics and gynecology practice.

How phenomenology can help us learn from the experiences of others.

INTRODUCTION: As a research methodology, phenomenology is uniquely positioned to help health professions education (HPE) scholars learn from the experiences of others. Phenomenology is a form of qualitative research that focuses on the study of an individual's lived experiences within the world. Although it is a powerful approach for inquiry, the nature of this methodology is often intimidating to HPE researchers. This article aims to explain phenomenology by reviewing the key philosophical and methodological differences between two of the major approaches to phenomenology: transcendental and hermeneutic. Understanding the ontological and epistemological assumptions underpinning these approaches is essential for successfully conducting phenomenological research. PURPOSE: This review provides an introduction to phenomenology and demonstrates how it can be applied to HPE research. We illustrate the two main sub-types of phenomenology and detail their ontological, epistemological, and methodological differences. CONCLUSIONS: Phenomenology is a powerful research strategy that is well suited for exploring challenging problems in HPE. By building a better understanding of the nature of phenomenology and working to ensure proper alignment between the specific research question and the researcher's underlying philosophy, we hope to encourage HPE scholars to consider its utility when addressing their research questions.

Prenatal use of medications for gastroesophageal reflux disease and early childhood fracture risk.

BACKGROUND: Gastroesophageal reflux disease is a common condition in pregnancy and is often managed with medications. Specific medications have been linked to osteoporosis and fragility fracture in older adults. This study assessed whether maternal use of antireflux medications is associated with early childhood fracture. METHODS: TRICARE beneficiaries during pregnancy were retrospectively identified using the Military Health System Data Repository and pharmacy data. Mother and infant data were linked; children with continuous enrollment for the first 5 years of life were included. Differences in the children's fracture risk were analyzed through multivariate analysis, adjusting for region, rank, and military branch of service. RESULTS: A total of 378 150 patients comprised the final cohort with 3.3% (n = 12 479) prescribed antireflux medications during pregnancy. A significant decrease in fracture rate was found among children of women who were prescribed antireflux medications during pregnancy compared with those who were not (0.8% vs 1.2%, RR = 0.70, 95% CI 0.58-0.85). There was no difference in fracture risk between histamine type 2 receptor antagonists and proton pump inhibitors. A significantly increased fracture incidence was seen in pregnancies with multiple gestations (RR = 1.38, 95% CI 1.04-1.85). There was no identified difference in fracture risk for women with gestational diabetes, preeclampsia, preterm or low birthweight, chronic hypertension, induction, or breech presentation when compared to women without these conditions. CONCLUSIONS: We found no increase in early childhood fracture risk with maternal antireflux medication use. This suggests that prenatal exposure to antireflux medications does not affect fetal bones to a clinically significant extent.

Pregnancies and live births, active component service women, U.S. Armed Forces, 2012-2016.

This report summarizes data on the demographic and military characteristics of women and women of childbearing potential (WOCBP) in the active component of the U.S. Armed Forces during 2012-2016. Data on pregnancy-related care and birth rates are also presented. In 2016, WOCBP comprised the vast majority of active component service women. The largest proportions of WOCBP were in the categories of women who were 20-24 years old, non-Hispanic white, junior enlisted rank, and in a communications/intelligence occupation. WOCBP were roughly equally distributed in the Army, Navy, and Air Force, whereas only 7.5% served in the Marine Corps. Slightly more than one-quarter of WOCBP had ever deployed to the U.S. Central Command area of responsibility (CENTCOM AOR). In 2016, 13.1% of all WOCBP had at least one pregnancy-related event and 1.1% of deployed WOCBP had a pregnancy event during a deployment to CENTCOM AOR. The prevalence of pregnancy decreased slightly over the surveillance period. There were 63,879 live births during the surveillance period, for an overall live birth rate of 64.9 live births per 1,000 person-years (p-yrs). This rate of live births decreased steadily from 69.8 per 1,000 p-yrs in 2012 to 59.7 per 1,000 p-yrs in 2016. Rates of live births were highest among women who were 30-34 years old, enlisted or junior officer rank, Army, in healthcare occupations, and married. About one-quarter of the total live births were cesarean deliveries.

Contraception among active component service women, U.S. Armed Forces, 2012-2016.

This report summarizes the annual prevalence of permanent sterilization, as well as use of long- and short-acting reversible contraceptives (LARCs and SARCs, respectively), contraceptive counseling services, and use of emergency contraception from 2012 through 2016 among active component U.S. service women. Overall, 262,907 (76.2%) women of childbearing potential used either a LARC or a SARC at some time during the surveillance period. From 2012 through 2016, permanent sterilization decreased from 4.2% to 3.6%; LARC use increased from 17.2% to 21.7%; SARC use decreased from 38.5% to 30.4%; and emergency contraception use increased from 0.4% to 1.9%. Annual prevalence of contraceptive counseling only was relatively stable around 4.0%. This report estimates the length of continuation of LARCs, demonstrating that 86.1% continued their intrauterine device at 12 months, 78.5% at 24 months, and 73.4% at 36 months. These data demonstrate that the vast majority of service women have utilized at least one form of contraception, and that women are selecting LARCs in greater numbers with each passing year. The prevalence of contraceptive utilization among deployed service women is also reported.

Complications and care related to pregnancy, labor, and delivery among active component service women, U.S. Armed Forces, 2012-2016.

Diagnoses of "complications of pregnancy, childbirth, and the puerperium" include both morbid complications and indications for routine care of pregnant women. During 2012-2016, a total of 55,601 U.S. service members with live births (n=63,879) had 657,060 medical encounters with primary diagnoses of "pregnancy complications." The most frequent diagnoses were "other" specified conditions complicating pregnancy, childbirth, or the puerperium. Numbers of medical encounters with a primary (first-listed) diagnosis of any pregnancy-related complication or indication for care decreased marginally each year between 2012 (n=178,703) and 2016 (n=146,282). The percentage of live births affected by pre-eclampsia and gestational diabetes remained relatively stable during the surveillance period. For all age groups, percentages of live births affected by preterm labor decreased, but live births affected by obesity complications increased. The percentage of live births affected by gestational diabetes was more than twice as high for obese women, compared with non-obese women (12.4% vs. 5.5%). Findings suggest some opportunities to prevent sequelae for the mother and child and to mitigate longer-term impacts on force readiness.

Intrapartum obstetric care in the United States military: Comparison of military and civilian care systems within TRICARE.

BACKGROUND: Expectant mothers who are beneficiaries of TRICARE (universal insurance to United States Armed Services members and their dependents) can choose to receive care within direct (salary-based) or purchased (fee-for-service) care systems. We sought to compare frequency of intrapartum obstetric procedures and outcomes such as severe acute maternal morbidity (SAMM) and common postpartum complications between direct and purchased care systems within TRICARE. METHODS: TRICARE (2006-2010) claims data were used to identify deliveries. Patient demographics, frequency of types of delivery (noninstrumental vaginal, cesarean, and instrumental vaginal), comorbid conditions, SAMM, and common postpartum complications were compared between the two systems of care. Multivariable models adjusted for patient clinical/demographic factors determined the odds of common complications and SAMM complications in purchased care compared with direct care. RESULTS: A total of 440 138 deliveries were identified. Compared with direct care, purchased care had higher frequency (30.9% vs 25.8%, P<.001) and higher adjusted odds (aOR 1.37 [CI 1.34-1.38]) of cesarean delivery. In stratified analysis by mode of delivery, purchased care had lower odds of common complications for all modes of delivery (aOR[CI]:noninstrumental vaginal: 0.72 [0.71-0.74], cesarean: 0.71 [0.68-0.75], instrumental vaginal: 0.64 [0.60-0.68]) than direct care. However, purchased care had higher odds of SAMM complications for cesarean delivery (aOR 1.31 [CI 1.19-1.44]) compared with direct care. CONCLUSION: Direct care has a higher vaginal delivery rate but also a higher rate of common complications compared with purchased care. Study of direct and purchased care systems in TRICARE may have potential use as a surrogate for comparing obstetric care between salary-based systems and fee-for-service systems in the United States.