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The Women's Reproductive Health Survey (WRHS) of Active-Duty Service Members.

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Rand Health Quarterly, 15 May 2023, 10(2):11
PMID: 37200828 PMCID: PMC10187555

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Abstract 

The Women's Reproductive Health Survey (WRHS) of active-duty service members represents the first time since the 1990s that the U.S. Department of Defense (DoD) has sponsored a department-wide survey of only service women. Maintaining the readiness of the U.S. armed forces requires attention to the health and health care needs of all who serve, including active-duty service women (ADSW). With respect to reproductive health, Congress passed two pieces of legislation in the 2016 and 2017 National Defense Authorization Acts that required DoD to provide ADSW access to comprehensive family planning and counseling services and to do so at predeployment and annual physical exams. The legislation also required DoD to conduct a survey of ADSW's experiences with family planning services and counseling and use and availability of preferred birth control methods. RAND Corporation researchers developed the WRHS to address these two pieces of congressional legislation. The Coast Guard requested that RAND also field the survey among its ADSW. In this study, the authors detail the methodology, sample demographics, and results from the survey (conducted between early August and early November 2020) across a number of domains: health care utilization, birth control and contraceptive use, reproductive health during training and deployment, fertility and pregnancy, and infertility. Differences are examined by service branch, pay grade, age group, race/ethnicity, marital status, and sexual orientation. The results are intended to inform policy initiatives to help support the readiness, health, and well-being of ADSW.

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Rand Health Q. 2023 May; 10(2): 11.
Published online 2023 May 15.
PMCID: PMC10187555
PMID: 37200828

The Women's Reproductive Health Survey (WRHS) of Active-Duty Service Members

Sarah O. Meadows, Rebecca L. Collins, Megan S. Schuler, Robin L. Beckman, and Matthew Cefalu
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Short abstract

The Women's Reproductive Health Survey addresses legislation requiring a survey about access to family planning and counseling services among active-duty service women.

Keywords: Enlisted Personnel, Family Planning, Female Populations, Military Health and Health Care, Pregnancy, United States Department of Defense

Abstract

The Women's Reproductive Health Survey (WRHS) of active-duty service members represents the first time since the 1990s that the U.S. Department of Defense (DoD) has sponsored a department-wide survey of only service women. Maintaining the readiness of the U.S. armed forces requires attention to the health and health care needs of all who serve, including active-duty service women (ADSW). With respect to reproductive health, Congress passed two pieces of legislation in the 2016 and 2017 National Defense Authorization Acts that required DoD to provide ADSW access to comprehensive family planning and counseling services and to do so at predeployment and annual physical exams. The legislation also required DoD to conduct a survey of ADSW's experiences with family planning services and counseling and use and availability of preferred birth control methods.

RAND Corporation researchers developed the WRHS to address these two pieces of congressional legislation. The Coast Guard requested that RAND also field the survey among its ADSW. In this study, the authors detail the methodology, sample demographics, and results from the survey (conducted between early August and early November 2020) across a number of domains: health care utilization, birth control and contraceptive use, reproductive health during training and deployment, fertility and pregnancy, and infertility. Differences are examined by service branch, pay grade, age group, race/ethnicity, marital status, and sexual orientation. The results are intended to inform policy initiatives to help support the readiness, health, and well-being of ADSW.

Maintaining readiness and lethality of the U.S. armed forces requires attention to the health and health care needs of all who serve. Currently, women make up approximately 17 percent of the active-duty force. With the rescission in 2016 of the 1994 Direct Ground Combat Exclusion Rule, women became eligible to serve in every military occupation. Like their civilian women counterparts, service women face decisions regarding their reproductive health, including contraceptive use and timing of pregnancies (if desired). In the military context, service women's reproductive health and fertility patterns may potentially affect physical capabilities, assignments, and ability to deploy. Women in the military should expect to receive the same high level of medical care and treatment that their male counterparts receive—care and treatment that are intended to support the health and readiness of the force.

With respect to reproductive health, Congress passed two pieces of legislation targeted at the U.S. Department of Defense (DoD). First, the 2016 National Defense Authorization Act (NDAA), Section 718, required DoD to “establish clinical practice guidelines for health care providers employed by the Department of Defense on standards of care with respect to methods of contraception and counseling on methods of contraception for members of the Armed Forces” and to provide service women “access to comprehensive counseling on the full range of methods of contraception provided by health care providers [in accordance to established clinical practice guidelines] during health care visits, including pre-deployment health care visits, … health care visits during deployment, and … annual physical examinations.” Second, the 2017 NDAA, Section 747, required DoD to conduct a survey of service members’ experiences with “family planning services and counseling”—specifically, access to counseling and family-planning methods, experiences with use of contraceptives, and availability of preferred methods. The Defense Health Agency asked the RAND Corporation to develop a survey of DoD active-duty service women (ADSW) to address these two pieces of congressional legislation. The Coast Guard requested that RAND also field the survey among ADSW in the Coast Guard. The resulting Women's Reproductive Health Survey (WRHS) represents the first time in more than 30 years that women have been the specific focus of a DoD-wide survey.

Method

Sample and Response Rates

The WRHS was conducted between early August and early November 2020 among ADSW below the flag rank in the U.S. Air Force, Army, Marine Corps, Navy, and Coast Guard. Trainees and service women at military academies were excluded from the WRHS. From the sampling frame of 249,128 eligible ADSW, the WRHS utilized a stratified random sample (with stratification based on service branch and pay grade) of DoD ADSW from the Air Force, Army, Marine Corps, and Navy, as well as a census of all Coast Guard ADSW below flag rank (n = 6,113). Per this sampling design, 131,113 ADSW were selected to be contacted for WRHS participation. The final analytic sample consisted of surveys from 23,950 ADSW.

Table 1 shows the WRHS sampling frame, sample size, and response rates by service branch and pay grade. Response rates were calculated as (number of usable surveys / [total sample – ineligibles]) × 100.

Table 1

Sampling Frame, Sample Size, and Response Rates

 Sampling
Frame		Total Sample
Size		NoncontactsaAnalytic Sample SizeWeighted Response Rateb (%)
Service branch     
Air Force73,23537,670169,51625.3
Army83,80443,106166,37114.8
Marine Corps16,8458,6651801,28814.9
Navy69,13135,55964,45312.5
Coast Guard6,1136,11342,32238.0
Pay grade     
E1–E4105,27555,0701895,3209.4
E5–E671,99538,044136,60316.8
E7–W526,49313,88853,66426.0
O1–O329,59515,74294,95130.8
O4–O615,7708,36963,41240.2
Total249,128131,11322223,95017.8
aNoncontacts includes sample members for whom we did not have either a mailing or email address in the Defense Manpower Data Center sample data file.
bResponse rates were calculated with the following equation: (number of usable surveys/[total sample – ineligibles]) × 100. Ineligibles are individuals who were no longer in the military at the time of the survey or were ineligible for an unspecified reason.

In this case, ineligibles are sample members who were no longer in the military at the time of the survey or were ineligible for an unspecified reason (n = 6). This response-rate calculation corresponds to the American Association for Public Opinion Research's Response Rate 1 (American Association for Public Opinion Research, 2016).1 We also present weighted response rates, using the design weights (which are described in the next section). The overall weighted response rate was 17.8 percent.

Weights

The WRHS analytic sample does not identically match the population of ADSW from which it was drawn for two reasons: survey design and nonresponse. First, the sampling frame utilized stratification based on service branch and pay grade, such that the probability of being selected for WRHS participation varied across different combinations of service branch and pay grade. In accordance with standard survey practices, survey design weights were used to adjust for these differing sampling probabilities because of stratification. A service member's design weight is the inverse of her probability of being selected for sampling.2 Specifically, the design weight is equal to the number of eligible individuals in the service member's respective stratum divided by the number selected for sampling from that stratum.

Additionally, nonresponse weights were used to account for differences between ADSW selected for participation in the WRHS who did and did not complete the survey. Specific types of sampled service members were more likely to respond to the survey than others (e.g., higher versus lower pay grades); nonresponse weights were used to make the respondents representative of all individuals selected for sampling. Nonresponse weights were computed as inverse probability weights, in which the probability of being a respondent was estimated using a statistical model.

Final analytic weights were calculated as the product of the design and nonresponse weights. These weights were used in all analyses presented in this study to make the analytic sample representative of the overall population of ADSW eligible for WRHS inclusion.

Imputation of Missing Data

The nonresponse weighting described above accounts for differences between those who responded to our survey and those who did not. These weights do not, however, account for drop-off (i.e., stopping the survey before reaching the end) or intermittent missing data for a respondent. To account for these types of missing data, we used a single imputation to fill in missing values. On the basis of the comprehensive comparison of imputation approaches in the 2018 Health Related Behaviors Survey (see Meadows et al., 2021), we used a sequential imputation model with predictive mean matching for all variable types (Little and Rubin, 2019; van Buuren, 2018; White, Royston, and Wood, 2011). We implemented this using the mice package in R version 3.6.0 (R Foundation, undated; van Buuren and Groothuis-Oudshoorn, 2011). Imputation allows for the inclusion of all available data when performing analyses and avoids problems associated with case-wise deletion of observations with missing data.

Analysis Approach

All analyses, unless otherwise noted, used the final analytic weights and imputations previously described. Variance inflation due to weighting was handled by using the survey procedures of SAS 9.4 when producing our summary statistics. Confidence intervals for estimates were computed using the Wald method.

In some cases, point estimates or confidence intervals are not shown in results tables. We do this for two reasons. First, to protect respondent confidentiality, both point estimates and confidence intervals are suppressed when fewer than 15 service members are included in the denominator of any given cell. That is, when the eligible population is fewer than 15. Second, when estimates are deemed too unstable to be considered reliable, confidence intervals, but not point estimates, are provided. This occurs when the half width of a confidence interval is 15 percent or greater (i.e., greater than the point estimate itself).

Limitations

First, although the response rate is higher than in many recent DoD-wide surveys (e.g., the 2015 and 2018 Health Related Behaviors Surveys), it is still considered low by absolute standards. This, however, does not mean the results are not valid or trustworthy or are biased. The response rate for the WRHS is in line with other DoD surveys. For example, the 2018 Workplace and Gender Relations Survey of Active Duty Members also had an 18 percent unweighted response rate and a 17 percent weighted response rate (Breslin et al., 2019). Second, for some groups (e.g., recently deployed female Marines), sample and cell sizes are small. This means that the precision of some estimates may be low and confidence intervals may be large. Third, there are possible limitations related to the interpretation of survey items that refer to services obtained through the Military Health System (MHS). For example, the survey language does not specify whether care provided “within the MHS” or “by MHS providers” refers to only direct care (i.e., generally provided at military treatment facilities [MTFs]) or includes both direct and purchased care (i.e., care covered by TRICARE but generally not provided within the context of an MTF or by a military provider). Similarly, when the survey refers to “the MHS,” it does not explicitly specify that this includes Coast Guard clinics.3 Individual respondents might have interpreted these MHS survey items differently. Fourth, it is important to keep in mind that the survey was fielded during the COVID-19 pandemic, although its impact on the study is not obvious. On the one hand, junior enlisted ADSW might have had a difficult time accessing their DoD emails if they worked remotely during the survey period. ADSW in general might not have sought out needed or wanted care because they believed that it was unavailable given COVID-related restrictions, when, in reality, that might not have been the case. On the other hand, ADSW might have had more flexibility in their schedules, which could have positively affected their ability both to take the survey and to get needed or wanted care.

Sociodemographic and Military Characteristics

Table 2 presents sociodemographic and military characteristics of the weighted sample. Results are presented by service branch, as well as for the DoD total (i.e., the Air Force, Army, Marine Corps, and Navy, excluding the Coast Guard). Superscripts denote statistically significant differences across all five service branches.

Table 2

Demographic and Military Characteristics, by Service Branch

 Percentage of Total Sample
DoD TotalAir ForceArmyMarine CorpsNavyCoast Guard
Pay grade      
E1–E442.5%
(41.5–43.6)		39.6%c, d, e
(38.4–40.7)		40.4%c, e
(38.3–42.5)		60.7%a, b, d, e
(57.6–63.8)		43.8%a, c, e
(41.6–46.0)		31.0%a, b, c, d
(28.6–33.3)
E5–E628.8%
(28.0–29.6)		27.9%c, d, e
(26.9–28.9)		26.1%d, e
(24.7–27.6)		23.6%a, d, e
(21.0–26.2)		34.2%a, b, c
(32.4–36.0)		34.1%a, b, c
(32.0–36.2)
E7–E99.8%
(9.4–10.2)		12.7%b, c, d, e
(12.1–13.4)		11.1%a, c, d, e
(10.3–11.9)		5.3%a, b
(4.3–6.3)		6.2%a, b
(5.6–6.8)		6.5%a, b
(5.5–7.5)
W1–W50.9%
(0.8–1.0)		NA2.3%c, d
(2.0–2.6)		0.6%b, d. e
(0.3–0.9)		0.2%b, c, e
(0.1–0.2)		2.3%c, d (1.8–2.8)
O1–O311.7%
(11.3–12.1)		12.3%c, d, e
(11.7–12.9)		12.9%c, d, e
(12.2–13.7)		7.5%a, b, d, e
(6.3–8.6)		10.7%a, b, c, e
(9.9–11.5)		17.5%a, b, c, d
(16.0–18.9)
O4–O66.3%
(6.0–6.5)		7.5%c, d
(7.1–8.0)		7.1%c, d, e
(6.6–7.6)		2.4%a, b, d, e
(1.9–2.9)		4.9%a, b, c, e
(4.5–5.3)		8.7%b, c, d
(7.7–9.6)
Age      
8–24 years33.9%
(32.8–34.9)		29.7%c, d, e
(28.6–30.9)		30.6%c, d, e
(28.4–32.8)		61.7%a, b, d, e
(58.7–64.8)		35.4%a, b, c, e
(33.1–37.7)		21.5%a, b, c, d
(19.3–23.7)
25–34 years42.5%
(41.5–43.4)		44.0%c
(42.9–45.1)		41.2%c, d, e
(39.4–43.0)		29.5%a, b, d, e
(26.7–32.4)		45.5%b, c
(43.4–47.5)		47.3%b, c
(45.1–49.5)
35–44 years19.1%
(18.6–19.7)		21.8%c, d, e
(20.9–22.6)		21.7%c, d, e
(20.5–22.8)		7.9%a, b, d, e
(6.7–9.0)		16.1%a, b, c, e
(15.0–17.1)		27.4%a, b, c, d
(25.6–29.2)
45+ years4.5%
(4.3–4.8)		4.5%b, c, d (4.1–4.9)6.5%a, c, d, e
(6.0–7.1)		0.8%a, b, d, e
(0.5–1.2)		3.0%a, b, c
(2.7–3.4)		3.8%b, c
(3.1–4.5)
Education level
High school or less55.1%
(54.2–56.0)		46.2%c, d, e
(45.0–47.3)		47.2%c, d, e
(45.3–49.2)		83.3%a, b, d, e
(81.3–85.2)		67.3%a, b, c, e
(65.6–69.0)		61.1%a, b, c, d
(58.9–63.2)
Some college17.1%
(16.4–17.7)		22.7%b, c, d, e
(21.8–23.6)		19.4%a, c, d, e
(18.1–20.7)		4.4%a, b, d, e
(3.1–5.6)		11.3%a, b, c, e
(10.3–12.3)		15.9%a, b, c, d
(14.3–17.5)
Bachelor's degree or more27.9%
(27.2–28.5)		31.1%c, d, e
(30.2–32.1)		33.4%c, d, e
(31.9–34.8)		12.4%a, b, d, e
(10.9–13.9)		21.4%a, b, c
(20.1–22.7)		23.0%a, b, c
(21.3–24.8)
Race/ethnicity      
Non-Hispanic white44.3%
(43.3–45.2)		52.3%b, c, d, e
(51.1–53.4)		39.4%a, c, e
(37.7–41.2)		45.5%a, b, e
(42.1–48.8)		41.3%a, e
(39.3–43.3)		66.8%a, b, c, d
(64.6–69.1)
Non-Hispanic black25.0%
(24.1–26.0)		19.7%b, d, e
(18.7–20.7)		32.0%a, c, d, e
(30.1–33.9)		16.4%b, d, e
(13.5–19.3)		24.2%a, b, c, e
(22.3–26.1)		7.4%a, b, c, d
(5.9–8.8)
Hispanic19.6%
(18.7–20.4)		17.3%c
(16.4–18.2)		19.7%c, e
(18.1–21.3)		30.4%a, b, d, e
(27.2–33.6)		19.1%c, e
(17.3–20.9)		14.8%b, c, d
(13.2–16.5)
Non-Hispanic Asian6.5%
(6.0–7.0)		5.1%b, d
(4.6–5.6)		7.7%a, c, e
(6.7–8.8)		4.9%b (3.4–6.3)7.0%a, e
(5.9–8.1)		4.1%b, d
(3.1–5.1)
Other race/ethnicity4.6%
(4.3–5.0)		5.6%b, c, d (5.1–6.1)1.1%a, c, d, e (0.9–1.4)2.9%a, b, d, e
(1.9–3.8)		8.4%a, b, c
(7.3–9.4)		6.8%b, c
(5.8–7.9)
Marital status      
Married48.4%
(47.4–49.3)		51.7%c, d
(50.6–52.9)		52.0%c, d
(50.1–54.0)		42.0%a, b, e
(38.7–45.3)		41.8%a, b, e
(39.8–43.8)		53.0%c, d
(50.7–55.2)
Cohabiting11.1%
(10.5–11.7)		10.8%b, d
(10.1–11.6)		8.6%a, d, e
(7.6–9.6)		11.0%
(9.0–13.1)		14.6%a, b, e
(13.1–16.1)		11.3%b, d
(9.8–12.8)
Separated, divorced, or widowed28.6%
(27.6–29.6)		26.2%b, c, e
(25.2–27.3)		25.3%a, c, d, e (23.3–27.3)38.8%a, b
(35.3–42.3)		32.7%b, e
(30.6–34.7)		27.2%a, b, d
(25.1–29.4)
Never married11.9%
(11.3–12.5)		11.2%c, d
(10.5–11.9)		14.1%c, d
(12.9–15.2)		8.1%a, b, d, e
(6.6–9.7)		10.9%a, b, c, e
(9.8–12.1)		8.5%c, d
(7.2–9.7)
Parental status      
Dependent in householdf37.7%
(36.8–38.7)		39.1%b, c, d
(38.0–40.2)		42.7%a, c, d, e
(40.9–44.5)		25.3%a, b, d, e
(22.6–27.9)		33.4%a, b, c, e
(31.5–35.2)		38.2%b, c, d
(36.1–40.3)
Sexual orientation      
Heterosexual or straight82.6%
(81.8–83.4)		84.5%c, d
(83.6–85.3)		83.3%c
(81.7–84.9)		76.4%a, b, d, e
(73.4–79.5)		81.3%a, c
(79.7–82.9)		82.6%c
(80.9–84.4)
Gay or lesbian5.5%
(5.1–6.0)		4.5%c, d, e
(4.0–4.9)		5.9%
(4.9–6.9)		6.9%a
(5.3–8.5)		5.9%a
(5.0–6.9)		7.9%a (6.7–9.1)
Bisexual11.8%
(11.2–12.5)		11.1%c
(10.3–11.8)		10.8%c
(9.4–12.2)		16.7%a, b, e
(13.9–19.5)		12.8%e
(11.3–14.2)		9.4%c, d
(8.0–10.9)

NOTES: All data are weighted. 95 percent confidence intervals are presented in parentheses. The Air Force does not use warrant officers. NA = not applicable.

aStatistically significantly different from the Air Force estimate.
bStatistically significantly different from the Army estimate.
cStatistically significantly different from the Marine Corps estimate.
dStatistically significantly different from the Navy estimate.
eStatistically significantly different from the Coast Guard estimate.
fIncludes both biological and nonbiological children.

ADSW are predominately enlisted, junior ranking, and under the age of 35. With respect to education level, 55 percent of ADSW have a high school degree, and the remaining 45 percent have some college experience or a college degree. Approximately 44 percent of ADSW identify as non-Hispanic white, a quarter identify as non-Hispanic black, and approximately one-fifth identify as Hispanic. Nearly half of ADSW are currently married; approximately a third are responsible for a coresident child under the age of 18. Regarding sexual orientation, 17 percent of ADSW identify as gay or lesbian or bisexual.

Key Findings

In this section, we highlight key findings, organized by substantive area. This summary does not include results for any subgroup analysis or confidence intervals around point estimates.

Health Care Utilization

Within this domain, we examined ease of getting an appointment, sponsorship, appointment wait time, women's health clinics (WHCs), and human papillomavirus (HPV) vaccine uptake. Key findings include the following:

  • Just over half of DoD ADSW indicated that it was usually or always easy to get an appointment with an MHS provider (58.3 percent). Results were similar for the Coast Guard (54.6 percent).

    • The percentage of ADSW in DoD who said that it was never easy to schedule an appointment with a specialist (29.2 percent) or obstetrics-gynecology physician (OBGYN) (27.9 percent) was larger than it was for a generic appointment (12.3 percent).

    • Roughly half of DoD ADSW indicated that it was usually or always easy to get any care, tests, or treatment needed through the MHS (44.2 percent), whereas about a quarter said that it was never easy to get these services (23.4 percent). Results were similar for the Coast Guard (43.6 percent said usually or always easy, and 22.3 percent said never easy).

  • A sponsor is a service member who is TRICARE-eligible. Half of DoD ADSW indicated that a scheduler asked whether they were the sponsor (50.8 percent), less than a third (roughly 30 percent) said that they were not asked, and about a fifth (18.3 percent) could not remember whether they had been asked. The pattern of responses was similar for the Coast Guard.

  • Overall, across the DoD services, about one-third of ADSW (31.9 percent) indicated that they waited between a week and a month (8 to 28 days) for their most recent health care appointment. The same was true for the Coast Guard (36.8 percent). Roughly one-tenth experienced a wait time of less than 24 hours (10.5 percent for DoD and 6.1 percent for the Coast Guard) or more than one month (9.0 percent for DoD and 13.3 percent for the Coast Guard). Similarly, about one-tenth of ADSW indicated that they were unable to get an appointment (9.4 percent for DoD and 8.4 percent for the Coast Guard).

    • TRICARE guidelines say that routine care appointments, such as those provided by a primary care physician, must happen within a week (or seven calendar days) of a request. Almost two-thirds (61 percent) of ADSW in DoD indicated that they were able to get an appointment within a week. Half (50.5 percent) of ADSW in the Coast Guard were also able to get an appointment with a primary care physician within a week.

    • TRICARE guidelines also say that well-woman visits (e.g., for pap smears) and appointments with specialty providers occur within four weeks (or 28 days) of a request. Among ADSW in the DoD services, 72.6 percent indicated that they were able to get an appointment with an OBGYN within 28 days, and 70.2 percent indicated that they were able to get an appointment with a specialist within 28 days. Among ADSW in the Coast Guard, the comparable percentages were 72.7 and 69.7.

  • Roughly one-third (35.4 percent) of all DoD ADSW indicated that their installation had a WHC. It is worth noting that roughly the same percentage of ADSW (31.5 percent) indicated that they were unsure of whether their installation had a WHC. In contrast to the DoD services, only 4 percent of Coast Guard ADSW indicated that their installation had a WHC and roughly one-fifth (17.9 percent) did not know whether their installation housed a WHC.

    • Among only ADSW who reported that they did have access to a WHC on their installation, just over half of DoD ADSW reported using a WHC in the past year (56.7 percent). Although few ADSW in the Coast Guard had access, among those who did, two-thirds used a center (66.8 percent).

    • Among ADSW who used a WHC in the past year, a larger percentage said that it was usually or always easy to get an appointment with an OBGYN than the percentage for the entire sample (54.8 percent versus 44.0 percent). The same was true for ADSW in the Coast Guard (59.3 percent versus 42.7 percent). Self-reports about wait times were similar: Among DoD ADSW, 82.5 percent who used a WHC were able to get an appointment within 28 days, whereas the overall total was 72.6 percent.

  • One-third of DoD ADSW indicated that they had received three doses of an HPV vaccine (32.6 percent). An additional one-third were unsure of how many doses they had received (34.7 percent). Roughly one-fourth had not received any doses at all (23.1 percent). Findings were similar for the Coast Guard—33.7 percent had received three doses, 29.3 percent were unsure, and 24.1 percent had not received the vaccine.

Birth Control and Contraceptive Use

Within this domain, we examined current contraceptive use, contraception counseling from MHS providers during the annual periodic health assessment (PHA), contraception sources (both through and outside the MHS), access to preferred contraceptive methods, and contraception use for menstrual regulation or suppression. Key findings include the following:

  • Overall, roughly 60 percent of ADSW reported any current contraceptive use. Approximately three in ten were currently using a highly effective form of contraception (i.e., intrauterine device [IUD], implant, or sterilization), representing half of all ADSW currently using any form of contraception.

  • Approximately three in ten of both DoD and Coast Guard ADSW had ever used an IUD since joining the military.

  • Less than 15 percent of DoD and Coast Guard ADSW reported use of emergency contraceptives in the past year.

  • Regarding contraceptive counseling, approximately a quarter of DoD ADSW and a fifth of Coast Guard ADSW had discussed the benefits, side effects, and risks of different types of birth control with an MHS provider during a PHA in the past year. The PHA is one of several settings in which ADSW could receive contraception counseling (Defense Health Agency Procedural Instruction 6200.02, 2019). Counseling could also have been offered during a PHA but declined by the respondent.

  • Since joining the military, the majority of ADSW have tried to access birth control through the MHS (75 percent of DoD ADSW and 70 percent of Coast Guard ADSW). Among DoD ADSW, 51 percent had experiences that did not involve a delay, 22 percent had experienced a delay at least once, and 6 percent were unable to ever obtain the birth control they needed through the MHS.

  • Approximately one in five DoD and Coast Guard ADSW reported being unable to access their preferred form of birth control through the MHS at some point since joining the military.

  • Top reasons for being unable to access a preferred birth control method included the following: not available at the duty location, not covered by TRICARE or insurance (particularly for Coast Guard ADSW), and not available at deployment location (particularly for Navy ADSW).

  • During the past year, approximately half of DoD and Coast Guard ADSW obtained birth control; the most common source was MHS providers. Approximately half of DoD and Coast Guard ADSW either agreed or strongly agreed that they felt comfortable getting birth control from an MHS provider. However, one-third of ADSW in DoD and one-fourth of ADSW in the Coast Guard indicated that they would be more comfortable getting birth control from a provider outside the MHS.

  • Approximately one in five DoD and Coast Guard ADSW reported that they had felt pressured by an MHS provider to use a specific type of birth control.

  • ADSW were most likely to report perceived pressure regarding birth control pills, IUDs, or birth control implants.

  • Across service branches, 97 percent of DoD ADSW and 99 percent of Coast Guard ADSW reported that they had not heard of the Decide + Be Ready app.

  • Overall, 17 percent of DoD ADSW and 10 percent of Coast Guard ADSW reported that their menstrual cycles typically interfered with their jobs for a week or more.

  • Across service branches, about 60 percent of ADSW reported that they had at some point needed or wanted to regulate or suppress their menstrual cycles since joining the military.

  • The most common forms of birth control used for menstrual regulation or suppression were birth control pills (ever used by 38 percent of DoD ADSW and 41 percent of Coast Guard ADSW) and IUDs (ever used by 17 percent of DoD ADSW and 16 percent of Coast Guard ADSW).

Reproductive Health During Training, Predeployment, and Deployment

Within this domain, we examined predeployment contraception counseling and access, contraception access during deployment, contraception use for menstrual regulation or suppression during deployment, urinary tract or vaginal infections, and access to feminine hygiene products. Key findings include the following:

  • Among ADSW who had deployed within the past 24 months, a minority reported receiving any contraceptive counseling from an MHS provider prior to deployment: 18 percent of DoD ADSW and 9 percent of Coast Guard ADSW. This is one of several settings in which ADSW could receive contraception counseling (Defense Health Agency Procedural Instruction 6200.02, 2019). The survey did not ask women who did not receive predeployment contraceptive counseling why they did not receive it.

  • Among those who received contraceptive counseling prior to deployment, it was typically provided within one month of deployment (41 percent of DoD) or between one and three months prior to deployment (43 percent of DoD).

  • Of DoD ADSW deployed in the past 24 months who sought contraception prior to deployment, more than half (57 percent) received their preferred birth control method through the MHS, roughly a third (37 percent) did not receive any form of birth control through the MHS, and less than a tenth (6 percent) received a nonpreferred method.

  • The majority (three-quarters of DoD ADSW and 88 percent of Coast Guard ADSW) received an adequate supply for the deployment length.

  • Roughly two-thirds (64 percent) of DoD ADSW and about half (54 percent) of Coast Guard ADSW had ongoing access to contraception during deployment, most commonly through an MHS provider.

  • Fewer than one in ten ADSW had discussed use of contraceptive methods for menstrual regulation or suppression with an MHS provider prior to deployment.

  • The most common contraceptive used for menstrual regulation or suppression during deployment was birth control pills (used by approximately one in five ADSW), followed by an IUD (used by approximately 12 percent of ADSW), and an implant (used by less than 10 percent of ADSW).

  • Approximately one in three ADSW reported having a urinary tract or vaginal infection during training since joining the military.

  • During training, 44 percent of DoD ADSW and 32 percent of Coast Guard ADSW often or sometimes lacked access to needed feminine hygiene products. Nearly half of DoD ADSW often or sometimes lacked access to privacy or bathing facilities to address feminine hygiene needs during training.

  • Overall, approximately one in five DoD ADSW and one in ten Coast Guard ADSW reported a urinary tract or vaginal infection during their most recent deployment.

  • During their most recent deployment, approximately one in three of DoD and Coast Guard ADSW lacked access to needed feminine hygiene products, privacy to address feminine hygiene needs, or bathing facilities to address feminine hygiene needs.

Fertility and Pregnancy

Within this domain, we focused on a few key areas: understanding how commonly and frequently ADSW experience pregnancy during their military careers, the outcome of these pregnancies, the frequency with which pregnancies are unintended, the impacts of pregnancy on service (i.e., duty restrictions and leave) and of military service on family formation, and rates of maternal depression. Key findings include the following:

  • Across DoD ADSW, 43 percent have at some point been pregnant while serving, and about 20 percent have been pregnant multiple times. Pregnancy rates during service were similar in the Coast Guard.

  • Just over 16 percent of DoD ADSW and 13 percent of Coast Guard ADSW were pregnant in the one-year period covered by the survey. The DoD rate is 65 percent higher than the rate in the United States among 15–44-year-olds (9.8 percent).

  • Among DoD ADSW with a past-year pregnancy, more than one in three (37 percent) had an unintended pregnancy. Combining this with the percentage of DoD ADSW with a past-year pregnancy, we estimate that approximately 6 percent of DoD ADSW overall experience an unintended pregnancy each year. The rate was similar in the Coast Guard. This is consistent with the 2018 Health Related Behaviors Survey (Meadows et al., 2021), which reported a rate of 5.5 percent. The unintended pregnancy rate in the United States is 4.5 percent (Finer and Zolna, 2016).

  • Unintended pregnancy is more often attributable to failure to use birth control rather than inconsistent or improper use or to contraceptive failure. Among DoD ADSW who had an unintended pregnancy in the past year, more than half (56.2 percent) reported that they did not use birth control at the time of conception. This rate was similar for the Coast Guard.

  • Approximately 65 percent of pregnancies among DoD ADSW result in a live birth, 25 percent in miscarriage, and the remaining 10 percent in another outcome. This was similar in the Coast Guard.

  • Among DoD ADSW who were pregnant in the past year, 52 percent reported that they felt depressed during the pregnancy or after they gave birth. Rates of maternal depression were lower in the Coast Guard (42.5 percent).

  • About 1.2 percent of DoD ADSW have experienced a pregnancy during deployment; half that number, 0.6 percent, experienced a pregnancy during combat deployment.

  • Half of DoD ADSW (49.7 percent) reported that they had “delayed getting pregnant or starting a family” during their service.

  • Three-quarters (76 percent) of ADSW take 12 weeks of leave after giving birth; 7.1 percent take more.

  • One in three DoD ADSW reported having duty restrictions during pregnancy (33.6 percent). Coast Guard ADSW were more likely than those in DoD to have duty restrictions (51 percent).

  • Most typically (among 48.0 percent of ADSW), restricted duty lasted less than four weeks.

Infertility

In this domain, we examined overall rates of infertility among ADSW, as well as use of, and barriers to use of, fertility assistance. Key findings include the following:

  • Overall, 15.2 percent of DoD and 10.7 percent of Coast Guard ADSW reported having tried unsuccessfully to conceive for 12 or more months. In the U.S. general population, 12.5 percent of women ages 20–44 self-reported unsuccessfully trying to conceive for 12 months or more or were told by a doctor that they were unable to become pregnant (Kelley et al., 2019). On the basis of only self-reported inability to conceive, the Centers for Disease Control and Prevention (CDC) has reported that the infertility rate among married U.S. women between the ages of 15 and 49 is 6 percent among those who had ever given birth and 19.4 percent among those who had never given birth (Centers for Disease Control and Prevention, 2021). When calculated only among married women between the ages of 18 and 49 (there are no women under the age of 18 in the WRHS data), the infertility rate among DoD ADSW is 21.8 percent, and among Coast Guard ADSW it is 16.5 percent. The WRHS data do not allow us to identify whether a respondent had ever given birth.

  • Twelve percent of all DoD ADSW and 8.2 percent of Coast Guard ADSW reported an unmet need for fertility services since joining the military.

  • The fertility service most commonly received was medical advice, received by nearly nine in ten ADSW (87.3 percent) seeking fertility assistance, followed by infertility testing (40.8 percent), drugs to increase ovulation (25.5 percent), and artificial insemination (10.2 percent). Coast Guard patterns were similar to those for DoD ADSW.

  • Overall, 82.7 percent of DoD ADSW receiving infertility services from any source reported that TRICARE paid for the service; 31.1 percent reported paying out-of-pocket. Rates in the Coast Guard were similar.

  • There are substantial barriers to infertility treatment for a minority of ADSW. In DoD, 6.6 percent of ADSW receiving fertility assistance had to travel more than 100 miles for infertility testing, and 7.3 percent had to do so to obtain drugs to improve ovulation.

    • ADSW in the Coast Guard had to travel farther than those in any other service to obtain infertility advice and were less likely to receive infertility testing and drugs to improve ovulation at their home installation than ADSW serving in all DoD branches except the Marine Corps.

  • Among DoD ADSW who discontinued treatment before a successful pregnancy, the most commonly reported reasons for doing so were long wait times for services, making a permanent change of station to one where the service was not available, or deciding to try to get pregnant without medical assistance. Each was cited by about one in four ADSW. Responses were similar for the Coast Guard.

  • Among DoD ADSW overall, 1.1 percent have used cryopreservation (“frozen their eggs”) during their service; 43.5 percent said that they would consider doing so if the cost was completely covered by TRICARE.

    • ADSW in the Coast Guard were less likely than ADSW serving in DoD to say that they would consider cryopreservation if the cost was covered (36.9 percent).

Policy Implications

Maintaining readiness and lethality of the U.S. armed forces requires attention to the health and health care needs of all who serve. The WRHS was, in part, designed to help DoD identify reproductive health issues that ADSW may face and ways to address these issues. Therefore, in this section we highlight policy areas that DoD and the Coast Guard should consider to not only support force readiness but also to ensure that ADSW's needs with respect to reproductive health are adequately addressed.

Health Care Utilization

  • Explore options for expanding the prevalence and availability of care through WHCs. Results from the WRHS suggest that certain types of care (for example, from an OBGYN) was easier for ADSW to get through a WHC. Although we cannot be certain of whether this is a causal relationship, given that the MHS has specific goals with respect to the ease and timeliness of making appointments with specialty providers, the availability of WHCs may present an opportunity to improve access and wait times.

Birth Control and Contraceptive Use

  • Provide training for MHS providers regarding the full range of contraceptive methods. Delivering additional training on contraceptives to MHS providers who provide routine physical exams, virtual health care visits, predeployment health care visits, or health care during deployment would ensure that providers are prepared to discuss the full range of available contraceptive methods. Such training could cover standard guidelines for presenting contraceptive options to mitigate ADSW's perceptions that MHS providers may be pressuring them to choose a particular contraceptive method, as well as to inform providers of appropriate referral options as necessary (e.g., if providers are not credentialed to write prescriptions or insert long-acting reversible contraceptives, such as IUDs).

  • Consider expanding use of full-service contraceptive clinics, such as those established under Operation PINC (Process Improvement for Non-Delayed Contraception) at the Naval Medical Center San Diego (Adams, 2017). This same-day contraceptive clinic is staffed by a physician and a medical assistant, ensuring that ADSW can see an MHS provider with comprehensive training regarding contraception. Under this model, ADSW can obtain long-acting reversible contraceptives without delay.

  • Incorporate alerts into the electronic health record system to remind providers to address contraception, including for menstrual suppression, during routine physical exams. Although physical exams are not explicitly required as part of the annual PHA, the PHA is one source of physical exams for ADSW. Additionally, TRICARE provides coverage for an annual, in-person “well-woman” physical exam. Automated alerts to providers at these clinical encounters may help improve fidelity to the requirement of providing comprehensive contraceptive counseling during “annual physical exams” established under the 2016 NDAA. Alerts might also ask providers to indicate whether (1) they offered counseling and (2) ADSW were offered counseling but declined it so that the reasons behind apparently low rates of counseling receipt can be better understood.

  • Expand opportunities for ADSW to access contraceptive counseling through the MHS. In keeping with the intent of the NDAA to ensure the accessibility of contraceptive counseling, counseling could be offered at a variety of touch points throughout the MHS to ensure uptake among ADSW, including (but not limited to) PHAs and well-woman visits. Furthermore, the MHS could consider additional delivery modalities for contraceptive counseling, including online modules or during telehealth visits.

Reproductive Health During Training, Predeployment, and Deployment

  • Schedule predeployment appointments at least 90 days before deployment for ADSW. For ADSW who are initiating contraception (including for menstrual suppression or regulation), modifications to the dose or method may be necessary to minimize side effects or to achieve satisfactory regulation. Currently, nearly one-third of ADSW seeking contraception prior to deployment are not able to access it through the MHS; a longer interval between predeployment appointment and deployment may also allow ADSW more time to obtain their preferred contraceptive method.

  • When ADSW are being deployed, ensure that they receive an adequate supply of their contraceptive to last the entire deployment. Although the majority of ADSW received an adequate supply for the length of deployment, nearly one-quarter of DoD respondents received an inadequate supply. Consider standardizing contraceptive dispensing prior to deployment to ensure that ADSW receive sufficient contraceptive supplies for the entire deployment.

  • Consider strategies for improved access to feminine hygiene supplies, facilities, and treatment for urinary or vaginal infections during training and deployment, particularly for ADSW in the Army and Marine Corps. Urinary tract or vaginal infections affect nearly one in three ADSW during training, and more than 40 percent of DoD ADSW experienced limited access to feminine hygiene supplies and facilities during training. One potential strategy may include furnishing ADSW with self-test and self-treatment kits for urinary tract infections and other urogenital health issues; a recent qualitative study of female soldiers showed acceptance of and willingness to use self-test and self-treatment kits (Kostas-Polston, Braun, and Miedema, 2020). However, ADSW must additionally have access to a health care professional to ensure that infections are appropriately treated and resolve completely.

Fertility and Pregnancy

  • Improve ADSW's comfort in seeking contraception from the MHS and increase contraceptive counseling and access to highly effective contraception. Failure to use any contraceptive method was cited by ADSW in about half of unintended pregnancies and improper or inconsistent use in another quarter of them. Thus, education and encouragement of contraceptive use are vital. It is important that ADSW discuss contraceptive methods with a provider, feel comfortable obtaining contraception, and make a well-educated choice that aligns with their preference.

  • Devote resources to understanding and addressing rates of miscarriage among ADSW. Evidence is mixed regarding the role of deployment in ADSW's miscarriages (Ippolito et al., 2017). Risk factors for miscarriage in the U.S. general population, such as heavy alcohol consumption and smoking, should be considered for targeting by DoD and the Coast Guard.

  • Develop a comprehensive strategy to address maternal depression. This strategy should include routinely screening for maternal depression at pre- and postnatal MHS visits and referral of positive screens for mental health treatment. DoD and the Coast Guard should also track rates of both maternal depression and screening for maternal depression outside of medical records to better understand the scope of the problem. As part of screening and tracking, consider setting DoD- and Coast Guard–specific goals and milestones for reducing maternal depression and increasing screening for it. DoD and the Coast Guard should also implement evidence-based programs to prevent maternal depression (O'Hara and McCabe, 2013).

Infertility

  • Implement policies and programs to improve the balance between career and family formation among ADSW. Half of all ADSW reported that they had delayed getting pregnant or starting a family during their service. Fertility decreases gradually with age and quickly after age 35, as does the effectiveness of medical intervention to improve the probability of conception (Seshadri et al., 2021). If ADSW are choosing to postpone parenthood for career reasons (mirroring civilian trends; see Mathews and Hamilton, 2016), this may contribute to the observed levels of infertility. Making it easier for ADSW to parent without putting off career advancement may reduce delays in parenting that ultimately impair ADSW's ability to conceive (Schmidt et al., 2012).

  • Improve access to medical fertility assistance. Locating fertility services closer to more ADSW, providing assistance with infertility service transitions for ADSW undergoing a permanent change of station, and shortening wait times would address some issues, as would expanding the services covered by TRICARE. In vitro fertilization (IVF) and cryopreservation are not currently covered, unless the need for them is associated with specific duty exposures, and nearly one in three ADSW receiving treatment reported out-of-pocket fertility-related medical expenses. Moreover, a high percentage of ADSW would consider cryopreservation if it were covered. Counseling regarding the efficacy of IVF and cryopreservation for producing a successful pregnancy and birth should be provided if coverage is expanded, so ADSW have an accurate understanding of the benefits and limitations of these procedures.

Future Research

Although a survey can be an efficient mechanism to collect data from a large population and provide an overview of associations between variables, it does not always allow for the type of analysis that would uncover the reasons behind those associations. Thus, future research efforts should consider using qualitative data collection methods (e.g., focus groups, interviews) to supplement quantitative survey data to better understand the experiences of ADSW and their reproductive health.

Notes

1The American Association for Public Opinion Research is an association of public opinion and survey research professionals.

2The design weight for members of the Coast Guard was 1 because the sample was a census.

3All active-duty members, retirees, and family members of the Coast Guard are eligible for the benefits offered by the TRICARE program, including care in DOD MTFs, per Chapter 55 of Title 10, U.S. Code.

This research was sponsored by the Defense Health Agency and the U.S. Coast Guard and conducted within the Forces and Resources Policy Center of the RAND National Security Research Division (NSRD).

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