Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696596911701.pdf (United States)
STATEMENT FOR THE RECORD OF THE HEARING TITLED “VETERANS’ ACCESS TO REPRODUCTIVE HEALTH CARE” UNITED STATES HOUSE OF REPRESENTATIVES COMMITTEE ON VETERANS’ AFFAIRS, SUBCOMMITTEE ON HEALTH JULY 1, 2020 BY THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS 409 12TH ST SW WASHINGTON DC, 20024 Chairwoman Brownley, Ranking Member Dunn, and distinguished members of the House Committee on Veterans’ Affairs, Subcommittee on Health, thank you for the opportunity to submit this statement for the Committee’s record of its hearing titled “Veterans' Access to Reproductive Health Care”.
The American College of Obstetricians and Gynecologists (ACOG) is the nation’s leading group of physicians providing health care for women.

With more than 60,000 members, ACOG advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care.
Reproductive health care is essential to the health of women throughout the country.

ACOG is committed to ensuring access to the full spectrum of evidence-based quality reproductive health care for all women.

We urge Congress to act urgently and swiftly to advance policies that facilitate access to evidence-based reproductive health care for veterans and dismantle policies that disadvantage veterans in their ability to access this essential and critical care.
Impacts of Military Service on Women’s Health There are nearly two million women veterans in the United States.
Women are the fastest-growing group within the veteran population, with the total population expected to increase at an average rate of about 18,000 women per year for the next 10 years.i,ii Approximately 43 percent of Veteran’s Health Administration (VHA) patients who are women are between the ages of 18 and 44.iii As more women are serving in the military, and a greater proportion of United States veterans are women, it is essential that the VHA is well prepared to address the unique health care needs of this demographic group.iv Military service is associated with unique risks to women’s reproductive health.v Research regarding women veterans has increased significantly over the past two decades, and several studies characterize the greater physical and psychiatric morbidity and diminished social support of these women compared with their civilian counterparts.vi,vii,viii,ix Military deployment to severe environments, including war zones, carries risk, including potential for long-term health impacts for both men and women.
Specific to women’s health, deployment can result in limited access to medical services and sanitary equipment and increase the inconvenience and logistic difficulty of hygienic management of menstruation.x For some women, deployment may interrupt preventive care, including cancer screenings and other types of diagnostic testing, or ongoing treatment or evaluation for conditions.xi This may predispose deployed women to greater risk of gynecologic conditions, such as urinary tract infections or bacterial vaginosis.xii,xiii,xiv This type of risk may affect the long-term health of women veterans and emphasizes the critical need for this population to be afforded high quality, comprehensive reproductive health care.
A Paucity of Data Exists on Maternal Health Among Veterans The aforementioned data clearly illustrate the unique needs of the veteran population, including during pregnancy and the postpartum period.

However, there exists a paucity of data on maternal health outcomes among veterans, and whether they experience higher rates of adverse outcomes, including severe maternal morbidity and maternal mortality.
The United States is the only industrialized nation with a maternal mortality rate that is on the rise, increasing 26 percent between 2000 and 2014.xv It is estimated that more than half of these deaths are preventable.xvi Equally concerning are the stark racial inequities: Black women are three times more likely to die from a pregnancy-related complication than non-Hispanic White women, and American Indian/Alaska Native women are 2.5 times more likely to die from a pregnancy-related complication than non-Hispanic White women.xvii The lack of data concerning maternal health outcomes in the veteran population is especially concerning given the high proportion of Black women veterans compared to Black women in the general population.xviii ACOG urges the Committee to advance H.R.
6141, the Protecting Moms Who Served Act, which would help inform us of the scope of maternal mortality and severe maternal morbidity among veterans, with a particular focus on minority women veterans, as well as make investments in maternity care coordination at VA facilities to bolster quality of care and ensure that veterans have access to broad support services during the perinatal period.
If enacted, this legislation would help us better understand the unique needs of veterans during the perinatal period and improve maternal health outcomes among veterans.

Veterans Are Subjected to Burdensome and Harmful Restrictions on Health Care Services As the Committee is aware, under current regulations, the VA specifically prohibits abortion care within its medical benefits coverage without any exceptions.
This denial of coverage for abortion means that veterans have lesser coverage than civilian federal employees, service members, and incarcerated individuals.

It is unacceptable for veterans to be disadvantaged.
ACOG opposes all regulations that limit or delay access to abortion and affirms that the disparity in insurance coverage of abortion must be eliminated to provide veterans equitable and comprehensive coverage and care.xix Abortion is an essential component of women’s health care.xx Like all medical matters, decisions regarding reproductive health care, including abortion care, should be made by patients in consultation with their clinicians and without undue interference by outside parties.xxi Like all patients, veterans seeking abortion are entitled to privacy, dignity, respect, and support.xxii Forcing veterans to seek abortion care outside of the health care system they depend on imposes prohibitive geographic and financial barriers on women, and disproportionately negatively impacts women with low incomes, women living in rural areas, and women in states with a paucity of abortion clinics.xxiii The Committee’s hearing today comes at a pivotal time.
Abortion, although still legal outside of the VA, is increasingly out of reach due to mounting government-imposed restrictions targeting women, physicians, and other clinicians who provide care to women.xxiv The existing mosaic of state laws and regulations has escalated access disparities and threatens to criminalize or otherwise penalize physicians and other clinicians for providing evidence-based, compassionate care consistent with their medical judgment, standards of care, and their patients’ needs.
This poses a crisis for veterans who are prohibited from accessing abortion care within the health care system they depend on and may subsequently face significant barriers in accessing abortion care outside of the VHA.

This warrants urgent scrutiny and swift action by Congress to lift burdensome and harmful restrictions on access to abortion care.
Politics should never outweigh scientific evidence, override standards of medical care, or drive policy that puts a person’s health and life at risk.xxv Policy related to reproductive health care must be based on medical science and facts.

The government can serve a valuable role in making health policy when its purpose is to improve patient health and advance medical and scientific progress.

Restrictions on access to abortion achieve neither.
ACOG guidance acknowledges the negative impact that restrictions on abortion access have on women’s health.xxvi Government-imposed restrictions may inflict substantial damage on women’s health care, interfering with the patient-physician relationship and decreasing access to abortion for all women, particularly for women with low incomes and those living long distances from clinics.xxvii These restrictions also result in the marginalization of abortion services from routine clinical care and are harmful to women’s health.
A recent study published by the National Academies of Medicine, Engineering, and Science affirms that the greatest threats to the safety and quality of abortion in the United States are unnecessary government regulations on abortion.xxviii In its assessment, the report cited that these threats impact all six attributes of health care quality: safety, effectiveness, patient- centeredness, timeliness, efficiency, and equity.xxix Additionally, under current regulations, the VA is not authorized to provide or cover the cost of abortion counseling.
This restriction prevents clinicians from discussing the full range of reproductive care with veterans, undermines the doctrine of informed consent, and infringes upon the patient-physician relationship.

Good medical practice demands that a patient and physician decide together on treatment based on the specific needs of each patient.
Physicians have a legal, professional, and ethical obligation to share with their patients all accurate and unbiased information about health care options, make appropriate referrals, and respect their patients’ autonomy, privacy, and decisions.xxx This restriction disrupts the patient-physician relationship, denying veterans nondirective comprehensive information about their health care.
The prohibition of abortion counseling unduly marginalizes abortion services from routine clinical care, is harmful to veterans’ health, and should be lifted.

ACOG also affirms that access to comprehensive contraceptive care and contraceptive methods is an integral component of women’s health care.
The Affordable Care Act established that access to women’s preventive services, including contraception, is an essential health benefit and required plans to cover contraceptives without cost-sharing, but did not extend this requirement to the VA. Consequently, veterans who rely on the VA for contraception often must pay a copay.
Copayments for contraception limit contraceptive access even for those with health insurance.xxxi Additionally, while the VA offers veterans three-month supplies of oral contraceptives, research has shown that more than 64 percent of veterans who relied on hormonal contraception experienced at least one gap in coverage of seven days or longer.xxxii These gaps put veterans at risk of unintended pregnancy.
Research indicates that access to a 12-month supply of oral contraceptives can help eliminate gaps in birth control use.xxxiii ACOG encourages payment and practice policies that support provision of up to 13-month supplies of combined hormonal methods to improve contraceptive continuation.

In addition, ACOG urges the Committee to consider the needs of veterans experiencing infertility.
Urogenital injury and pelvic trauma are common injuries among veterans of recent conflicts, and infertility is one of the possible outcomes of these injuries, and for some in vitro fertilization (IVF) may be the only option for becoming pregnant.xxxiv While ACOG applauds the recent improvements to the VHA medical benefits package to include infertility evaluation and some infertility treatments, limitations on and barriers to eligibility for that coverage continue to make this care inaccessible for many families.xxxv ACOG urges the Committee to advance H.R.
2803, the Access to Infertility Treatment and Care Act, which would require coverage of infertility and fertility preservation services, including through the use of assisted reproductive technology, to a veteran or their spouse or partner.
ACOG urges Congress to act urgently and swiftly to exercise the authorities at its disposal to lift the onerous and harmful restrictions on access to abortion care within the VA and ensure veterans have equitable coverage and access to comprehensive reproductive health care services, including abortion, contraception, and infertility treatment.
Promote a research agenda that studies the effect of military status on reproductive health ACOG urges the Committee to support a robust investment in research designed to evaluate the association of military service and women’s reproductive health to inform and improve the development of empirically derived best practices for their reproductive health care.xxxvi In addition to the aforementioned need for research on maternal health outcomes among veterans, research areas that warrant consideration include the following: • Co-occurrence of medical and mental health conditions in women in the military and women veterans and effect on reproductive health outcomes; • The association of military deployment and unintended pregnancy and the effects of military deployment on subsequent pregnancy outcomes; • Best practices for the safe pharmacologic management of veterans with psychiatric illness (i.e.
depression or post-traumatic stress disorder) who are pregnant or wish to become pregnant; • The provision of perinatal care for veterans with disabilities, including cognitive or physical impairment that stems from traumatic brain injury, polytrauma, or other injury.xxxvii *** Thank you for the opportunity to highlight our clinical guidance regarding reproductive health care, the importance of evidence-based research, and the urgent need to ensure that veterans have access to comprehensive reproductive health care.
ACOG looks forward to continuing to work with the Committee to improve and protect veterans’ access to comprehensive reproductive health care.

i National Center for Veterans Analysis and Statistics, U.S. Department of Veterans Affairs, The Past, Present, and Future of Women Veterans 10 (2017), available at https://www.va.gov/vetdata/docs/SpecialReports/Women_Veterans_2015_Final.pdf.

ii Ibid.

iii Women Veterans Health Care Facts and Statistics about Women Veterans.

U.S. Department of Veterans Affairs.


Available at: https://www.womenshealth.va.gov/WOMENSHEALTH/latestinformation/facts.asp#:~:text=Women%20Veterans% 20Health%20Care,- Facts%20and%20Statistics&text=In%202017%20the%20median%20age,of%20women%20Veteran%20VHA%20p atients.

iv Health care for women in the military and women Veterans.

Committee Opinion No.

547.

American College of Obstetricians and Gynecologists.

Obstet Gynecol 2012;120:1538–42.

v Ibid.


vi Frayne SM, Seaver MR, Loveland S, Christiansen CL, Spiro A3rd, Parker VA, et al.

Burden of medical illness in women with depression and posttraumatic stress disorder.

Arch Intern Med 2004;164:1306–12.

vii Sayers SL, Farrow VA, Ross J, Oslin DW.

Family problems among recently returned military veterans referred for a mental health evaluation.

J Clin Psychiatry 2009;70:163–70.


viii Bean-Mayberry B, Yano EM, Washington DL, Goldzweig C, Batuman F, Huang C, et al.

Systematic review of women veterans’ health: update on successes and gaps.

Womens Health Issues 2011;21:S84–97.

ix Goldzweig CL, Balekian TM, Rolon C, Yano EM, Shekelle PG.

The state of women veterans’ health research.

Results of a systematic literature review.

J Gen Intern Med 2006; 21(suppl 3):S82–92.

x Health care for women in the military and women Veterans.
Committee Opinion No.

547.

American College of Obstetricians and Gynecologists.

Obstet Gynecol 2012;120:1538–42.

xi Ibid.

xii Doyle P, Maconochie N, Ryan M. Reproductive health of Gulf War veterans.

Philos Trans R Soc Lond B Biol Sci 2006; 361:571–84.

xiii Powell-Dunford NC, Cuda AS, Moore JL, Crago MS, Kelly AM, Deuster PA. Menstrual suppression for combat operations: advantages of oral contraceptive pills.

Womens Health Issues 2011;21:86–91.

xiv Pierce PF.
xiv Pierce PF.

Physical and emotional health of Gulf War veteran women.

Aviat Space Environ Med 1997;68:317– 21. xv MacDorman, M., Declercq, E., Cabral, H., Morton, C., “Is the United States Maternal Mortality Rate Increasing?

Disentangling trends from measurement issues: Short title: U.S. Maternal Mortality Trends.” Obstet Gynecol 2016 Sep; 128(3):447-55. xvi Building U.S. Capacity to Review and Prevent Maternal Deaths.

(2018).

Report from nine maternal mortality review committees.
Available at: https://reviewtoaction.org/Report_from_Nine_MMRCs xvii Petersen EE, Davis NL, Goodman D, et al.

Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016.

MMWR Morb Mortal Wkly Rep 2019;68:762–765.

DOI: http://dx.doi.org/10.15585/mmwr.mm6835a3.


xviii National Center for Veterans Analysis and Statistics, U.S. Department of Veterans Affairs, Military Service History and VA Benefit Utilization Statistics (2017), available at https://www.va.gov/vetdata/docs/SpecialReports/Minority_Veterans_Report.pdf xix Health care for women in the military and women Veterans.

Committee Opinion No.

547.

American College of Obstetricians and Gynecologists.

Obstet Gynecol 2012;120:1538–42.


xx Abortion Policy Statement, The American College of Obstetricians and Gynecologists, https://www.acog.org/Clinical-Guidance-and-Publications/Statements-of-Policy/Abortion-Policy (Nov. 2014) xxi Ibid.

xxii Ibid.

xxiii Barriers to Abortion Care and Their Consequences for Patients Traveling for Services: Qualitative Findings from States.

Jerman,J., Frohwirth, L. Kavanaugh, ML.

& Blades, N. Perspect Sex Reprod Health.


2017 Jun; 49(2):95-102. xxiv Increasing access to abortion.

Committee Opinion No.

613.

American College of Obstetricians and Gynecologists.

Obstet Gynecol 2014;124:1060—5.

xxv Abortion Can Be Medically Necessary.

Statement of the American College of Obstetricians and Gynecologists (Sept. 2019), at https://www.acog.org/About-ACOG/News-Room/Statements/2019/Abortion-Can-Be- MedicallyNecessary xxvi Increasing access to abortion.

Committee Opinion No.

613.


American College of Obstetricians and Gynecologists.

Obstet Gynecol 2014;124:1060–5.

xxvii Ibid.

xxviii Safety and Quality of Abortion Care in the United States.

National Academies of Sciences, Engineering, and Medicine.

(March 2018).

At https://www.nap.edu/read/24950/chapter/1 xxix Ibid.

xxx Informed consent.

ACOG Committee Opinion No.

439.

American College of Obstetricians and Gynecologists.

Obstet Gynecol 2009;114:401–8.

xxxi Access to contraception.


Committee Opinion No.

615.

American College of Obstetricians and Gynecologists.

Obstet Gynecol 2015;125:250–5.

xxxii Adherence to hormonal contraception among women veterans: differences by race/ethnicity and contraceptive supply.

Borrero S, Zhao X, Mor M, Schwarz EB, et al.

Obstet Gynecol 2013 Aug; 209(2):103.E1-103.E11.


DOI: https://doi.org/10.1016/j.ajog.2013.03.024 xxxiii Diana Greene Foster et al., Number of Oral Contraceptive Pill Packages Dispensed and Subsequent Unintended Pregnancies, 117 Obstetrics & Gynecology 566 (2011).

xxxiv Edmonds SW, Zephyrin LC, Christy A, Ryan GL.

Infertility Services for Veterans: Policies, Challenges, and Opportunities.

Semin Reprod Med.

2019;37(1):12-16. doi:10.1055/s-0039-1692127.

xxxv U.S. Department of Veterans Affairs.


Community Care.

In Vitro Fertilization Treatment.

Available at https://www.va.gov/COMMUNITYCARE/programs/veterans/IVF.asp.

xxxvi Health care for women in the military and women Veterans.

Committee Opinion No.

547.

American College of Obstetricians and Gynecologists.

Obstet Gynecol 2012;120:1538–42.

xxxvii Ibid.