Selection, Initiation, Continuation, and Efficacy of Reversible Contraception Among Enlisted U.S. Service Women in Their First Term of Service From 2012 to 2020.

BACKGROUND: Pregnancy is the second most common cause of limited duty days among active duty service members in the U.S. Military. Pregnancy accounts for 10% of all days on restricted duty, despite impacting a minority of active duty service members. One out of five service women will experience an unintended pregnancy every year despite the availability of no-cost contraception and reproductive healthcare. Young, single, junior enlisted service women experience the highest rate of unintentional pregnancy. Previous studies have demonstrated service branch-based variability in selection, initiation, and continuation of specific contraceptive methods related to service branch culture and access to contraception during basic training. It is unclear if these differences impact overall contraception use or fertility rates among junior enlisted service women in their first term of enlistment. This study examines rates of contraceptive selection, initiation, continuation, and efficacy among junior enlisted service women in their first 4-year enlistment period, and the service branch specific variability in these outcomes. METHODS: This study is a secondary analysis of Military Healthcare Data Repository records from women who began basic training between 2012 and 2020 and remained on active duty for at least 12 months. We used Kaplan-Meier analyses to examine the effect of age and military branch on contraceptive continuation and efficacy. We used binomial regression for interval censored data, to assess the association of service branch with rates of contraceptive initiation, contraception use, births, and childbirth-related duty restrictions. RESULTS: We identified 147,594 women who began basic training between 2012 and 2020. The mean age of these women at the beginning of basic training was 20.4 ± 3.1 years. Women in the marines and navy had higher contraceptive initiation rates than women in the army or air force. Among women initiating a contraceptive pill, patch, or ring (short-acting reversible contraception), 58.3% were still using some form of hormonal contraception 3 months later. Among women initiating depot-medroxyprogesterone (DMPA), 38.8% were still using any form of hormonal contraception 14 weeks later. Long-acting reversible contraceptive methods, such as intrauterine or subdermal contraceptives, had higher continuation rates and less service-based variability in continuation and failure rates than short-acting reversible contraception or depot-medroxyprogesterone. The proportion of days on any form of prescription contraception during the first 4 years on active duty varied from 23.3% in the army to 38.6% in the navy. The birth rate varied from 34.8 births/1,000 woman-years in the air force up to 62.7 births/1,000 woman-years in the army. Compared with women in the air force, women in the army experienced 2,191 additional days of postpartum leave and 13,908 days on deployment restrictions per 1,000 woman-years. DISCUSSION: Service branch specific variability in contraceptive use is associated with differences in days of pregnancy-related duty restrictions during first 4 years on active duty among junior enlisted females. Robust implementation of best practices in contraceptive care across the military health system to improve contraceptive initiation and continuation appears to offer an opportunity to improve military readiness and promote the health and well-being of active duty service women, particularly in the army.

Brief report: Influence of mandatory contraceptive education emphasizing long-acting reversible methods on continuation rates among military recruits.

OBJECTIVES: Determine if the replacement of patient-initiated, individual contraceptive education with mandatory group contraceptive education, during US Navy basic training, was associated with decreased LARC continuation. STUDY DESIGN: Secondary analysis of administrative billing data from female military recruits who began basic training between September 2012 and February 2020. RESULTS: Servicewomen who started LARC method during rather than after basic training had higher continuation rates. Servicewomen who started training before the implementation of mandatory group education had higher IUD continuation than those trained after. CONCLUSIONS: Implementation of mandatory group contraceptive education during basic training was not associated with a decline in LARC continuation.

Improving Global Access to Transgender Health Care: Outcomes of a Telehealth Quality Improvement Study for the Air Force Transgender Program.

Purpose: To describe the development of the United States Air Force's (USAF) telehealth program from fall 2017 through fall of 2020 in response to the unique challenges associated with providing care for a global transgender military population. Methods: Telehealth visit completion rates were monitored at time of encounters and through electronic health record reports. Patient satisfaction data were obtained by immediate postvisit survey, across provider care received, logistics of setting up the appointment, and quality of the virtual health system connection. Patient cases highlighting opportunities for transgender telehealth were summarized. Results: Between September 9, 2019 and October 28, 2020, 99 telehealth encounters with video-to-video connection occurred. Twenty-three of the encounters were for gender-affirming hormone therapy, 17 for mental health visits, and 59 for speech therapy. Thirty-five surveys were collected from 20 patients. Overall patients were "satisfied" or "very satisfied" with providers' ability to manage their chief complaint through this modality (average 4.9 out of 5 on 1 to 5 scale with 1 being "very dissatisfied" and 5 being "very satisfied") and "strongly agree" that telehealth is an effective means to accomplish care (average score 4.8 on 1 to 5 scale with 1 being "strongly disagree" and 5 "strongly agree"). Services provided spanned 11 USAF bases worldwide. Conclusions: Telehealth is successful in ensuring ongoing transgender health care services for a global military population. The success of this program may have implications for future military and civilian endeavors to bridge care gaps for transgender patients in resource-poor or distant-site locations.

Influence of military contraceptive policy changes on contraception use and childbirth rates among new recruits.

BACKGROUND: Unplanned pregnancy is a common problem among United States servicewomen. Variation among service branches in contraceptive education and access during initial training is associated with differences in contraceptive use and childbirth rates despite access to a uniform health benefit including no-cost reproductive healthcare and contraception. However, it is unclear whether changes in branch-specific contraceptive policies can influence reproductive outcomes among junior enlisted women in that service branch. OBJECTIVE: To assess the longitudinal effect of contraceptive policy changes on contraception use and childbirth rates among military recruits. MATERIALS AND METHODS: Secondary analysis was performed of insurance records from 70,852 servicewomen who started basic training between October 2013 and December 2016, assessing the longitudinal impact of a Navy policy change expanding contraceptive access during basic training implemented in January 2015, and a Marine Corps policy change restricting contraceptive access during basic training implemented in January 2016 on the following: contraception use (pills, patches, rings, injectable, implantable, and intrauterine) at 6 months, long-acting reversible contraception use at 6 months, and childbirth prior to 24 months after service entry. We used logistic and Cox regression models, adjusted for age group, to compare outcomes of women in the Navy and Marine Corps who started basic training before and after their service branch's policy change with outcomes among women in the Army and Air Force. RESULTS: Compared to the longitudinal difference observed among women attending Army or Air Force basic training, changing policies to increase contraceptive access during Navy basic training in January 2015 increased contraception use from 33.1% of sailors to 39.2% of sailors before and after the policy change (interaction term odds ratio, 1.31; 95% confidence interval, 1.22-1.41) and long-acting reversible contraception use 11.0% to 22.7% (odds ratio, 1.78; 95% confidence interval, 1.50-2.08). However, this policy change was not associated with a decline in childbirth rates among sailors (7.5% versus 6.1%) relative to the change among women in the Army and Air Force over the same time period (interaction term hazard ratio, 0.90; 95% confidence interval, 0.79-1.03). The January 2016 Marine Corps policy change decreased contraception use (29.6% to 24.4%; odds ratio, 0.78; 95% confidence interval, 0.70-0.88), long-acting reversible contraception use 14.6% to 7.3% (odds ratio, 0.39; 95% confidence interval, 0.31-0.48), and increased childbirth rates (8.0% to 9.6%; hazard ratio, 1.26; 95% confidence interval, 1.03-1.55) among Marines compared to outcomes in the Army and Air Force over the same time period. CONCLUSION: Basic training contraceptive policy influences contraception use among junior enlisted servicewomen. Implementing best practices across the military may increase contraception use and decrease childbirth rates among junior enlisted servicewomen.

Contraceptive use and childbirth rates by service branch during the first 24 months on active duty in the United States military from 2013 to 2018: a retrospective cohort analysis.

OBJECTIVE: To measure the association of military branch-specific contraceptive education and access policy during basic training with contraceptive use and childbirth among new recruits. STUDY DESIGN: Secondary analysis of insurance records from 92,072 active duty servicewomen who started basic training between 2013 and 2017. RESULTS: Exposure to reproductive health education and access to contraception during basic training differ by military branch. Highly effective contraception use (pills, patch, ring, shot, implants or intrauterine contraception) at 6 months on active duty [Army (18.1%), Air Force (27.4%), Marines (26.5%) and Navy (37.6%), p<.001], long-acting reversible contraceptive method use (implant or intrauterine) at 6 months [Army (2.0%), Air Force (3.7%), Marines (11.0%) and Navy (19.6%), p<.001] and childbirth in the first 24 months of service [Army (11.1%, 95% CI 10.7-11.5), Air Force (6.0%, 95% CI 5.6-6.4), Marines (8.4%, 95% CI 7.8-9.0) and Navy (6.7%, 95% CI 6.3-7.1)] varied by service branch. After adjusting for age at basic training and contraceptive use at 6 months on active duty, childbirth rates differed among all branches. The Army (hazard ratio 1.86, 95% CI 1.71-2.01), Marines (1.48, 95% CI 1.33-1.65) and Navy (1.24, 95% CI 1.13-1.35) all had a higher risk of delivery than the Air Force. CONCLUSION: Variation in branch-specific contraceptive education and access policy during basic training is associated with differences in rates of contraceptive use at 6 months on active duty and childbirth prior to 24 months on active duty. This occurs despite all recruits having access to an identical medical benefit including no-cost access to contraception after completing initial training. Further study is needed to determine the etiology of these differences. IMPLICATIONS: Guidelines for contraceptive education and access during basic training, highly effective contraception use after 6 months of service and childbirth in the first 24 months of service vary among branches of the United States military. Reducing this variability may reduce childbirth rates and improve the reproductive health of junior enlisted servicewomen.