Influence of “Decide + Be Ready” Contraceptive Decision Aid on Pre-deployment Health Decisions Free

ABSTRACT

Introduction

The number of active duty servicewomen and the career opportunities available to them continue to increase. Of the approximately 350,000 women in uniform, 97% are estimated to be of reproductive age, underscoring the importance of reproductive health care. This study aimed to explore the influence of the Decide + Be Ready (DABR) contraceptive decision aid on providing contraceptive knowledge, facilitating a servicewoman’s contraceptive choice before and during deployment, and enabling understanding of individual preferences around contraception in a population of active duty women most at risk for unintended pregnancy.

Materials and Methods

We conducted a qualitative study, recruiting active duty women between the ages of 17 and 24 with at least one prior deployment who were stationed at Naval Station Norfolk and presented for evaluation at a primary care clinic. Participants downloaded and reviewed the DABR application. A semi-structured interview was conducted and audio-recorded. Interviews were transcribed and underwent thematic analysis.

Results

Twenty women participated in the study over 2 weeks. Analysis revealed three overarching themes: perceived utility of and attitudes toward DABR, knowledge of and comfort with contraceptive options, and challenges specific to active duty women. In total, eight subthemes were also identified and explored.

Conclusions

The DABR app provided study participants with new information about contraception. Participants reported improved knowledge of gynecologic and reproductive health options available during deployment. Other findings raise interest for future studies exploring incorporation of peer validation in counseling and decision-making tools, challenges with the deployed environment for obstetric/gynecologic health, and medical support on naval deployments.

INTRODUCTION

The population of servicewomen and the career opportunities available to them while in the military continue to increase. Of the approximately 350,000 women serving in the U.S. Military, 97% are estimated to be of reproductive age.^1,2 Thus, contraceptive education and access remain a critical focus of military health care as failure to achieve menstrual suppression in certain scenarios (particularly deployments) or to prevent unintended pregnancy can be burdensome or harmful to the servicewoman and may impact the mission.

Pregnancy during a deployment can delay prenatal care, and the cost of a medical evacuation can reach $10,000 in addition to the implications of lost personnel for the mission.^3,4 Female service members have reported that such situations can result in repercussions ranging from social isolation, demotion of rank, or loss of pay.⁵ Data collected from one brigade during Operation Iraqi Freedom demonstrated that over a 15-month deployment, 10.8% of females had to be medically evacuated because of pregnancy-related concerns.⁶ Therefore, ensuring servicewomen have access to the full range of contraceptives before deployment is an important preventive strategy and a critical component of readiness. Further, many servicewomen have expressed a desire to achieve menstrual suppression while deployed. Women may find themselves in situations where they do not have adequate access to hand washing and waste facilities, requiring them to carry used feminine products or bury them.⁷

Active duty women report that these challenges may be due in part to pre-deployment and deployment health care barriers. In the pre-deployment setting, 60% of women reported that they did not speak with a provider regarding contraceptive options and 78% did not discuss the potential to achieve menstrual suppression while deployed.³ Other challenges vary from not being aware of various contraceptive options, believing that birth control was not provided during deployment because of military policy, or not having time to meet with a provider before deployment.³

Once deployed, women reported access to oral contraception and the need to ration 1 month’s prescription at a time. Other barriers included fear of health care–seeking stigma and inability to maintain confidentiality because of the small-scale facilities.³ Some women also reported having limited access to female providers and being uncomfortable with seeking contraception counseling from a male.⁵

However, even those who were able to access their contraceptive choice reported unforeseen challenges. Fifty-five percent of women using the contraceptive patch during deployment in Operation Iraqi Freedom said that it would not adhere to their skin in the desert environment.⁸ Navy servicewomen reported unexpected side effects from oral contraceptive methods because of confusion on when to self-administer the medication as they sail through various time zones.⁹

In order to fill this knowledge gap and facilitate the servicewomen’s ability to choose a contraceptive method that fits her needs, a decision aid mobile health application (app), Decide + Be Ready (DABR), was developed.¹⁰ The objective of our study was to explore the use of DABR in facilitating contraceptive education and shared decision-making among servicewomen.

METHODS

We conducted a qualitative study to explore the experience of women with the DABR contraceptive decision aid. The study was approved by the institutional review board at Naval Medical Center Portsmouth (Portsmouth, VA) and complies with the U.S. Federal Policy for the Protection of Human Subjects. There was no external funding. The population studied consisted of women from 17 to 24 years of age who are currently serving as enlisted members of the U.S. Navy at Naval Station Norfolk. This demographic represents the population most at risk for unintended pregnancy.¹¹ Participants were excluded if they had never been deployed, worked in a health care setting, were pregnant at the time of the interview or actively planning pregnancy in the next 6 months, or had used DABR as a decision-making tool in the past. Participants were recruited until thematic saturation was achieved through ongoing analysis.

Participants were recruited from August 23 to September 3, 2021, at a free-standing medical clinic in Norfolk, VA. No recruited participant met exclusion criteria. Participants were consented and then instructed to download the DABR app onto their personal device and to spend at least 10-15 min interacting with the app. This was followed by an interview conducted in a private setting by the principal investigator (S.W.), a medical student at the time.

DABR begins with six structured educational modules about contraceptive options, including effectiveness, how each is used, frequency, side effects, impact on future fertility, and considerations for servicewomen. The user then fills out 11 questions, with a maximum of four answer choices. Questions explore attitudes toward pregnancy prevention, method of contraceptive delivery, frequency of contraceptive delivery, side effects, benefits, past contraceptive use, and comorbid conditions. DABR then lists out preferences based on these answers. The user can use the six structured modules to learn more about methods that were/were not recommended.¹⁰

Each semi-structured interview lasted approximately 30 min. Participants were asked open-ended questions that had been beta-tested in a representative population. Questions focused on the participants’ reaction to use of the various aspects of DABR, including questions targeting responses to the modules and the individualized profile created for the user. The interview then transitioned to questions that asked the participant to reflect on previous experiences with contraception and deployment. During this part of the interview, the investigator explored if this app would impact future contraceptive decisions in the deployed setting.

Interviews were transcribed using Nvivo transcription software (QSR International, Bakersfield CA, USA). S.W. and C.W. read all the transcripts, highlighting parts relevant to contraceptive decision-making and deployment-related concerns.

We utilized a reflexive approach to thematic analysis.¹² A data extraction tool, containing elements related to tensions related to decision-making and deployment-related topics, was designed in Excel after preliminary review of the transcripts. S.W. and C.W. completed the Excel table for each document, analyzing the completed table to refine coding, and new themes were noted during this process. Analysis identified final overarching themes and subthemes across responses of data.

RESULTS

We identified three overarching themes with eight subthemes. Here, we offer examples and participant quotes to support our findings. Participants will be referred to by their assigned participant identification letters A through T.

Utility of DABR

Influence of DABR on contraceptive decision-making

The influence of the contraceptive decision aid was demonstrated in two key ways. Most participants reported that DABR taught them about different contraceptive methods. For example, participant A stated, “I didn’t know about a patch that you just put on your skin. I never knew about that, so that’s something I will consider … the pill is something you have to take every day at around the same time … I’m not that strict with myself when it comes to that, so the patch would definitely be a different option.” In addition to providing knowledge, participant A reported that DABR also facilitated self-reflection about which contraceptive method was most suited to her lifestyle. In addition to learning about contraceptive methods, participant M expressed interest in further exploring her options. She reflected, “It’s kind of opened my eyes up to the IUD [intrauterine device] to make me want to go research a little bit more.”

Newfound knowledge on contraceptive methods influenced eight participants to report they will change their contraceptive method. Of the other five women who reflected on this theme, three participants planned to continue with their current contraceptive method and two did not desire contraception (Table I).

When asked to reflect on the attitudes developed toward DABR, participants viewed the app as a tool to help make a choice. For example, participant D said, “I think it was helpful because a lot of women might not know which birth control to pick or they might be in between two methods of birth control and this [DABR] could be helpful.” Some of the participants felt that had they had the app at their disposal previously it would have helped them avoid trial and error with various birth control options because of how a profile is built for each individual user. Participant O suggested, “I liked it because it was unique to me.” Overall, the responses to the encounter with the application were positive. Women described their experience as being detailed, easy, informative, and helpful.

Influence of DABR on contraception decision-making for deployment

DABR empowered women to express specific desires for their gynecologic health while deployed. Two specific desires elicited included menstrual suppression and long-acting reversible contraception (LARC) during deployment. Participants reported that menstrual suppression did or would improve their overall experience while on deployment. When participant N was asked why she used contraception on deployment, she responded, “I wanted my period to stop.” One participant shared her struggles with heavy menstrual bleeding; when asked if the app would have changed her behavior, participant A stated, “I definitely wish I had birth control on deployment.”

In line with the desire for menstrual suppression while deployed, some women specifically expressed a desire for LARC methods. “I would have rather … not had a period while deployed, so … I was thinking … the one that goes in your arm,” said participant G. In addition to the subdermal contraceptive implant, women also expressed desire for the IUD during deployment. When participant K was asked if she would have chosen to use a contraception while deployed, she responded affirmatively and selected IUD.

Knowledge and Comfort With Contraception

Community validation

One emerging theme that was reflected in two ways was a desire for peer validation related to contraception and menstrual health. One barrier, or potential tool, to contraceptive decision-making was that participants in the study valued the experiences of family members and peers. For example, participant J reflected, “I don’t know much about the pill, but I just know from my friends and family that it’s not as effective as other options.” Information about the oral contraceptive method and its effectiveness is presented in DABR, yet this participant focused on friends and family as a source of data, even after DABR exposure. Women also reflected on hearing negative experiences of contraceptive impact in peers. Participant M said, “I do know that people who have been on …the pill and they still can’t get pregnant.” Another participant mentioned that although the app recommended an IUD for her based on her values, she would not pursue the option because of her sister’s experience.

Participants value others’ experiences with gynecologic/reproductive health. This theme carried over to multiple participants expressing a desire for the application to have a section where it talks about a “normal” period that women experience. They reflect that this could help validate the feeling that their cycles are abnormal before talking to a provider—highlighting that community validation could be used as a tool regarding the conversation of reproductive health.

This value for community validation could stem from the method in which most participants reported first learned about contraception. Initial exposure to the topic for a majority of participants was from their family members (mother, grandmother, and sister), school, the military, a health care provider, or no one.

Hesitations with contraception

There was hesitation from participants regarding contraceptive side effects. Participant S said, “I stopped taking birth control on deployment because what they gave me was causing me to have [bacterial vaginosis (BV)] …It was the NuvaRing, I don’t know if maybe it was left out of the refrigerator … I would put it in and I’d get BV, I had never had it before in my life, I didn’t know what it was and I got tested for it and then we all went away, I tried again, and then I got it again. So, I just stopped using it altogether.” Other participants expressed being uncomfortable with not having a menstrual cycle. For example, participant A said, “I didn’t like that because I feel …blood should still exit every month, so I just stopped taking my birth control.” They also expressed fear that extended hormonal contraception could impact future fertility. With regard to the injectable progestin-only contraceptive, participant M worried about “long-term effects of pregnancy because that’s something that also matters to me … I know if you’re on the shot for too long it can mess up your bone density or it could sometimes affect, you know, pregnancy.” After answering questions in DABR many participants were advised that a LARC would align best with their preferences. Some participants reflected that, despite this recommendation, they would not ever pursue a LARC. Participant A stated, “I don’t want [anything] in my arm, I don’t want [anything] stuck up me for too long, at least a patch …I can see it is visible, change it and not change it.” Despite the information in the app that LARC methods are not permanent, participant A reported that she would not want the LARC because “you can’t change it and that that’s a decision to… stick with, to say you know I’m just not, you know, be able to have kids. That’s a big lifestyle decision.”

Motivations for contraception use were also revealed. A majority of participants used contraception for pregnancy prevention, followed by cycle regulation, acne, and period-associated symptoms.

Pre-deployment education/preparation

Participants acknowledged the need for contraceptive information dissemination in the pre-deployment setting and recommended two ways to do so. First, they suggested methods of promoting DABR to include medical, command, posters, social media, Fleet and Family briefs, women’s wellness meetings, and/or at boot camp. In addition to recommending ways that contraceptive information could be most effectively provided to women, some participants also encouraged a mandated pre-deployment wellness appointment. Participant J said, “Kind of like the women’s appointment that we have annually, I think we should do that with everyone on the ship just to prepare for the deployment … a lot of times when you get on deployment and this comes up or that comes up … it’s kind of harder to ask if those situations when you are deployed rather than if you were about to take care of before.” Participant M recommended a similar idea that would serve as a preventive measure to protect both sailors and the mission: “Women are the ones who can become pregnant … their boyfriend or girlfriend might be on the ship, so of course, those risk factors of having sex do come up in ports … so it is something that they should look into because pregnancy is not allowed on deployment, so that’s … one person down and it could long-term hurt the ship, in a sense. Contraception is something we should really talk about before deployment.”

Access to contraception/menstrual products while deployed

Another theme that emerged was access to contraception and menstrual products while deployed. Women reported that while on deployment, they would supply their own menstrual hygiene products and pain control methods because medical supplies could run out of stock. Additionally, participants reported that with deployments getting extended, they would find themselves without enough birth control. In one case, a participant reported difficulty obtaining emergency contraception. Participant K shared, “Yeah, I wasn’t on birth control and the guy I was dating was on the ship and they didn’t have it set up where I can just get … a Plan B from medical. So, we’re going to go out in town and try to find out where we can get.”

Of the participants who were able to continue contraception on deployment, there were still challenges with gynecologic health. Participant F reflected, “I couldn’t control my period because it’s … the difference between … times and … all that stuff, you just … the stress level and stuff like that really hits you. … I think the implant really helps so you don’t have a period on deployment, no period where you don’t have to worry about that stuff. So, I really like that, but I had the pills on deployment, and I hated it.” On the other hand, those participants using a contraceptive implant endorsed that their menstrual bleeding patterns were irregular during deployment, causing them to desire removal; however, no one on board had the training to do so. In addition, participants also commented on the impact of schedules on appropriate adherence to oral contraception. “We had different watches every day at different times. So having to make sure it was …at the same time, I had to wake up in the middle of my sleep at a certain time to just take the pill and then try to go back to sleep So, yeah, it did really affect it,” said participant K.

Active Duty-specific Challenges

Constraints of deployment

Three women reflected on either experiencing unintended pregnancy herself or among her peers while deployed. Pregnancy necessitates removing the servicewoman from the deployed setting. This may also occur with complicated gynecologic issues. One female in this study was removed from deployment for endometriosis-related pain that was not manageable with the resources available. A similar situation may arise if providers lack expertise with a particular medical issue.

Participants in this study also reflected on gynecologic issues stemming from what they perceive to be the environment of deployment. Specifically, a few participants felt that there was an increase in vaginal candidiasis. Participant P pointed out that “the water is different, and I had multiple conversations with other women who [said], ‘Yeah, I’ve got a yeast infection when we got underway.’ I experienced that when we got underway and … one of my corpsman [said] we’ll get you in [approximately] 2 weeks because they’re going to set up a whole thing for all of the women … that’s not fast enough …regardless. And that’s not acceptable.”

Attitudes toward military health care

Some participants expressed distrust toward Navy medical personnel. Women reported that they felt DABR taught them more than medical providers about contraception. When reflecting on previous encounters regarding contraception, they felt that providers mandated a method without asking what was important to them. Participant H expressed frustration: “She literally told me nothing about it other than it could possibly stop your cycles, there’s no guarantee but it’ll alleviate my pain—but my pain is regulated by whether or not I’m bleeding.” Participants also shared that they did not always believe medical providers’ counseling and this prompted them to stop taking their birth control. Participant R, e.g., said “I went to medical and they told me, well, you know, the white substance that comes out is considered your period. But …that doesn’t make any sense.”

Attitudes varied based on command. Some participants reflected on not feeling supported by their command in attending appointments for follow-up doses of the injectable progestin-only contraceptive, prompting them to switch methods. Others discussed that their command appeared to understand their reproductive health needs. While participant R reports having challenging experiences: “medical on a carrier is always terrible,” participant D said, “It’s not … that hard, you can use any form of birth control on deployment” all depending on the ship’s medical staff”.

DISCUSSION

Our qualitative study highlights the potential utility of DABR in contraceptive education and shared decision-making. We identified several themes around its utility, knowledge and comfort with contraception, and military-specific challenges. The data identified points of further discussion including the value of peer and family influence on contraceptive use. Despite the knowledge of the participants’ risk for unintended pregnancy, this study still empowered participants to desire contraceptive methods based on their own values and preferences rather than that of the provider, which may tend toward the most effective methods. The study also identified deployment-related issues with comprehensive contraceptive care and a perceived increase in yeast infections.

Although the study demonstrated success with the use of DABR as a contraceptive decision aid, we also identified areas for improvement. Participants communicated value of community validation in their selection of contraceptive methods. Participants suggested including a section for reviews of the various contraceptive methods into DABR. However, would the community influence be as powerful as seen in this study, with anonymous reviews, from unknown individuals? Alternatively, the findings suggest an opportunity for providers to incorporate the user’s knowledge and perspective of community experiences in shared decision-making. Patient-centered contraceptive counseling is most successfully practiced when the values of the provider do not influence those of the patient.¹³ Review of the literature affirms that peer influence on contraception choice can be a barrier to accurate knowledge.¹⁴ However, it has been demonstrated that if the health care system cultivates this influence and incorporates educated peer counselors in the decision-making process, patients will leave the encounter more educated and more often with a highly effective LARC.¹⁵ By encouraging use of tools such as DABR, military medicine may also educate servicewomen who can then serve as reliable peers in the decision-making process.

In addition to providing new perspectives on contraceptive decision-making, this study revealed some ongoing challenges to address to ensure servicewomen can effectively and safely utilize contraceptive methods. For example, participants reported that providers on deployment are not always credentialed to remove LARC, especially the contraceptive implant. As demonstrated through this study, bleeding patterns and the characteristics of a woman’s cycle can change with the environment of deployment. Comprehensive contraceptive services include counseling, initiation, and discontinuation, if desired. Since the contraceptive implant is a method that many servicewomen are offered before deployment, as it has been thought to show benefit to the active duty female,¹⁶ it would be important to ensure appropriate follow-up care, including removal, is available during the deployment. While issues with removal of IUDs did not arise during the study, this may be another area for further exploration. The question may arise: is it ethical to provide servicewomen with contraceptive methods that cannot be managed during deployment? At the very least, it is important to counsel women about potential limitations of care during deployment. The best practice to ensure gynecologic health on deployment is through planning and prevention.^16,17 This provides an ideal platform for utilization of a new military health app, Deployment Readiness Education for Service Women—which specifically addresses preparation for deployment.¹⁸

Another theme that emerged in the study related to medical conditions resulting from deployments. Two participants believed that the water provided on deployment for hygiene leads to yeast infections. In a 2003 study, 30.1% of servicewomen surveyed reported gynecological infections on deployment.¹⁹ This study considered factors outside of the water provided by ship, as they interviewed women from varying military branches. The study weighed heavily on behavioral and environmental issues including but not limited to medication use, underwear material, tampon use, damage to vaginal mucosa, sparse laundry facilities, poor hygiene, unsanitary restrooms, and lack of privacy.¹⁹ There are no data specific to the active duty navy female, which points to a potential area for study.

The limitations of this qualitative study include lack of significant diversity in the participants’ backgrounds. We studied a young demographic who may still be within their first duty station and have yet to experience the breadth of Navy medicine. A majority of participants deployed shipboard, thus we did not capture submarine or land deployments. Additionally, at this duty station, there is a walk-in contraceptive clinic that not all servicewomen have access to at different commands, potentially altering participants’ experiences with contraception in the military.

CONCLUSIONS

We explored the influence of DABR on contraceptive decision-making in active duty women, revealing points of further effort and study. Our results suggest improved knowledge and perception of empowerment to make decisions among the sample population could aid in the prevention of unintended pregnancy.

ACKNOWLEDGMENTS

None declared.

FUNDING

The work was supported by Uniformed Services University of Health Sciences (USUHS) Capstone Program.

CONFLICT OF INTEREST STATEMENT

None declared.

DATA AVAILABILITY

The data that support the findings of this study are available on request from the corresponding author. All data are freely accessible.

DECLARATIONS

None declared.

CLINICAL TRIAL REGISTRATION

Not applicable.

INSTITUTIONAL REVIEW BOARD

This study was approved by Naval Medical Center Portsmouth’s Institutional Review Board.

INSTITUTIONAL ANIMAL CARE AND USE COMMITTEE (IACUC)

Not applicable.

INDIVIDUAL AUTHOR CONTRIBUTION STATEMENT

S.W. and C.W. collected and analyzed the data and drafted the original manuscript. C.W. and A.T. reviewed and edited the manuscript. All authors read and approved the final manuscript.

INSTITUTIONAL CLEARANCE

This study has been approved by USU and Naval Medical Center Portsmouth for publication.

REFERENCES

Author notes