Kelsey Holt

Unintended Pregnancy and Contraceptive Use Among Women in the U.S. Military: A Systematic Literature Review

U.S. servicewomens ability to plan pregnancies is of concern to the military in terms of troop readiness and cost and is an important public health issue. Contraception access and use are crucial, particularly given the high prevalence of sexual assault in the military and the benefits of menstrual suppression for deployment. We systematically searched for publications on contraception, unintended pregnancy, and abortion in the military. Pregnancy and unintended pregnancy rates are higher among servicewomen than the general U.S. population. Contraceptive use may be somewhat higher than the nonmilitary population, although use decreases during deployment. Reported use of hormonal methods for menstrual suppression is lower than interest. There are limited data on these topics; more large, representative studies and longitudinal data from all branches are needed, along with qualitative research to explore findings more deeply. Emergency contraception and abortion are particularly underresearched.ABSTRACTU.S. servicewomen’s ability to plan pregnancies is of concern to the military in terms of troop readiness and cost and is an important public health issue. Contraception access and use are crucial, particularly given the high prevalence of sexual assault in the military and the benefits of menstrual suppression for deployment. We systematically searched for publications on contraception, unintended pregnancy, and abortion in the military. Pregnancy and unintended pregnancy rates are higher among servicewomen than the general U.S. population. Contraceptive use may be somewhat higher than the nonmilitary population, although use decreases during deployment. Reported use of hormonal methods for menstrual suppression is lower than interest. There are limited data on these topics; more large, representative studies and longitudinal data from all branches are needed, along with qualitative research to explore findings more deeply. Emergency contraception and abortion are particularly underresearched.

Military Sexual Trauma Among US Servicewomen During Deployment: A Qualitative Study

OBJECTIVES We explored qualitatively US servicewomens experiences with and perceptions of military sexual trauma (MST), reporting, and related services. METHODS From May 2011 to January 2012, we conducted 22 telephone interviews with US servicewomen deployed overseas between 2002 and 2011. We analyzed data thematically with modified grounded theory methods. RESULTS Factors identified as contributing to MST included deployment dynamics, military culture, and lack of consequences for perpetrators. Participants attributed low MST reporting to negative reactions and blame from peers and supervisors, concerns about confidentiality, and stigma. Unit cohesion was cited as both a facilitator and a barrier to reporting. Availability and awareness of MST services during deployment varied. Barriers to care seeking were similar to reporting barriers and included confidentiality concerns and stigma. We identified several avenues to address MST, including strengthening consequences for perpetrators. CONCLUSIONS We identified barriers to MST reporting and services. Better understanding of these issues will allow policymakers to improve MST prevention and services.

Reproductive Health Access Among Deployed U.S. Servicewomen: A Qualitative Study

Servicewomens reproductive health experiences during deployment are important given that the majority of women in the U.S. military are of reproductive age and that this population experiences a disproportionately high rate of unintended pregnancy. Few studies have explored womens reproductive health experiences and their perceived barriers and facilitators to health care access during deployment. From May 2011 to January 2012, we conducted 22 in-depth interviews with women in the U.S. military about their reproductive health experiences during deployment, including their access to health services. Participants identified a range of barriers to accessing medical care in deployment settings, including confidentiality concerns, lack of female providers, and health-seeking stigma, which were reported to disproportionately impact reproductive health access. Some participants experienced challenges obtaining contraceptive refills and specific contraceptive methods during deployment, and only a few participants received predeployment counseling on contraception, despite interest in both menstruation suppression and pregnancy prevention. These findings highlight several policy and practice changes that could be implemented to increase contraceptive access and reduce unintended pregnancy during deployment, including mandated screening for servicewomens contraceptive needs before operational duty and at least annually, and increasing the number of female providers in deployed settings.

A nationally representative survey of healthcare provider counselling and provision of the female condom in South Africa and Zimbabwe

Objectives Female condoms are the only female-initiated HIV and pregnancy prevention technology currently available. We examined female condom counselling and provision among providers in South Africa and Zimbabwe, high HIV-prevalence countries. Design A cross-sectional study using a nationally representative survey. Setting All facilities that provide family planning or HIV/sexually transmitted infection (STI) services. Participants National probability sample of 1444 nurses and physicians who provide family planning or HIV/STI services. Primary and secondary outcome measures Female condom practices with different female patients, including adolescents, married women, women using hormonal contraception and by HIV status. Using multivariable logistic analysis, we measured variations in condom counselling by provider characteristics. Results Most providers reported offering female condoms (88%; 1239/1415), but perceived a need for novel female barrier methods for HIV/STI prevention (85%; 1191/1396). By patient type, providers reported less frequent female condom counselling of adolescents (55%; 775/1411), women using hormonal contraception (65%; 909/1409) and married women (66%; 931/1416), compared to unmarried (74%; 1043/1414) or HIV-positive women (82%; 1161/1415). Multivariable results showed providers in South Africa were less likely to counsel women on female condoms than in Zimbabwe (OR=0.48, 95% CI 0.35 to 0.68, p≤0.001). However, South African providers were more likely to counsel women on male condoms (OR=2.39, 95% CI 1.57 to 3.65, p≤0.001). Nurses counselled patients on female condoms more frequently than physicians (OR=5.41, 95% CI 3.26 to 8.98, p≤0.001). HIV training, family planning training, location (urban vs rural) and facility type (hospital vs clinic) were not associated with greater condom counselling. Conclusions Female condoms were integrated into provider counselling and care, although providers reported a need for new female-initiated multipurpose prevention technologies, suggesting female condoms do not meet all patient/provider needs or are not adequately well known or accessible. Providers should be included in HIV training efforts to raise awareness of new and existing products, and encouraged to educate all women.

Impact of learning HIV status on contraceptive use in the MIRA trial

Background and methodology We examined the effect of becoming HIV-positive on contraceptive practices in a Phase III randomised controlled trial of the diaphragm for HIV prevention. We coded self-reported contraceptive use into seven categories of methods in order of effectiveness. We compared the proportion using each category of contraception at baseline and last visit between women who did and did not become HIV-positive. We compared changes in the proportion using each category of contraception from baseline to last visit and calculated the percentage of women that moved to a more or less effective method category or stayed the same. We examined immediate and long-term changes in contraceptive use category after learning HIV-positive status. Results A total of 4645 women remained HIV-negative and 309 became HIV-positive. The proportion using each category of contraception was similar between groups at baseline and last visit. In both groups approximately one-fifth changed to a less effective method category between baseline and last visit. Few women reported using long-acting methods. Among HIV-positive women, shorter-term changes in the proportion using each category of contraception were similar to longer-term changes, though somewhat more women were using a method in the same category 3 months after seroconversion. Discussion and conclusions Learning about HIV-positive status did not appear to significantly change patterns of use of effective contraceptives or the probability of switching to a more or less effective method. Information about, and access to, long-acting methods should receive more attention and be a routine part of family planning programmes and prevention trials.

A call for collaboration on respectful person-centered health care in family planning and maternal health.

BackgroundStriking tales of people judged, disrespected, or abused in reproductive, maternal, newborn, child, and adolescent health (RMNCAH) services are commonly exchanged among friends and families throughout the world while remaining sorely under-addressed in global health. Disrespect and abuse of individuals and providers in health services across the RMNCAH continuum must be stopped through collaborative, multi-tiered efforts.Call for collaborationA new focus on health care quality in the Sustainable Development Goals offers an opportunity to seriously reexamine user experiences and their impact on health care utilization. The new framework provides an opening to redress the insidious problem of negative interactions with care across the RMNCAH services continuum and redraft the blueprint for service delivery and performance measurement, placing individuals and their needs at the center. Both the maternal health and family planning fields are at a turning point in their histories of defining and addressing individuals’ experiences of care. In this commentary, we review these histories and the current state-of-the-art in both fields. Though the approaches and language in each sub-field vary, person-centered care principles related to the essential role of individuals’ preferences, needs and values, and the importance of informed decision-making, respect, privacy and confidentiality, and non-discrimination, are integral to all. Promoting respectful, person-centered care also requires recognizing the factors that lead to poor treatment of clients, including gender norms and unsupportive working conditions for providers. Lessons can be learned from innovative efforts across the continuum to support health care providers to provide respectful, person-centered care.ConclusionEfforts in the maternal health and family planning fields to define respectful, person-centered care provide a useful foundation from which to connect across the continuum of RMNCAH services. Now is the time to creatively work together to develop new approaches for promoting respectful treatment of individuals in all RMNCAH services.

‘These people who dig roots in the forests cannot treat HIV’: Women and men in Durban, South Africa, reflect on traditional medicine and antiretroviral drugs

ABSTRACT Relatively few empirical investigations of the intersection of HIV biomedical and traditional medicine have been undertaken. As part of preliminary work for a longitudinal study investigating health-seeking behaviours among newly diagnosed individuals living with HIV, we conducted semi-structured interviews with 24 urban South Africans presenting for HIV testing or newly enrolled in HIV care; here we explored participants’ views on African traditional medicine (TM) and biomedical HIV treatment. Notions of acceptance/non-acceptance were more nuanced than dichotomous, with participants expressing views ranging from favourable to reproachful, often referring to stories they had heard from others rather than drawing from personal experience. Respect for antiretrovirals and biomedicine was evident, but indigenous beliefs, particularly about the role of ancestors in healing, were common. Many endorsed the use of herbal remedies, which often were not considered TM. Given people’s diverse health-seeking practices, biomedical providers need to recognise the cultural importance of traditional health practices and routinely initiate respectful discussion of TM use with patients.