February 2021 Newsletter

24 | MHCE - News www.mhce.us FEBRUARY 2021 EDITION
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."
If You Want to Recruit and Retain More
Women, Reexamine Military Health Care
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the service and repealed the involuntary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
Journalpublished 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, posttraumatic
stress disorder, depression,
musculoskeletal problems and endocrine
dysfunction, among others.
"PTSD, for instance, has been associated
with a higher risk of spontaneous preterm
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
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.