In December 2018, the journal Military Medicine released a small report aimed at understanding the experiences women on active military duty have in accessing birth control after having an abortion. Hidden inside this report was an important piece of information: The unintended pregnancy rate for women in the military is higher than it is in the general population.

The researchers cited a statistic from a 2017 report by Ibis Reproductive Health: 7 percent of active-duty women aged 18 to 44 reported an unwanted pregnancy in 2010 (the most recent year this info is available), compared with 4.5 percent of women of reproductive age in the general U.S. population. That shakes out to about 72 unwanted pregnancies per 1,000 women in the military, versus 45 unwanted pregnancies per 1,000 women overall. These are small numbers, but the delta in unwanted pregnancy rates is significant because military members have access to world-class health care and contraception coverage (something many, many civilian women in the U.S. lack).

TRICARE, the medical insurance available to all active duty and military spouses, covers well-woman exams annually with no cost or copay. It also fully covers most birth control methods, including the pill, IUD, and diaphragms, as well as non-prescriptive emergency contraceptives, such as Plan B One-Step Emergency Contraceptive. “I’ll be honest with you, when I was in the Marines, it was actually easier [to get birth control] than it is as a civilian,” says Risa Carpenter, a retired Marine Corps veteran. “I had an easier time making an appointment, the wait time was less, and everything was covered.”

It’s experiences like Carpenter’s that make the unintended pregnancy rate among military women so surprising. “Because active-duty personnel have access to high-quality health care at no cost,” the Ibis report reads, “one might expect unintended pregnancy rates to be lower in the military compared to the general U.S. population; however, the opposite appears to be true.” This is particularly concerning because once a woman in the military is pregnant, she has extremely limited access to abortion services.

So what are the factors contributing to this higher-than-average unintended pregnancy rate? I spoke to some military experts to get answers.

Military culture and sexuality

Retired Lieutenant Colonel Ellen Haring, PhD, the CEO of the Service Women’s Action Network (SWAN), says that age of service members can often play into unwanted pregnancies. “We have a high number of very young people in the military,” Dr. Haring says. Just how many? The average age of an enlisted soldier in 2017 was 27 years old and 45 percent of active-duty members are age 25 or younger, according to the Department of Defense. Those ages skew even younger depending on which branch of the military you look at—according to the Army’s official website, in 2016, 66 percent of enlisted members (meaning, non-officers) were under 30 years old. Compare that to the general population, where only 10 percent of people are aged 18-24 and 27 percent of the population is aged 25-44.

When you’re young, Dr. Haring says, “you’re most fertile. [And] it’s also when you’re the most clueless in terms of birth control and pregnancy.”

Dr. Haring says age and unwanted pregnancy consistently came up when compiling SWAN’s 2018 report, Access to Reproductive Health Care: The Experiences Of Military Women. “Something our data did show is that there is a discrepancy between officers and enlisted; enlisted did have a higher rate of unwanted pregnancies than the officers. So to me, that speaks to either age or education.”

But Nneka Obiekwe, a volunteer at the Department of Defense Military Crisis Hotline and founder of Vanede, which provides support to survivors of domestic and sexual violence, says age isn’t the only culprit. In her view, the military’s overly masculine energy plays a major role. “Women in the military aren’t always empowered enough to acknowledge or disclose some of the issues they’re dealing with [related to women’s health] because of the masculine culture,” Obiekwe says, adding that there’s often a desire to be seen as “one of the guys.” Remember: Only 18 percent of service members are female. Broken up by branch, the Navy has the highest percentage of women, at 24 percent, while women in the Marines are the least-represented at 10 percent.

“Discussing women’s health, like your period, UTIs, abdominal pain, or other things that are associated with being a woman…many women feel they have to just grin and bear it,” Obiekwe says, citing the concerns of people she’s spoken to through her work on the crisis hotline. “They feel like they can’t draw attention to challenges specifically tied with being a woman because it will be used to say that they’re too weak, not prepared, or in a setting they aren’t qualified to be in.” Thus, she says, it creates a culture where servicewomen may not feel able to discuss their health needs or ask for the necessary support.

“[Women] don’t want someone to think they aren’t following the rules, or not being taken seriously because they’re under the assumption that they’re promiscuous, especially in a male dominant environment.” —Nneka Obiekwe, founder of Vanede

Then there’s the issue of sex. “There are a lot of rules in the military pertaining to who you can and can’t fraternize with,” Obiekwe says. (For example, it’s against military policy for service members of different ranks to date or engage in sexual activity, a law that has been in place since 1998. General Orders, which is the military’s set code of conduct, also generally prohibits sex while on deployment.) “Because of that, women may try to minimize talking about their sexual activity [with their doctors], [by] not requesting contraceptives,” she says. “They don’t want someone to think they aren’t following the rules, or to not be taken seriously because they’re under the assumption that they’re promiscuous, especially in a male-dominated environment.”

How deployment plays a role

SWAN’s report found that of the 260 active-duty women it surveyed who chose to be on some form of birth control, one in four said they were not able to access their preferred method while on deployment.

Before shipping overseas, female soldiers must think ahead about what they will need in terms of contraception—and yet not all military doctors are understanding of that. “When we did our report, we found that military women are being grilled by their doctors before deployment saying, ‘You’re going to be deployed. Why do you need birth control?'” Dr. Haring says. “Which is ridiculous because many women take birth control for other reasons than to prevent a pregnancy,” she adds (such as suppressing their periods, or managing other health issues like PCOS, polycystic ovary syndrome). There were also nearly 7000 reported cases of sexual assault in the military in 2017, another reality that could spur a woman to seek birth control.

Yet according to one study, even when female soldiers are able to get birth control, the nature of their jobs can complicate using it—and potentially make it less effective. The pill, for example, is only 91 percent effective at preventing pregnancy if taken every single day at the same time. While it’s human error for anyone to forget to take their pill every now and then, imagine trying to remember while on patrol in a foreign country.

Some methods of birth control don’t always hold up well during deployment conditions, either. “Some birth controls require refrigeration, like the NuvaRing,” Dr. Haring says. “So if you’re in a remote location that doesn’t have access to refrigeration, that could be an issue.”

There’s also limited access to medical facilities on deployment, and they’re austere at best. “Availability of health-care services, pharmacy services, and basic needs, including access to running water and plumbing, vary widely” from deployment location to location, according to a 2015 report from the Department of Defense.According to one report, more than half of the women reported that they were not comfortable going to this health-care provider for gynecological symptoms during deployment, and nearly one-quarter would not go at all.

Abortion access while in the military

The difficulties some women have obtaining (or continuing to access) proper contraceptive care are intensified by the fact that the military does not have very many options for dealing with an unwanted pregnancy when it does happen. When you’re a pregnant service member, you realistically have two options: carry the child to term, or seek an abortion off-base.

That’s because TRICARE offers abortion services only in cases of rape, incest, or if the woman’s life is at risk. Non-deployed soldiers in a circumstance that falls outside of these perimeters must pay out of pocket, and find a clinic on their own. For veterans, abortions are not covered in any capacity. “If you’re in prison and you’re raped, you can get an abortion, but veterans can’t,” Dr. Haring says.

Even in the case of rape, abortion access can be challenging if a person is deployed. Again, they might not have easy access to medical services, or may be in a country where abortion is severely restricted or illegal (making the off-base solution non-existent). “When you’re deployed, often you know everyone in your unit, and you might not feel comfortable asking a young medic, who is also your peer, for help,” Dr. Haring says. “There is one organization, Women On Waves, that sends abortion pills to deployed soldiers who request or need it,” she adds. Otherwise, soldiers seeking abortions are pretty much on their own.

SWAN’s report shares the experience of a woman named Sally who became pregnant while on active duty. She had an abortion off-base—which she paid for out of pocket—but there were complications. When she went to a hospital on base for treatment, she was told they couldn’t help her because the complications stemmed from her abortion. “Nothing in the law says service members can’t be given a list of resources, or treated because of complications, but women are still treated this way,” Dr. Haring says.

What’s the solution?

At the hotline, Obiekwe often suggests callers who feel too timid to raise questions pertaining to sexual health on-base seek out private health-care services off-base—which may or may not be covered by TRICARE, depending on the service—where they can have a more open conversation with a health-care provider without worrying what’s going in their file. (HIIPA, which protects patients’ medical records, has a military-related exemption that allows providers to disclose information to command officers in certain cases, such as fitness for duty evaluations.) Soldiers wishing to be discrete can visit clinics such as Planned Parenthood or another free clinic where services are low-cost, or charged on a sliding scale. Records can also be kept confidential with these organizations.

Obiekwe says it’s not enough for birth control and women’s services to be offered; women need to feel empowered to use them. “This comes from the top down,” she says. “I have seen time and time again that if service members do not feel that they have the support of their commander, they will not use the resources available to them, even if the resources are great.” To this end, she says women need to feel like they can have open conversations about women’s health without fearing how others will view them or if it will hurt their career. “This is why it would help to have more women leaders,” Obiekwe says.

Obiekwe emphasizes the importance of having peer advisors, which de-escalates the politics around rank. “It’s creating an environment that can sustain in the hierarchy,” she explains. “If someone is your peer, you can be more open.” So when you raise concerns about access to birth control or issues with a particular doctor, “that peer leader is responsible for getting that [concern] in front of leadership and really starting to have some sort of top-down change.” Because there is no formal peer advisor program currently in place in any military branch that she is aware of, Obiekwe says it’s up to the women in leadership roles to extend a hand to women in lower ranks, forming these relationships with them.

She also encourages more open dialogue between officers and enlisted members and the opportunity to ask contraception-related questions—something many might not think of in the midst of all the other preparations that must take place before shipping off overseas. “In the military, there are conferences soldiers and their families attend before deployment, which address everything from budgeting to mental health services. This is an example of a time it would work to include questions about birth control and pregnancy,” Obiekwe says.

Obiekwe’s hope is that over time, these actions will cause the atmosphere in the military to change. Change to one where women don’t feel their particular health needs are something to hide, makes them any less strong, or can be used against them.

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