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Abortion Need among U.S. Servicewomen: Evidence from an Internet Service
Women's Health Issues xxx-xx (2019) 1–6
www.whijournal.com
Original article
Abortion Need among U.S. Servicewomen: Evidence from an Internet Service Laura Fix, MSW a,*, Jane W. Seymour, MPH a, Daniel Grossman, MD b, Dana M. Johnson, MPA c, Abigail R.A. Aiken, PhD c, Rebecca Gomperts, MD d, Kate Grindlay, MSPH a a
Ibis Reproductive Health, Cambridge, Massachusetts Advancing New Standards in Reproductive Health, University of California San Francisco, Oakland, California Lyndon B. Johnson School of Public Affairs, University of Texas at Austin, Austin, Texas d Women on Web, Amsterdam, the Netherlands b c
Article history: Received 24 January 2019; Received in revised form 5 October 2019; Accepted 30 October 2019
a b s t r a c t Introduction: U.S. servicewomen have high rates of unintended pregnancy, but federal policy prohibits abortion provision at military treatment facilities and military insurance coverage of abortion, except in cases of rape, incest, or a life-endangering pregnancy. Such restrictions pose challenges to abortion access for servicemembers, particularly during deployment. We aimed to explore the experiences of U.S. servicewomen when accessing abortion during overseas tours and deployment. Methods: We reviewed de-identified data from email inquiries and online consultation forms from U.S. servicewomen or military spouses seeking medication abortion from the telemedicine service Women on Web between January 2010 and December 2017. We used descriptive statistics and inductively coded textual responses to describe client characteristics, circumstances of pregnancy, reasons for abortion, and barriers to abortion care. Results: Our sample included data for 323 individuals. Reasons for abortion related to military service included disruption of deployment, fear of military reprimand, and potential career impacts. Additionally, servicemembers faced barriers to abortion access related to overseas military deployment or tour, including a lack of legal abortion in-country, limited financial resources, language barriers, travel restrictions, and a lack of confidentiality. Conclusions: U.S. military servicewomen stationed in countries where safe, legal, abortion is restricted or unavailable face deployment-related barriers to abortion care, which compound those barriers they may face regardless of deployment status. Removal of federal bans on the provision and coverage of abortion care and improved education about existing regulations could improve access to timely abortion care and in some cases allow servicewomen who wish to obtain abortion care to remain deployed. Ó 2019 Jacobs Institute of Women's Health. Published by Elsevier Inc.
Women in the U.S. military face unique barriers to accessing abortion services, particularly while deployed. Coverage for abortion counseling, referral, preparation, and follow-up through TRICARE, the health insurance program for active duty This research was made possible by general support funding from The David and Lucile Packard Foundation. There are no financial conflicts to disclose. Laura Fix had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. * Correspondence to: Laura Fix, MSW, Ibis Reproductive Health, 2067 Massachusetts Avenue, Suite 320, Cambridge, MA 02140, USA. Phone: (617) 3490040x1056; fax: (617) 349-0041. E-mail address: lfi[email protected] (L. Fix).
servicemembers and their families, is prohibited by federal policy in most circumstances (Legal Information Institute, 2013; TRICARE, 2018). Additionally, overseas military treatment facilities (MTFs) cannot provide abortion care in most cases and must always follow local abortion policies and laws (Navy and Marine Corps Public Health Center, 2018; Woodson, 2013). Therefore, most servicewomen seeking abortion care must independently coordinate and obtain services at a civilian medical facility. Furthermore, servicewomen who do become pregnant are required to notify commanding officers, regardless of whether or not they intend to continue the pregnancy (Navy and Marine Corps Public Health Center, 2018).
1049-3867/$ - see front matter Ó 2019 Jacobs Institute of Women's Health. Published by Elsevier Inc. https://doi.org/10.1016/j.whi.2019.10.006
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Military restrictions on abortion coverage and provision and requirements for superior notification may have the greatest impact on access to care for deployed servicewomen. Each military branch has its own pregnancy regulations, but they are consistent regarding pregnancy during deploymentdif a woman is pregnant and deployed, she must return to her home station (Ritchie, 2001). If a woman wishes to access abortion services and is unable to do so in her country of deployment, she must notify command in order to return from deployment to receive an abortion (Ritchie, 2001). Notifying command or taking time off to obtain an abortion could compromise a servicewoman’s confidentiality or result in work- and duty-related consequences (Grindlay, Yanow, Jelinska, Gomperts, & Grossman, 2011). These military-specific barriers to abortion access are particularly concerning, as unintended pregnancy is more common among U.S. servicewomen compared with the general population (Grindlay & Grossman, 2013, 2015; Lindberg, 2011). One reason that unintended pregnancy is more common among servicewomen may be due to sexual assault; in 2018, the past-year sexual assault prevalence among active duty servicewomen was 6.2% (Department of Defense, 2019). Servicewomen whose pregnancies result from rape or incest may be exempt from requirements to notify their commanding officer of the pregnancy if they file a restricted report (Navy and Marine Corps Public Health Center, 2018). Furthermore, MTFs can provide abortion in cases of rape or incest, and in 2013, the passage of the Shaheen Amendment to the National Defense Authorization Act extended TRICARE coverage for abortion to cases of rape or incest (One Hundred Twelfth Congress of the United States of America, 2013). However, stigma, concerns about confidentiality, and feared negative responses from commanders or peers may deter servicewomen eligible for abortion coverage or provision through the military from disclosing a pregnancy resulting from rape, because these factors have been shown to be barriers to reporting sexual assault during deployment (Burns, Grindlay, Holt, Manski, & Grossman, 2014). Few studies have examined servicemembers’ experiences seeking abortion while in the U.S. military. A 2011 study explored 128 servicewomen’s experiences seeking abortion care during deployment from an online service providing information about medication abortion (Grindlay et al., 2011). Data from the routine consultation form and user queries to this online service demonstrated that these servicemembers faced numerous challenges obtaining abortion care, including legal and logistical barriers to services in the country of deployment and difficulties accessing care elsewhere owing to concerns about confidentiality and fear of blame or career impacts. More recently, a qualitative study explored servicewomen’s experiences obtaining abortion care during active duty service (Grindlay et al., 2017). In-depth interviews with 21 servicewomen revealed many of these same barriers to abortion care, including logistical and financial hurdles, confidentiality concerns, and fear of stigma or negative career effects. As a result of these barriers, some servicewomen experienced emotional tolls, such as feeling “stressed, unsupported, judged, burdened or embarrassed,” and delays in access to abortion care. The aim of this study was to explore U.S. servicewomen’s experiences accessing abortion during overseas tours and deployment subsequent to U.S. legislative changes that have expanded abortion coverage in cases of rape and incest. To achieve this aim, we reviewed data from Women on Web, an online service that provides information and access to medication abortion. The service links women in settings where safe
abortion is unavailable with a physician who can provide medication abortion via telemedicine. Women receive a remote consultation and medications are subsequently delivered through the mail (Women on Web, n.d.). Methods We reviewed requests submitted to Women on Web between January 2010 and December 2017 from respondents who identified as U.S. servicewomen seeking medication abortion, spouses of servicemembers, or friends or commanding officers seeking medication abortion on behalf of a servicewoman. We excluded 30 requests that lacked information in multiple categories: respondent demographics, pregnancy circumstance, and reason for abortion. We also excluded one record from a military contractor who would not be eligible for TRICARE. Women on Web counselors tagged consultations and email correspondence with servicemembers or their dependents as “U.S. Military” at the time of consultation and during a retrospective review of the data based on information provided by those who contacted the service. A trained research assistant queried the complete Women on Web database within our date range to identify additional untagged consultations and correspondence with servicemembers or dependents by searching for relevant keywords (e.g., military, servicemember, base, serving, and APO) and reviewing consultation data from countries for which the U.S. Military tag was previously applied. We analyzed de-identified quantitative data from Women on Web’s standardized online consultation form, which is used to determine eligibility for first trimester medication abortion. Variables from the online consultation forms included participants’ age, number of prior pregnancies, location by country, circumstances of pregnancy, and reason(s) for seeking abortion services. Servicewomen could select from prepopulated lists for both pregnancy circumstances and reasons for abortion, with multiple responses allowed; rape was included in the prepopulated list as a potential circumstance of pregnancy and, separately, as a reason for abortion. We used descriptive statistics to describe client characteristics, circumstances of pregnancy, reasons for seeking abortion, and the overall number of requests to the service by U.S. servicewomen between 2010 and 2017. We categorized abortion policies of the countries where servicewomen were based as legal on request, legal only for specific indications, or illegal, using the country’s abortion policies as reported in United Nations Abortion Policies (United Nations, 2013), The World’s Abortion Laws (Center for Reproductive Rights, 2018), and Boersma, Alberts, de Bruijn, Meyboom-de Jong, and Kleiverda (2012). Where data on legal status conflicted, the most permissive definition was reported (Boersma et al., 2012; Center for Reproductive Rights, 2018; United Nations, 2013). In addition to the structured consultation form, some participants supplied additional information about their circumstances or experiences via email to the service. We deductively coded de-identified email text for additional circumstances of pregnancy and reasons for seeking abortion care using the list of prepopulated options from the consultation form. We inductively coded the email text for additional themes related to reasons for and experiences of seeking abortion care, including those specific to military service, overseas tour, or deployment. Coding was completed by one investigator and independently reviewed by another. Questions were reconciled by the study team. Country of overseas assignment as recorded on the online consultation form accompanies each quote.
L. Fix et al. / Women's Health Issues xxx-xx (2019) 1–6 Table 1 Client Characteristics among U.S. Military Servicewomen and Military Spouses Who Sought Medication Abortion from Women on Web from January 2010 to December 2017 (N ¼ 323) Characteristics Age, years 18–25 26–35 36–44 Nonresponse Number of previous pregnancies 0 1 2 3 4 Nonresponse Number of children 0 1 2 3 Nonresponse Location of military assignment (with country abortion policies) Afghanistan* Bahrainy Belgiumy Cubay Curac¸aoz Cyprus*,x,k,{,#,** Djibouti*,x Egypt* Germanyy Honduras* Hong Kong*,x,k,{,#,** Iraq* Italyy Japan*,x,#,** Jordan*,x,k,{ Kenya*,x,k South Korea*,x,k,{,# Kuwait*,x,k,{ Philippines* Qatar*,x,k,{ Saudi Arabia*,x,k Turkeyy United Arab Emirates*,x,k United Kingdom (Northern Ireland)*,x,k United States of Americay At sea Nonresponse
n (%) 124 116 19 64
(38.4) (35.9) (5.9) (19.8)
31 105 49 39 23 76
(9.6) (32.5) (15.2) (12.1) (7.1) (23.5)
150 60 32 12 69
(46.4) (18.6) (9.9) (3.7) (21.4)
79 12 1 2 1 1 4 1 3 1 1 27 9 27 1 1 88 33 2 8 1 1 7 1 3 1 7
(24.5) (3.7) (0.3) (0.6) (0.3) (0.3) (1.2) (0.3) (0.9) (0.3) (0.3) (8.4) (2.8) (8.4) (0.3) (0.3) (27.2) (10.2) (0.6) (2.5) (0.3) (0.3) (2.2) (0.3) (0.9) (0.3) (2.2)
Abortion policies (Boersma, Alberts, de Bruin, Meyboom-deJong, & Kleiverda, 2012; Center for Reproductive Rights, 2018; United Nations, 2013). * Abortion is legal to save the woman’s life. y Abortion is legal on request. z Abortion is illegal. x Abortion is legal to preserve physical health. k Abortion is legal to preserve mental health. { Abortion is legal for fetal impairment. # Abortion is legal for rape or incest. ** Abortion is legal for economic or social reasons.
All individuals provided consent for the use of their anonymized data. The Allendale Investigational Review Board provided ethical approval for this study. Results Background Characteristics We analyzed online consultation forms for 323 individuals, 179 of whom had also submitted email inquiries. Of the 323
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Table 2 Circumstances of Pregnancy among U.S. Servicewomen Who Sought Medication Abortion from Women on Web from January 2010 to December 2017 (N ¼ 323) Circumstance of Pregnancy
All Regions, n (%)
Did not use contraception Contraception failure Rape Nonresponse
128 121 12 62
(39.6) (37.5) (3.7) (19.2)
individuals, 313 requests were for servicewomen and 10 were for military servicemembers’ spouses. Of the 313 requests for servicewomen, some were made by a friend (n ¼ 3), significant other (n ¼ 1), or commanding officer (n ¼ 1) on the servicewoman’s behalf. Background characteristics are presented in Table 1. Among those seeking services, the median age was 26 years and the median number of children was 0. Thirty-four percent were located in a country where abortion is legal only to save the life of the pregnant person (Afghanistan, Egypt, Honduras, Iraq, and the Philippines); 54% where abortion is legal only for specific indications (Cyprus, Djibouti, Hong Kong, Japan, Jordan, Kenya, South Korea, Kuwait, Qatar, Saudi Arabia, United Arab Emirates, and the United Kingdom [Northern Ireland]); and 10% where abortion is legal for any indication, including three women located in the United States (Bahrain, Belgium, Cuba, Germany, Italy, Turkey, and the United States). One participant was located in Curac¸ao, where abortion is illegal in all circumstances, and another was at sea. Circumstances of pregnancy The most frequently reported circumstances of pregnancy were contraceptive nonuse (40%) and contraceptive failure (38%). Four percent of participants reported a pregnancy resulting from rape (Table 2). Reasons for seeking abortion Using predetermined options listed in the online consultation form, with multiple responses allowed, servicewomen indicated a number of reasons for seeking abortion (Table 3); more than one-half (66%) indicated it was not the right time to have a child, 26% reported that they did not have enough money to raise a child, and 20% indicated a desire to finish school. One-quarter of those who indicated their pregnancy occurred as a result of rape also indicated rape as the reason for seeking abortion. Text responses revealed respondents’ more nuanced perceptions of a pregnancy’s impact on their military careers, including subthemes related to potential reprimand and ability to deploy. Women characterized pregnancy as something that would “not help” or could even “kill” their career. A servicewoman deployed to Iraq explained, “A child at this time in my life would do more harm to my career and my life that I have built for me and my daughter who is 3 and my family.” Eleven women sought abortion owing to concern that continuing a pregnancy would result in an abrupt end to their tour of duty. One servicewoman stationed in Kuwait indicated that pregnancy would hurt both her military and civilian career opportunities, saying, “I am pregnant on a deployment, they will certainly kick me out as in discharge me from the military, send me home from this deployment early, this will ruin my career in the military and outside.” Two servicewomen located in the United States were concerned about being prohibited from upcoming training or deployment. One explained, “I am in the military and have to be
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Table 3 Reasons for Seeking Abortion, among U.S. Military Servicewomen Who Sought Medication Abortion from Women on Web from January 2010 to December 2017* Reason for Seeking Abortion
n (%)
From questionnaire (n ¼ 323) Cannot have a child at this time in life 214 (66.3) No money to raise a child 83 (25.7) Wants to finish school 63 (19.5) Too young/too old 52 (16.1) Family is complete 35 (10.8) Is ill 5 (1.6) Unwanted pregnancy 11 (3.4) Would harm career 9 (2.8) Rape 3 (0.9) Nonresponse 54 (16.7) Military-specific reasons, from email correspondence (n ¼ 179) Fear of military reprimand 10 (5.6) Wants to complete deployment 11 (6.1) *
Multiple responses allowed.
very discreet about being pregnant, due to the fact that I’m deploying in a couple months to Afghanistan.” In addition to fear of sudden redeployment home or inability to deploy overseas, concern about potential punishment by the military was identified as a motivating factor for 10 servicewomen. One woman in Afghanistan feared she would be “punished if I am found to be pregnant in a warzone. I am not scheduled to return home for another 4 months and cannot wait that long for an abortion.” Another stationed in Cuba reported, “I cannot seek medical attention because I will be administratively punished for being pregnant.” Barriers to care Servicewomen’s inquiries indicated that there were policy, institutional, and logistical barriers to obtaining abortion care. For some servicewomen, these barriers intersected with or compounded concerns about maintaining confidentiality. Policy Barriers Women attributed an inability to obtain abortion care in their country of deployment to country-level abortion laws and to Department of Defense policy and practice. One servicewoman in South Korea illustrated the lack of options she faced owing to U.S. military abortion policy and the in-country legal status of abortion, stating, “I understand that abortion is illegal in South Korea, and I can’t get help from the Army since it’s not allowed. So I don’t know what I should do.” Another servicewoman in Japan who sought but was unable to obtain a referral or an abortion from her military medical provider explained, “When I went to my medical provider on base, she told me they didn’t offer any abortion services, and could not refer me to a clinic.” Servicewomen also spoke about barriers to obtaining abortion care in their country of deployment/military tour created by military practices, such as the need to obtain permission from military supervisors to travel outside of a military base. As one woman stationed in Japan explained, “It is against the rules to go off base and see any doctor without permission.” Prohibitions on travel off of military bases (n ¼ 10) or travel in a field environment (n ¼ 1) were also cited as reasons for seeking abortion care through the online service. As a servicemember in Kuwait wrote, “I am pregnant and need an abortion but am facing incredible challenges. I cannot leave base (we’re 5 miles from Iraqi border)
to get the procedure and cannot leave base for any other reasondno leave, no emergencies.” Logistical Barriers Many servicewomen (n ¼ 36) identified logistical challenges that prevented them from obtaining an abortion in their country of deployment/military tour, including language barriers, cost, travel, and timing. For some of these servicewomen (n ¼ 7), navigating the local health care system proved impossible as they did not speak the local language and could not find an English-speaking abortion provider. A few (n ¼ 3) mentioned that the cost of a local abortion procedure was more than they could afford. One servicemember stationed in Germany reported that she had no way to travel to a local civilian clinic, because “that requires 3 days of counseling and then [they] offer the abortion, all together it costs V600. I currently have no way of making those trips.” Seven women reported concerns about the limited timeframe within which they could obtain a medication abortion given the gestational age of their pregnancies. One soldier deployed to Italy feared running out of time to obtain an abortion, saying: My partner and I have decided that an abortion is best for us at this time. However, the military does not cover, refer or help with abortions at all. We are desperately looking for an Italian doctor or clinic.who is willing to administer the abortion pill to us. However, we haven’t had any luck. And because of the date of conception we don’t have much time. Desire for Confidentiality Some servicewomen felt the online service was their only option or that it was the only option that afforded confidentiality, because this could not be ensured inside the military. Many (n ¼ 38) reported feeling “desperate” or that they lacked other options for obtaining abortion care. Some (n ¼ 15) servicewomen’s desire to keep their pregnancy and abortion decision a secret led them to seek abortion care outside the military system rather than request assistance from their chain of command or military medical personnel. One servicewoman deployed in Afghanistan explained, “Due to the lack of confidentiality with the U.S. military, I am not in a position to request medical aid.” Another, stationed in Curac¸ao, felt unable to locate a medical facility “without someone in my chain of command finding out why I am going and I don’t want that to happen.” Pregnancies resulting from rape Even in situations where servicewomen could obtain an abortion through the military owing to a pregnancy resulting from rape or incest, some opted to seek care via telemedicine. Twelve servicewomen who contacted Women on Web to obtain an abortion reported that their pregnancy occurred as a result of rape, and one-half of these servicewomen contacted the service in 2013 or later, after TRICARE coverage was expanded to cover abortion in cases of rape (One Hundred Twelfth Congress of the United States of America, 2013). Three servicewomen specifically cited rape as the reason for obtaining an abortion, including one who contacted the service in 2013 after passage of the Shaheen Amendment. Of these three, two explicitly stated feeling unable to seek guidance or support from commanding officers or fellow servicemembers. One woman deployed in Afghanistan who
L. Fix et al. / Women's Health Issues xxx-xx (2019) 1–6
contacted the service in 2011 considered self-harm in the absence of other options, stating, “I was violated and I’m in the Army but because I did not tell at the time my story will not look right and I could face a lot of trouble. I am deployed to Afghanistan and I need an abortion but we are not able to get them here. I am so desperate I thought of hitting my stomach over and over till I miscarried.” One servicemember stationed in Italy, where abortion is legal, contacted the service in 2013 and explained, “I was raped after being drugged, and it resulted in pregnancy. However, I cannot tell anybody. Abortion is not legal military wise, I could get charged and then removed altogether if anyone were to know I’ve had one.” Discussion U.S. servicewomen in deployed and overseas settings included in our study faced multiple and overlapping barriers to abortion access, including policy, logistical, and privacy concerns. Many of the reasons why servicewomen reported seeking abortion were similar to those reported by women from the general population, including financial reasons, life plans, and a desire to focus resources on existing children (Biggs, Gould, & Foster, 2013; Finer, Frohwirth, Dauphinee, Singh, & Moore, 2005; Kirkman, Rowe, Hardiman, Mallett, & Rosenthal, 2009). In addition, participants highlighted reasons specific to their military service, including a concern that the pregnancy would harm their military career and prevent them from completing their tour of duty. Consistent with other published literature, we did not find evidence that study participants became pregnant to leave the deployed setting, a concern reported by servicemembers (Grindlay, Yanow, Jelinska, Gomperts, & Grossman, 2011). Sexual assault was reported by a small number of servicewomen as the reason for the pregnancy, including six who sought services from Women on Web after 2013, when abortion care after rape became a covered benefit under TRICARE. Some of these servicemembers who would have been eligible for abortion care and coverage through the military did not seem aware of their eligibility for services. This indicates that for some servicewomen, knowledge of abortion coverage and provision policies may be poor, and that barriers to reporting sexual assault may remain subsequent to passage of the Shaheen Amendment. This is in line with past work, which indicates there are many reasons why women may choose to avoid reporting sexual assault to military command, including lack of knowledge about TRICARE benefits (Burns et al., 2014; Mengeling, Booth, Torner, & Sadler, 2014). These findings suggest a need for additional research to assess awareness and use of the benefits available under the Shaheen Amendment. Most servicewomen seeking abortion services from Women on Web were located in countries where abortion was legally restricted. Women’s inquiries highlight that limited availability of abortion off-base and a lack of military assistance with care coordination in settings where abortion is legal were common motivations for seeking care online, along with language, cost, and travel barriers. Deployed servicewomen have few options other than requesting leave to return to the United States or to another country where abortion care is available. In addition to the time away from duty, requesting leave to travel for abortion care raised confidentiality concerns for servicewomen. This aligns with findings from previous research demonstrating that pregnant servicewomen’s concerns about privacy and confidentiality deterred them from seeking treatment at MTFs (Grindlay et al., 2017).
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This study has several limitations. First, the analyses relied on data from a self-selected population, those seeking medication abortion services online. As a result, our sample is not representative of all U.S. servicewomen seeking abortion services. Only 10% of our sample were based in settings where abortion was legal for any indication and servicewomen stationed in countries where abortion is legal and accessible may have different experiences from those of women seeking care online. Ease of access has been cited as a benefit of telemedicine use for medication abortion by civilian women and may also have been a factor in servicewomen’s use of the Women on Web service, particularly in settings where abortion is legal (Grindlay et al., 2013). Second, although we included all available data from identified servicewomen or military dependents who contacted Women on Web during the study period, analyses were limited to the information that women disclosed in their consultations, comments, and queries. Servicewomen or military spouses who contacted Women on Web during the study period but did not disclose their military affiliation, and did not include keywords used in our database search, may be missing from this sample. Additionally, responses were not required for every field in the consultation form, resulting in missing information for some participants on variables including circumstances of pregnancy. Although the magnitude of our findings may be affected by missingness and misclassification, it is unlikely that those who were classified as having a military affiliation are misclassified owing to the need for servicemembers to provide an Army or Fleet Post Office address and the incentive to disclose military status to Women on Web to allow for an individualized response. Therefore, the barriers and experiences identified in this study are valid for at least a subset of servicewomen. Third, our sample size and study design were not adequate to evaluate the overall effect of the Shaheen Amendment on abortion seeking among deployed servicewomen. Although the number of servicewomen who sought help from Women on Web during the study period was relatively small, there are other sites, such as online pharmacies, that sell abortion-inducing medications, that may have served this population as well (Murtagh, Wells, Raymond, Coeytaux, & Winikoff, 2018). More robustly powered studies are needed to compare requests to such services prior to and after the implementation of this policy to assess its impact. Implications for Practice and/or Policy The requirement that women inform their commanding officers of a confirmed pregnancy, regardless of whether or not they plan to continue the pregnancy (except in cases of rape or incest when a restricted report is filed), may jeopardize confidentiality and deter reporting of any pregnancy. Removing the pregnancy reporting requirement may allow servicewomen to make decisions about their pregnancies with less fear of stigma or discrimination. Moving forward, more publicly available information is needed about the implementation of abortion coverage for rape, incest, and life endangerment of the woman; how servicemembers are informed of this benefit; and whether eligible servicewomen use these services. Some servicewomen eligible for care through the military may instead prefer to access abortion care via telemedicine services because of the ease of use and concerns about confidentiality. Additional research is needed to understand servicewomen’s preferences for how they access abortion care and what motivates those preferences. For some servicewomen in this study, the policy prohibiting TRICARE coverage for counseling, referral, preparation, and
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follow-up for a noncovered abortion (Navy and Marine Corps Public Health Center, 2018) was a barrier to abortion access. Permitting TRICARE coverage for abortion counseling and referrals when abortion is either prohibited or unavailable at an MTF could improve access in these cases. Further, allowing abortion provision at MTFs regardless of the circumstances of pregnancy in countries where abortion is legal could eliminate the need for evacuation to the United States solely for an abortion procedure. Findings from this study indicate that some servicewomen are obtaining care from Women on Web to remain deployed. Increasing MTF provision of abortion care could benefit both servicewomen and the military by reducing time away from work, as well as the costs associated with international travel for servicewomen who wish to complete their overseas assignment or deployment.
Conclusions U.S. servicewomen who are on overseas deployment or assignment continue to face barriers to safe abortion care, particularly when stationed in countries where abortion is restricted. Removing the prohibitions on abortion provision at MTFs and TRICARE coverage of abortion, as well as ensuring that services are accessible, could improve access to timely care for servicewomen and reduce the need for time away from deployment.
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Author Descriptions References Biggs, M. A., Gould, H., & Foster, D. G. (2013). Understanding why women seek abortions in the US. BMC Womens Health, 13(1), 29. Boersma, A. A., Alberts, J. F., de Bruijn, J., Meyboom-de Jong, B., & Kleiverda, G. (2012). Termination of pregnancy in Curac¸ao: Need for improvement of sexual and reproductive healthcare. Global Journal of Health Science, 4(3), 30. Burns, B., Grindlay, K., Holt, K., Manski, R., & Grossman, D. (2014). Military sexual trauma among US servicewomen during deployment: A qualitative study. American Journal of Public Health, 104(2), 345–349. Center for Reproductive Rights. (2018). The world’s abortion laws. Available: www.worldabortionlaws.com. Accessed: December 20, 2018. Department of Defense. (2019). Department of Defense annual report on sexual assault in the military: Fiscal year 2018. Available: www.politico.com/f/? id¼0000016a-794c-d79f-adfb-fb4c003a0000. Accessed: October 4, 2019. Finer, L. B., Frohwirth, L. F., Dauphinee, L. A., Singh, S., & Moore, A. M. (2005). Reasons US women have abortions: Quantitative and qualitative perspectives. Perspectives on Sexual and Reproductive Health, 37(3), 110–118. Grindlay, K., & Grossman, D. (2013). Unintended pregnancy among active-duty women in the United States military, 2008. Obstetrics & Gynecology, 121(2 Pt 1), 241–246. Grindlay, K., & Grossman, D. (2015). Unintended pregnancy among active-duty women in the United States military, 2011. Contraception, 92(6), 589–595. Grindlay, K., Lane, K., & Grossman, D. (2013). Women’s and providers’ experiences with medical abortion provided through telemedicine: A qualitative study. Women’s Health Issues, 23(2), e117–e122. Grindlay, K., Seymour, J. W., Fix, L., Reiger, S., Keefe-Oates, B., & Grossman, D. (2017). Abortion knowledge and experiences among US servicewomen: A qualitative study. Perspectives on Sexual and Reproductive Health, 49(4), 245– 252. Grindlay, K., Yanow, S., Jelinska, K., Gomperts, R., & Grossman, D. (2011). Abortion restrictions in the U.S. military: Voices from women deployed overseas. Women’s Health Issues, 21(4), 259–264. Kirkman, M., Rowe, H., Hardiman, A., Mallett, S., & Rosenthal, D. (2009). Reasons women give for abortion: A review of the literature. Archives of Womens Mental Health, 12(6), 365–378.
Laura Fix, MSW, is a Project Manager at Ibis Reproductive Health whose focus is on abortion at later gestational ages, telemedicine for medication abortion provision, and reproductive health care for populations facing multiple barriers to care.
Jane W. Seymour, MPH, is a Project Manager at Ibis Reproductive Health and doctoral student in epidemiology at Boston University School of Public Health. Her work focuses on applying epidemiologic methods to assess access to health care, particularly contraception and abortion.
Daniel Grossman, MD, Director, Advancing New Standards in Reproductive Health and Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, focuses on improving access to contraception and safe abortion in the United States, Latin America, and sub-Saharan Africa.
Dana M. Johnson, MPA, is a PhD student at the LBJ School of Public Affairs, University of Texas at Austin. Her research interests combine healthcare and social policy, with a focus on policies that impact reproductive healthcare access.
Abigail R.A. Aiken, PhD, is an assistant professor at the LBJ School of Public Affairs, University of Texas at Austin. Her research focuses on impacts of laws and policies restricting access to abortion, as well as self-managed abortion.
Rebecca Gomperts, MD, is founder and director of Women on Waves, a Dutch nonprofit organization and Women on Web, a telemedical abortion service. She received her PhD at Karolinska University. Her research interests are abortion care and rights.
Kate Grindlay, MSPH, Associate at Ibis Reproductive Health, oversees a program to move an oral contraceptive over the counter in the United States. She also manages a portfolio of research focused on innovative approaches to reproductive health access in underserved communities.
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Original article
Abortion Need among U.S. Servicewomen: Evidence from an Internet Service Laura Fix, MSW a,*, Jane W. Seymour, MPH a, Daniel Grossman, MD b, Dana M. Johnson, MPA c, Abigail R.A. Aiken, PhD c, Rebecca Gomperts, MD d, Kate Grindlay, MSPH a a
Ibis Reproductive Health, Cambridge, Massachusetts Advancing New Standards in Reproductive Health, University of California San Francisco, Oakland, California Lyndon B. Johnson School of Public Affairs, University of Texas at Austin, Austin, Texas d Women on Web, Amsterdam, the Netherlands b c
Article history: Received 24 January 2019; Received in revised form 5 October 2019; Accepted 30 October 2019
a b s t r a c t Introduction: U.S. servicewomen have high rates of unintended pregnancy, but federal policy prohibits abortion provision at military treatment facilities and military insurance coverage of abortion, except in cases of rape, incest, or a life-endangering pregnancy. Such restrictions pose challenges to abortion access for servicemembers, particularly during deployment. We aimed to explore the experiences of U.S. servicewomen when accessing abortion during overseas tours and deployment. Methods: We reviewed de-identified data from email inquiries and online consultation forms from U.S. servicewomen or military spouses seeking medication abortion from the telemedicine service Women on Web between January 2010 and December 2017. We used descriptive statistics and inductively coded textual responses to describe client characteristics, circumstances of pregnancy, reasons for abortion, and barriers to abortion care. Results: Our sample included data for 323 individuals. Reasons for abortion related to military service included disruption of deployment, fear of military reprimand, and potential career impacts. Additionally, servicemembers faced barriers to abortion access related to overseas military deployment or tour, including a lack of legal abortion in-country, limited financial resources, language barriers, travel restrictions, and a lack of confidentiality. Conclusions: U.S. military servicewomen stationed in countries where safe, legal, abortion is restricted or unavailable face deployment-related barriers to abortion care, which compound those barriers they may face regardless of deployment status. Removal of federal bans on the provision and coverage of abortion care and improved education about existing regulations could improve access to timely abortion care and in some cases allow servicewomen who wish to obtain abortion care to remain deployed. Ó 2019 Jacobs Institute of Women's Health. Published by Elsevier Inc.
Women in the U.S. military face unique barriers to accessing abortion services, particularly while deployed. Coverage for abortion counseling, referral, preparation, and follow-up through TRICARE, the health insurance program for active duty This research was made possible by general support funding from The David and Lucile Packard Foundation. There are no financial conflicts to disclose. Laura Fix had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. * Correspondence to: Laura Fix, MSW, Ibis Reproductive Health, 2067 Massachusetts Avenue, Suite 320, Cambridge, MA 02140, USA. Phone: (617) 3490040x1056; fax: (617) 349-0041. E-mail address: lfi[email protected] (L. Fix).
servicemembers and their families, is prohibited by federal policy in most circumstances (Legal Information Institute, 2013; TRICARE, 2018). Additionally, overseas military treatment facilities (MTFs) cannot provide abortion care in most cases and must always follow local abortion policies and laws (Navy and Marine Corps Public Health Center, 2018; Woodson, 2013). Therefore, most servicewomen seeking abortion care must independently coordinate and obtain services at a civilian medical facility. Furthermore, servicewomen who do become pregnant are required to notify commanding officers, regardless of whether or not they intend to continue the pregnancy (Navy and Marine Corps Public Health Center, 2018).
1049-3867/$ - see front matter Ó 2019 Jacobs Institute of Women's Health. Published by Elsevier Inc. https://doi.org/10.1016/j.whi.2019.10.006
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Military restrictions on abortion coverage and provision and requirements for superior notification may have the greatest impact on access to care for deployed servicewomen. Each military branch has its own pregnancy regulations, but they are consistent regarding pregnancy during deploymentdif a woman is pregnant and deployed, she must return to her home station (Ritchie, 2001). If a woman wishes to access abortion services and is unable to do so in her country of deployment, she must notify command in order to return from deployment to receive an abortion (Ritchie, 2001). Notifying command or taking time off to obtain an abortion could compromise a servicewoman’s confidentiality or result in work- and duty-related consequences (Grindlay, Yanow, Jelinska, Gomperts, & Grossman, 2011). These military-specific barriers to abortion access are particularly concerning, as unintended pregnancy is more common among U.S. servicewomen compared with the general population (Grindlay & Grossman, 2013, 2015; Lindberg, 2011). One reason that unintended pregnancy is more common among servicewomen may be due to sexual assault; in 2018, the past-year sexual assault prevalence among active duty servicewomen was 6.2% (Department of Defense, 2019). Servicewomen whose pregnancies result from rape or incest may be exempt from requirements to notify their commanding officer of the pregnancy if they file a restricted report (Navy and Marine Corps Public Health Center, 2018). Furthermore, MTFs can provide abortion in cases of rape or incest, and in 2013, the passage of the Shaheen Amendment to the National Defense Authorization Act extended TRICARE coverage for abortion to cases of rape or incest (One Hundred Twelfth Congress of the United States of America, 2013). However, stigma, concerns about confidentiality, and feared negative responses from commanders or peers may deter servicewomen eligible for abortion coverage or provision through the military from disclosing a pregnancy resulting from rape, because these factors have been shown to be barriers to reporting sexual assault during deployment (Burns, Grindlay, Holt, Manski, & Grossman, 2014). Few studies have examined servicemembers’ experiences seeking abortion while in the U.S. military. A 2011 study explored 128 servicewomen’s experiences seeking abortion care during deployment from an online service providing information about medication abortion (Grindlay et al., 2011). Data from the routine consultation form and user queries to this online service demonstrated that these servicemembers faced numerous challenges obtaining abortion care, including legal and logistical barriers to services in the country of deployment and difficulties accessing care elsewhere owing to concerns about confidentiality and fear of blame or career impacts. More recently, a qualitative study explored servicewomen’s experiences obtaining abortion care during active duty service (Grindlay et al., 2017). In-depth interviews with 21 servicewomen revealed many of these same barriers to abortion care, including logistical and financial hurdles, confidentiality concerns, and fear of stigma or negative career effects. As a result of these barriers, some servicewomen experienced emotional tolls, such as feeling “stressed, unsupported, judged, burdened or embarrassed,” and delays in access to abortion care. The aim of this study was to explore U.S. servicewomen’s experiences accessing abortion during overseas tours and deployment subsequent to U.S. legislative changes that have expanded abortion coverage in cases of rape and incest. To achieve this aim, we reviewed data from Women on Web, an online service that provides information and access to medication abortion. The service links women in settings where safe
abortion is unavailable with a physician who can provide medication abortion via telemedicine. Women receive a remote consultation and medications are subsequently delivered through the mail (Women on Web, n.d.). Methods We reviewed requests submitted to Women on Web between January 2010 and December 2017 from respondents who identified as U.S. servicewomen seeking medication abortion, spouses of servicemembers, or friends or commanding officers seeking medication abortion on behalf of a servicewoman. We excluded 30 requests that lacked information in multiple categories: respondent demographics, pregnancy circumstance, and reason for abortion. We also excluded one record from a military contractor who would not be eligible for TRICARE. Women on Web counselors tagged consultations and email correspondence with servicemembers or their dependents as “U.S. Military” at the time of consultation and during a retrospective review of the data based on information provided by those who contacted the service. A trained research assistant queried the complete Women on Web database within our date range to identify additional untagged consultations and correspondence with servicemembers or dependents by searching for relevant keywords (e.g., military, servicemember, base, serving, and APO) and reviewing consultation data from countries for which the U.S. Military tag was previously applied. We analyzed de-identified quantitative data from Women on Web’s standardized online consultation form, which is used to determine eligibility for first trimester medication abortion. Variables from the online consultation forms included participants’ age, number of prior pregnancies, location by country, circumstances of pregnancy, and reason(s) for seeking abortion services. Servicewomen could select from prepopulated lists for both pregnancy circumstances and reasons for abortion, with multiple responses allowed; rape was included in the prepopulated list as a potential circumstance of pregnancy and, separately, as a reason for abortion. We used descriptive statistics to describe client characteristics, circumstances of pregnancy, reasons for seeking abortion, and the overall number of requests to the service by U.S. servicewomen between 2010 and 2017. We categorized abortion policies of the countries where servicewomen were based as legal on request, legal only for specific indications, or illegal, using the country’s abortion policies as reported in United Nations Abortion Policies (United Nations, 2013), The World’s Abortion Laws (Center for Reproductive Rights, 2018), and Boersma, Alberts, de Bruijn, Meyboom-de Jong, and Kleiverda (2012). Where data on legal status conflicted, the most permissive definition was reported (Boersma et al., 2012; Center for Reproductive Rights, 2018; United Nations, 2013). In addition to the structured consultation form, some participants supplied additional information about their circumstances or experiences via email to the service. We deductively coded de-identified email text for additional circumstances of pregnancy and reasons for seeking abortion care using the list of prepopulated options from the consultation form. We inductively coded the email text for additional themes related to reasons for and experiences of seeking abortion care, including those specific to military service, overseas tour, or deployment. Coding was completed by one investigator and independently reviewed by another. Questions were reconciled by the study team. Country of overseas assignment as recorded on the online consultation form accompanies each quote.
L. Fix et al. / Women's Health Issues xxx-xx (2019) 1–6 Table 1 Client Characteristics among U.S. Military Servicewomen and Military Spouses Who Sought Medication Abortion from Women on Web from January 2010 to December 2017 (N ¼ 323) Characteristics Age, years 18–25 26–35 36–44 Nonresponse Number of previous pregnancies 0 1 2 3 4 Nonresponse Number of children 0 1 2 3 Nonresponse Location of military assignment (with country abortion policies) Afghanistan* Bahrainy Belgiumy Cubay Curac¸aoz Cyprus*,x,k,{,#,** Djibouti*,x Egypt* Germanyy Honduras* Hong Kong*,x,k,{,#,** Iraq* Italyy Japan*,x,#,** Jordan*,x,k,{ Kenya*,x,k South Korea*,x,k,{,# Kuwait*,x,k,{ Philippines* Qatar*,x,k,{ Saudi Arabia*,x,k Turkeyy United Arab Emirates*,x,k United Kingdom (Northern Ireland)*,x,k United States of Americay At sea Nonresponse
n (%) 124 116 19 64
(38.4) (35.9) (5.9) (19.8)
31 105 49 39 23 76
(9.6) (32.5) (15.2) (12.1) (7.1) (23.5)
150 60 32 12 69
(46.4) (18.6) (9.9) (3.7) (21.4)
79 12 1 2 1 1 4 1 3 1 1 27 9 27 1 1 88 33 2 8 1 1 7 1 3 1 7
(24.5) (3.7) (0.3) (0.6) (0.3) (0.3) (1.2) (0.3) (0.9) (0.3) (0.3) (8.4) (2.8) (8.4) (0.3) (0.3) (27.2) (10.2) (0.6) (2.5) (0.3) (0.3) (2.2) (0.3) (0.9) (0.3) (2.2)
Abortion policies (Boersma, Alberts, de Bruin, Meyboom-deJong, & Kleiverda, 2012; Center for Reproductive Rights, 2018; United Nations, 2013). * Abortion is legal to save the woman’s life. y Abortion is legal on request. z Abortion is illegal. x Abortion is legal to preserve physical health. k Abortion is legal to preserve mental health. { Abortion is legal for fetal impairment. # Abortion is legal for rape or incest. ** Abortion is legal for economic or social reasons.
All individuals provided consent for the use of their anonymized data. The Allendale Investigational Review Board provided ethical approval for this study. Results Background Characteristics We analyzed online consultation forms for 323 individuals, 179 of whom had also submitted email inquiries. Of the 323
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Table 2 Circumstances of Pregnancy among U.S. Servicewomen Who Sought Medication Abortion from Women on Web from January 2010 to December 2017 (N ¼ 323) Circumstance of Pregnancy
All Regions, n (%)
Did not use contraception Contraception failure Rape Nonresponse
128 121 12 62
(39.6) (37.5) (3.7) (19.2)
individuals, 313 requests were for servicewomen and 10 were for military servicemembers’ spouses. Of the 313 requests for servicewomen, some were made by a friend (n ¼ 3), significant other (n ¼ 1), or commanding officer (n ¼ 1) on the servicewoman’s behalf. Background characteristics are presented in Table 1. Among those seeking services, the median age was 26 years and the median number of children was 0. Thirty-four percent were located in a country where abortion is legal only to save the life of the pregnant person (Afghanistan, Egypt, Honduras, Iraq, and the Philippines); 54% where abortion is legal only for specific indications (Cyprus, Djibouti, Hong Kong, Japan, Jordan, Kenya, South Korea, Kuwait, Qatar, Saudi Arabia, United Arab Emirates, and the United Kingdom [Northern Ireland]); and 10% where abortion is legal for any indication, including three women located in the United States (Bahrain, Belgium, Cuba, Germany, Italy, Turkey, and the United States). One participant was located in Curac¸ao, where abortion is illegal in all circumstances, and another was at sea. Circumstances of pregnancy The most frequently reported circumstances of pregnancy were contraceptive nonuse (40%) and contraceptive failure (38%). Four percent of participants reported a pregnancy resulting from rape (Table 2). Reasons for seeking abortion Using predetermined options listed in the online consultation form, with multiple responses allowed, servicewomen indicated a number of reasons for seeking abortion (Table 3); more than one-half (66%) indicated it was not the right time to have a child, 26% reported that they did not have enough money to raise a child, and 20% indicated a desire to finish school. One-quarter of those who indicated their pregnancy occurred as a result of rape also indicated rape as the reason for seeking abortion. Text responses revealed respondents’ more nuanced perceptions of a pregnancy’s impact on their military careers, including subthemes related to potential reprimand and ability to deploy. Women characterized pregnancy as something that would “not help” or could even “kill” their career. A servicewoman deployed to Iraq explained, “A child at this time in my life would do more harm to my career and my life that I have built for me and my daughter who is 3 and my family.” Eleven women sought abortion owing to concern that continuing a pregnancy would result in an abrupt end to their tour of duty. One servicewoman stationed in Kuwait indicated that pregnancy would hurt both her military and civilian career opportunities, saying, “I am pregnant on a deployment, they will certainly kick me out as in discharge me from the military, send me home from this deployment early, this will ruin my career in the military and outside.” Two servicewomen located in the United States were concerned about being prohibited from upcoming training or deployment. One explained, “I am in the military and have to be
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Table 3 Reasons for Seeking Abortion, among U.S. Military Servicewomen Who Sought Medication Abortion from Women on Web from January 2010 to December 2017* Reason for Seeking Abortion
n (%)
From questionnaire (n ¼ 323) Cannot have a child at this time in life 214 (66.3) No money to raise a child 83 (25.7) Wants to finish school 63 (19.5) Too young/too old 52 (16.1) Family is complete 35 (10.8) Is ill 5 (1.6) Unwanted pregnancy 11 (3.4) Would harm career 9 (2.8) Rape 3 (0.9) Nonresponse 54 (16.7) Military-specific reasons, from email correspondence (n ¼ 179) Fear of military reprimand 10 (5.6) Wants to complete deployment 11 (6.1) *
Multiple responses allowed.
very discreet about being pregnant, due to the fact that I’m deploying in a couple months to Afghanistan.” In addition to fear of sudden redeployment home or inability to deploy overseas, concern about potential punishment by the military was identified as a motivating factor for 10 servicewomen. One woman in Afghanistan feared she would be “punished if I am found to be pregnant in a warzone. I am not scheduled to return home for another 4 months and cannot wait that long for an abortion.” Another stationed in Cuba reported, “I cannot seek medical attention because I will be administratively punished for being pregnant.” Barriers to care Servicewomen’s inquiries indicated that there were policy, institutional, and logistical barriers to obtaining abortion care. For some servicewomen, these barriers intersected with or compounded concerns about maintaining confidentiality. Policy Barriers Women attributed an inability to obtain abortion care in their country of deployment to country-level abortion laws and to Department of Defense policy and practice. One servicewoman in South Korea illustrated the lack of options she faced owing to U.S. military abortion policy and the in-country legal status of abortion, stating, “I understand that abortion is illegal in South Korea, and I can’t get help from the Army since it’s not allowed. So I don’t know what I should do.” Another servicewoman in Japan who sought but was unable to obtain a referral or an abortion from her military medical provider explained, “When I went to my medical provider on base, she told me they didn’t offer any abortion services, and could not refer me to a clinic.” Servicewomen also spoke about barriers to obtaining abortion care in their country of deployment/military tour created by military practices, such as the need to obtain permission from military supervisors to travel outside of a military base. As one woman stationed in Japan explained, “It is against the rules to go off base and see any doctor without permission.” Prohibitions on travel off of military bases (n ¼ 10) or travel in a field environment (n ¼ 1) were also cited as reasons for seeking abortion care through the online service. As a servicemember in Kuwait wrote, “I am pregnant and need an abortion but am facing incredible challenges. I cannot leave base (we’re 5 miles from Iraqi border)
to get the procedure and cannot leave base for any other reasondno leave, no emergencies.” Logistical Barriers Many servicewomen (n ¼ 36) identified logistical challenges that prevented them from obtaining an abortion in their country of deployment/military tour, including language barriers, cost, travel, and timing. For some of these servicewomen (n ¼ 7), navigating the local health care system proved impossible as they did not speak the local language and could not find an English-speaking abortion provider. A few (n ¼ 3) mentioned that the cost of a local abortion procedure was more than they could afford. One servicemember stationed in Germany reported that she had no way to travel to a local civilian clinic, because “that requires 3 days of counseling and then [they] offer the abortion, all together it costs V600. I currently have no way of making those trips.” Seven women reported concerns about the limited timeframe within which they could obtain a medication abortion given the gestational age of their pregnancies. One soldier deployed to Italy feared running out of time to obtain an abortion, saying: My partner and I have decided that an abortion is best for us at this time. However, the military does not cover, refer or help with abortions at all. We are desperately looking for an Italian doctor or clinic.who is willing to administer the abortion pill to us. However, we haven’t had any luck. And because of the date of conception we don’t have much time. Desire for Confidentiality Some servicewomen felt the online service was their only option or that it was the only option that afforded confidentiality, because this could not be ensured inside the military. Many (n ¼ 38) reported feeling “desperate” or that they lacked other options for obtaining abortion care. Some (n ¼ 15) servicewomen’s desire to keep their pregnancy and abortion decision a secret led them to seek abortion care outside the military system rather than request assistance from their chain of command or military medical personnel. One servicewoman deployed in Afghanistan explained, “Due to the lack of confidentiality with the U.S. military, I am not in a position to request medical aid.” Another, stationed in Curac¸ao, felt unable to locate a medical facility “without someone in my chain of command finding out why I am going and I don’t want that to happen.” Pregnancies resulting from rape Even in situations where servicewomen could obtain an abortion through the military owing to a pregnancy resulting from rape or incest, some opted to seek care via telemedicine. Twelve servicewomen who contacted Women on Web to obtain an abortion reported that their pregnancy occurred as a result of rape, and one-half of these servicewomen contacted the service in 2013 or later, after TRICARE coverage was expanded to cover abortion in cases of rape (One Hundred Twelfth Congress of the United States of America, 2013). Three servicewomen specifically cited rape as the reason for obtaining an abortion, including one who contacted the service in 2013 after passage of the Shaheen Amendment. Of these three, two explicitly stated feeling unable to seek guidance or support from commanding officers or fellow servicemembers. One woman deployed in Afghanistan who
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contacted the service in 2011 considered self-harm in the absence of other options, stating, “I was violated and I’m in the Army but because I did not tell at the time my story will not look right and I could face a lot of trouble. I am deployed to Afghanistan and I need an abortion but we are not able to get them here. I am so desperate I thought of hitting my stomach over and over till I miscarried.” One servicemember stationed in Italy, where abortion is legal, contacted the service in 2013 and explained, “I was raped after being drugged, and it resulted in pregnancy. However, I cannot tell anybody. Abortion is not legal military wise, I could get charged and then removed altogether if anyone were to know I’ve had one.” Discussion U.S. servicewomen in deployed and overseas settings included in our study faced multiple and overlapping barriers to abortion access, including policy, logistical, and privacy concerns. Many of the reasons why servicewomen reported seeking abortion were similar to those reported by women from the general population, including financial reasons, life plans, and a desire to focus resources on existing children (Biggs, Gould, & Foster, 2013; Finer, Frohwirth, Dauphinee, Singh, & Moore, 2005; Kirkman, Rowe, Hardiman, Mallett, & Rosenthal, 2009). In addition, participants highlighted reasons specific to their military service, including a concern that the pregnancy would harm their military career and prevent them from completing their tour of duty. Consistent with other published literature, we did not find evidence that study participants became pregnant to leave the deployed setting, a concern reported by servicemembers (Grindlay, Yanow, Jelinska, Gomperts, & Grossman, 2011). Sexual assault was reported by a small number of servicewomen as the reason for the pregnancy, including six who sought services from Women on Web after 2013, when abortion care after rape became a covered benefit under TRICARE. Some of these servicemembers who would have been eligible for abortion care and coverage through the military did not seem aware of their eligibility for services. This indicates that for some servicewomen, knowledge of abortion coverage and provision policies may be poor, and that barriers to reporting sexual assault may remain subsequent to passage of the Shaheen Amendment. This is in line with past work, which indicates there are many reasons why women may choose to avoid reporting sexual assault to military command, including lack of knowledge about TRICARE benefits (Burns et al., 2014; Mengeling, Booth, Torner, & Sadler, 2014). These findings suggest a need for additional research to assess awareness and use of the benefits available under the Shaheen Amendment. Most servicewomen seeking abortion services from Women on Web were located in countries where abortion was legally restricted. Women’s inquiries highlight that limited availability of abortion off-base and a lack of military assistance with care coordination in settings where abortion is legal were common motivations for seeking care online, along with language, cost, and travel barriers. Deployed servicewomen have few options other than requesting leave to return to the United States or to another country where abortion care is available. In addition to the time away from duty, requesting leave to travel for abortion care raised confidentiality concerns for servicewomen. This aligns with findings from previous research demonstrating that pregnant servicewomen’s concerns about privacy and confidentiality deterred them from seeking treatment at MTFs (Grindlay et al., 2017).
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This study has several limitations. First, the analyses relied on data from a self-selected population, those seeking medication abortion services online. As a result, our sample is not representative of all U.S. servicewomen seeking abortion services. Only 10% of our sample were based in settings where abortion was legal for any indication and servicewomen stationed in countries where abortion is legal and accessible may have different experiences from those of women seeking care online. Ease of access has been cited as a benefit of telemedicine use for medication abortion by civilian women and may also have been a factor in servicewomen’s use of the Women on Web service, particularly in settings where abortion is legal (Grindlay et al., 2013). Second, although we included all available data from identified servicewomen or military dependents who contacted Women on Web during the study period, analyses were limited to the information that women disclosed in their consultations, comments, and queries. Servicewomen or military spouses who contacted Women on Web during the study period but did not disclose their military affiliation, and did not include keywords used in our database search, may be missing from this sample. Additionally, responses were not required for every field in the consultation form, resulting in missing information for some participants on variables including circumstances of pregnancy. Although the magnitude of our findings may be affected by missingness and misclassification, it is unlikely that those who were classified as having a military affiliation are misclassified owing to the need for servicemembers to provide an Army or Fleet Post Office address and the incentive to disclose military status to Women on Web to allow for an individualized response. Therefore, the barriers and experiences identified in this study are valid for at least a subset of servicewomen. Third, our sample size and study design were not adequate to evaluate the overall effect of the Shaheen Amendment on abortion seeking among deployed servicewomen. Although the number of servicewomen who sought help from Women on Web during the study period was relatively small, there are other sites, such as online pharmacies, that sell abortion-inducing medications, that may have served this population as well (Murtagh, Wells, Raymond, Coeytaux, & Winikoff, 2018). More robustly powered studies are needed to compare requests to such services prior to and after the implementation of this policy to assess its impact. Implications for Practice and/or Policy The requirement that women inform their commanding officers of a confirmed pregnancy, regardless of whether or not they plan to continue the pregnancy (except in cases of rape or incest when a restricted report is filed), may jeopardize confidentiality and deter reporting of any pregnancy. Removing the pregnancy reporting requirement may allow servicewomen to make decisions about their pregnancies with less fear of stigma or discrimination. Moving forward, more publicly available information is needed about the implementation of abortion coverage for rape, incest, and life endangerment of the woman; how servicemembers are informed of this benefit; and whether eligible servicewomen use these services. Some servicewomen eligible for care through the military may instead prefer to access abortion care via telemedicine services because of the ease of use and concerns about confidentiality. Additional research is needed to understand servicewomen’s preferences for how they access abortion care and what motivates those preferences. For some servicewomen in this study, the policy prohibiting TRICARE coverage for counseling, referral, preparation, and
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follow-up for a noncovered abortion (Navy and Marine Corps Public Health Center, 2018) was a barrier to abortion access. Permitting TRICARE coverage for abortion counseling and referrals when abortion is either prohibited or unavailable at an MTF could improve access in these cases. Further, allowing abortion provision at MTFs regardless of the circumstances of pregnancy in countries where abortion is legal could eliminate the need for evacuation to the United States solely for an abortion procedure. Findings from this study indicate that some servicewomen are obtaining care from Women on Web to remain deployed. Increasing MTF provision of abortion care could benefit both servicewomen and the military by reducing time away from work, as well as the costs associated with international travel for servicewomen who wish to complete their overseas assignment or deployment.
Conclusions U.S. servicewomen who are on overseas deployment or assignment continue to face barriers to safe abortion care, particularly when stationed in countries where abortion is restricted. Removing the prohibitions on abortion provision at MTFs and TRICARE coverage of abortion, as well as ensuring that services are accessible, could improve access to timely care for servicewomen and reduce the need for time away from deployment.
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Laura Fix, MSW, is a Project Manager at Ibis Reproductive Health whose focus is on abortion at later gestational ages, telemedicine for medication abortion provision, and reproductive health care for populations facing multiple barriers to care.
Jane W. Seymour, MPH, is a Project Manager at Ibis Reproductive Health and doctoral student in epidemiology at Boston University School of Public Health. Her work focuses on applying epidemiologic methods to assess access to health care, particularly contraception and abortion.
Daniel Grossman, MD, Director, Advancing New Standards in Reproductive Health and Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, focuses on improving access to contraception and safe abortion in the United States, Latin America, and sub-Saharan Africa.
Dana M. Johnson, MPA, is a PhD student at the LBJ School of Public Affairs, University of Texas at Austin. Her research interests combine healthcare and social policy, with a focus on policies that impact reproductive healthcare access.
Abigail R.A. Aiken, PhD, is an assistant professor at the LBJ School of Public Affairs, University of Texas at Austin. Her research focuses on impacts of laws and policies restricting access to abortion, as well as self-managed abortion.
Rebecca Gomperts, MD, is founder and director of Women on Waves, a Dutch nonprofit organization and Women on Web, a telemedical abortion service. She received her PhD at Karolinska University. Her research interests are abortion care and rights.
Kate Grindlay, MSPH, Associate at Ibis Reproductive Health, oversees a program to move an oral contraceptive over the counter in the United States. She also manages a portfolio of research focused on innovative approaches to reproductive health access in underserved communities.