Defense Health Care: Health Care Benefit for Women Comparable to Other Plans
Published: 2002-05-01T00:00:00

Fast Facts:

Highlights:
section_title: What GAO Found
paragraphs: Half of all beneficiaries in the Department of Defense's (DOD) Tricare health care program are women. With a health care system historically oriented towards men, DOD has had to work to ensure that its women beneficiaries receive the full range of medical services they are entitled to, including obstetrical and gynecological care and diagnostic services such as Pap smears and mammograms. TRICARE-covered benefits are in line with American College of Obstetricians and Gynecologists guidelines and are comparable to women's health benefits offered by two of the largest health plans under the Federal Employees Health Benefits Program (FEHBP). DOD also requires some beneficiaries to share in the cost of their health care. Both DOD's and FEHBP's copayments, which are the same for men and women, vary depending on the plan option and the providers selected. Women beneficiaries report being satisfied with the health care benefits they receive under TRICARE. Some women beneficiaries, however, have expressed concerns about obtaining services when they are stationed overseas or in remote areas. Some active duty women are also concerned that command personnel may not understand women's health care needs.

section_title: Letter
paragraphs: About half of all beneficiaries who are eligible to use TRICARE, the  Department of Defense’s (DOD) health care program, are women—either  active duty personnel, family members, or retirees. With a health care  system historically oriented towards men, DOD has been challenged to  ensure that its women beneficiaries receive the full range of services  including primary, specialty, preventive, and reproductive care. The  National Defense Authorization Act (NDAA) for fiscal year 2002 directed  that we study the adequacy and quality of the health care provided to  women by DOD. As agreed with the committees of jurisdiction, we will  describe (1) the health care benefit targeted to women covered under the  TRICARE program and how this benefit compares to national clinical  guidelines and other health plans’ offerings and (2) women beneficiaries’  satisfaction with and concerns about DOD’s health care benefit.
To conduct our work, we reviewed relevant policies and procedures and  interviewed officials from DOD’s Health Affairs’ Office of Clinical and  Program Policy; DOD’s TRICARE Management Activity (TMA); and the  Surgeons General Offices for the Air Force, Army, and Navy. We also  interviewed officials from the American College of Obstetricians and  Gynecologists (ACOG) and reviewed two of the largest health care plans  under the Federal Employees Health Benefits Program (FEHBP) to  compare the covered benefits with TRICARE’s. To determine beneficiaries’  perceptions on women’s health care services in TRICARE, we relied on our  past work on DOD health care, and we reviewed the latest available data  from two DOD surveys: a DOD-wide health care survey on beneficiary  satisfaction and a survey targeted at inpatient care during childbirth at  selected military treatment facilities (MTF). In addition, we held interviews  with the Defense Advisory Committee on Women in the Services  (DACOWITS), a group that advises the Secretary of Defense on issues  concerning active duty women, and the National Military Family  Association (NMFA), an advocacy group that obtains beneficiary views on  issues concerning military families. However, we did not independently  validate this information or determine the prevalence of beneficiary  concerns. It should also be noted that while our review focuses on health  care for women beneficiaries, a number of our findings pertain to men as  well, which we note where appropriate. Our work was conducted from  November 2001 through April 2002 in accordance with generally accepted  government auditing standards. (For more on our scope and methodology,  see app. I.)
subsections: section_title: Background
paragraphs: DOD’s medical mission includes maintaining the health of 1.7 million active  duty personnel and providing health care to them during military  operations. About 12 percent of the Navy’s active duty personnel, about 16  percent of the Army’s active duty personnel, and about 19 percent of the Air  Force’s active duty personnel are women. DOD also offers health care to  women who are family members of active duty personnel, retirees, family  members of retirees, and survivors of active duty and retired active duty  members (see fig.1).
DOD beneficiaries are provided benefits through one of three health plans:  TRICARE Prime (an HMO option), TRICARE Extra (a preferred provider  option), and TRICARE Standard (a fee-for-service option). Active duty  members are required to enroll in TRICARE Prime, but family members  and retirees under age 65 can choose among any of the three plans. DOD also provides benefits to military beneficiaries who are Medicare-eligible.   Beneficiary copayments vary depending on the TRICARE option. Active  duty personnel and their family members who are enrolled in TRICARE  Prime do not have copayments.
Under TRICARE, health care is provided in MTFs worldwide and by  civilian providers. Priority for care at MTFs varies depending on the  beneficiary type—active duty, family member, or retiree—and the  TRICARE option. Active duty members have the highest priority for care at  MTFs, followed by other beneficiaries enrolled in TRICARE Prime.   Beneficiaries who are eligible for military health care, but not enrolled in  TRICARE Prime, may receive care at MTFs on a space-available basis.  Active duty members are required to use MTF care, if available. Family  members and retirees may obtain care at either military or civilian  facilities, depending on the TRICARE plan they choose.
Policy regarding health care for all DOD beneficiaries is developed by the  Office of the Assistant Secretary of Defense for Health Affairs (Health  Affairs). TMA oversees the operation of the TRICARE Program. Health  Affairs and TMA coordinate with the Air Force, Army, and Navy to  implement TRICARE, but the Surgeon General of each branch of the  military has authority over its own MTFs. TMA also oversees the TRICARE  contracts with the civilian providers.
DOD and the three branches of the military have implemented policies and  initiatives specifically aimed at improving the delivery of health services for  women. (See app. II for details.) For example, a 1998 DOD policy states  that women enrolled in TRICARE Prime shall have the option to choose a  primary care manager (PCM) who has advanced training in women’s  health issues. Additionally, MTFs have begun providing “family-centered”  obstetrical care by involving the family in the continuum of care from  prenatal through postpartum. Other efforts have been aimed at educating  line commanders and beneficiaries about the importance of women’s  health care services to readiness.
section_title: DOD’s Health Care Benefit for Women is Comparable to Other Plans
paragraphs: DOD offers a full range of health care services for women beneficiaries  through the TRICARE benefit. In general, TRICARE-covered benefits for  women reflect national clinical guidelines developed by ACOG and are  comparable to widely used FEHBP health plans. DOD—like the FEHBP  plans we reviewed—requires some beneficiaries to share in the cost of  their health care. These copayments, which are the same for men and  women, vary depending on the plan option and providers selected.
subsections: section_title: DOD Health Care Services for Women
paragraphs: In addition to the range of health care services offered to all DOD  beneficiaries, TRICARE provides health care services targeted specifically  to women. The benefit is uniform across all three branches of the military,  and generally for all beneficiary types, including active duty members,  family members, and retirees. These services include the following primary,  specialty, preventive, and reproductive care.
Comprehensive obstetrical and gynecological care, including care  related to pregnancy and family planning, and screening for  gynecological cancers:  prenatal, maternity, and postpartum care, including HIV and  Hepatitis B screening for pregnant women, and genetic testing when  medically indicated to determine if an unborn child has genetic  defects, and   family planning, including contraceptives, diagnosis and treatment of  infertility, and sterilization;  pelvic exams and Pap smears;  breast examinations and mammography;  breast reconstructive surgery for mastectomy patients and other breast   hormone replacement therapy and counseling regarding the benefits  and risks of hormone replacement therapy for menopausal women; and  bone density studies to diagnose and monitor osteoporosis, osteopenia,  and for those at high-risk of bone disease.
section_title: TRICARE Health Benefits for Women Are In Line With National Guidelines and Other Health Plans
paragraphs: The TRICARE benefit is consistent with the guidelines for women’s health  issued by ACOG for primary, specialty, preventive, and reproductive care.  TRICARE benefits are also comparable to the range of benefits for women  offered under two FEHBP health plans—BlueCross and BlueShield Service  Benefit Plans (BlueCross BlueShield), a fee-for-service and preferred  provider plan with the largest number of participants in FEHBP; and Kaiser  Foundation Health Plan of the Mid-Atlantic States, Inc. (Kaiser), one of the  FEHBP’s largest HMO plans. Specifically, BlueCross BlueShield and Kaiser  also offer the full range of women’s health care services covered by  TRICARE as listed above, including obstetrical and gynecological care,  maternity care, family planning, mammography, reconstructive breast  surgery, hormone therapy, and bone density studies. For example,  TRICARE coverage for Pap smears and mammograms is in line with the  FEHBP plans that we reviewed as well as with ACOG guidelines that call  for screenings based on age and risk. (See table 1.)
Benefits not provided under TRICARE are also comparable to the benefits  not covered under the FEHBP plans we reviewed. For example, TRICARE  does not cover  over-the-counter contraceptives or over-the-counter pregnancy tests,  artificial insemination including in vitro fertilization,  routine genetic testing to determine paternity or child’s gender,  surgery to reverse sterilization, and  abortion, except when the life of the mother is endangered.
BlueCross BlueShield and Kaiser generally do not cover these services  either, although there are limited exceptions. For example, Kaiser covers  artificial insemination and in vitro fertilization in certain cases. While in  vitro fertilization services are not covered under the TRICARE benefit,  DOD officials told us that these services are offered with a required patient  copayment at five MTFs:  Keesler Air Force Base, Biloxi, Mississippi; Naval  Medical Center, San Diego, California; Walter Reed Army Medical Center,  Washington, D.C.; Wilford Hall Medical Center, San Antonio, Texas; and  Wright-Patterson Air Force Base, Dayton, Ohio.
In addition, the TRICARE benefit requires some beneficiaries to share in  the cost of their health care—a characteristic also found in the FEHBP  plans we reviewed. However, the various plan options make direct  comparisons difficult. TRICARE Prime enrollees who are active duty  members or their family members have no copayments, while Kaiser  requires its beneficiaries to pay a $10 copayment for routine screenings.  TRICARE Extra and Standard beneficiaries and BlueCross BlueShield  beneficiaries share in the cost of care, with the copayments varying  depending on the plan option and the type of provider chosen by the  beneficiary.
section_title: Most Women Beneficiaries Are Satisfied With DOD’s Health Care Benefit, but Some Concerns Exist
paragraphs: Overall, women beneficiaries report being satisfied with the TRICARE  health care benefit, but some have concerns about the type of care they  receive. Generally, these concerns stem from where beneficiaries are  located and their expectations about the types of providers, sources of  care, and supplies that should be available. For active duty women, the  attitudes of the command personnel can also influence women  beneficiaries’ satisfaction.
subsections: section_title: DOD Survey Data Indicate Women Are Generally Satisfied With Health Care Services
paragraphs: According to DOD survey data from 2000, women beneficiaries report  being generally satisfied with the TRICARE health benefit and their access  to health care services. Results of this survey indicate that women are as  satisfied as men with their DOD health plan on four measures pertaining to  their experiences with their providers and accessing care. For example, the  average rating from women for the health care they received in the last 12  months from all providers was 7.8 on a scale where 10 represents the best  health care possible—the same rating as given by men. In addition, 85  percent of women and 87 percent of men reported that they were usually or  always satisfied with how well providers communicated. (See table 2.)
section_title: Some Women Beneficiaries Have Concerns About the Available Care
paragraphs: While most of DOD’s women beneficiaries are satisfied with the care they  receive, some have expressed concerns about their health care. These  concerns generally stem from the beneficiary’s location—overseas, in  remote areas, or in deployed settings—and expectations about the type and  source of care available. For active duty women, concerns also stem from  the attitudes and the climate established by the command personnel who  may not understand women’s health care needs.
subsections: section_title: Some Concerns Are About Care in Overseas, Remote, and Deployed Settings
paragraphs: Military beneficiaries—both men and women—stationed in overseas or  remote locations provide a significant challenge for DOD's health system.   In locations overseas, DOD supplements its MTF care with civilian host  nation care, where medical practice, language, and culture can differ  significantly from U.S. civilian care. For example, health care in Japan and  Italy is characterized by more inpatient admissions and longer hospital  stays than in the U.S. system. In many countries, nurses and administrative  staff do not speak English, and the English fluency of doctors varies,  making it difficult for patients to discuss their medical problems with host  nation personnel. In addition, patients expressed concerns that medical  terms might not be translated accurately. Cultural differences have  similarly affected beneficiary perceptions of care. For example, in some  areas of Europe and the Pacific, doctors are unaccustomed to American  patients who may take a more active role in their health care and ask  questions about their diagnosis or treatment strategies, procedures, and  expected outcomes. As a result, these patients can become frustrated with  the more reserved attitude of host nation doctors. Other cultural  differences can create a gap in care. For example, in Japan and Korea,  patients’ families, not nursing staff, typically provide sheets, towels, and  toiletries and assist patients during hospitalizations. In 2000, we reported  that differences such as these have caused frustrations for some  beneficiaries—both men and women—and in some cases have resulted in  their delaying care until they can travel to an MTF.
Remote locations—both in the United States and overseas—also present a  challenge to DOD in providing care to all of its beneficiaries. In 2000, we  reported that, according to DOD, there are some deficiencies in provider  availability in rural areas of TRICARE regions in the United States. In  remote areas, beneficiaries can have difficulty finding providers, especially  for certain types of specialty care, and often have to follow the accepted  community access standards, which may require traveling a long distance  to obtain care. For example, in some parts of South Dakota, a 2-hour drive  is considered routine, and in Alaska, all patients are transported to the  lower 48 states for certain types of care. In remote locations overseas,  many of DOD’s beneficiaries rely on the State Department to provide or  help arrange their medical care through a list of local providers who meet  U.S. medical standards.
In deployed settings, such as in the field or on a ship, active duty members  may be limited in the choice of health care services and supplies available  since DOD tailors the medical capability to the setting and the size of the  unit deployed. For women, this constraint has raised concerns about  privacy. In 1999, we reported that women deployed to Bosnia described the  base camp clinics as very small and lacking interior walls and doors to  shield individuals being examined. These deployed women also had  concerns that their medical problems would not be kept confidential by  staff at the clinics and that word of their visit would be known around the  camp. Deployed women also raised concerns about the availability of  supplies, such as feminine hygiene products and birth control pills, in the  field or on ships. Due to limited storage space, women may not be able to  obtain their preferred brand, but most women were able to obtain adequate  supplies. At the end of 2001, DOD officials and representatives from  beneficiary groups told us that these concerns remain among deployed  women.
section_title: Some Concerns About Care Stem From Beneficiary Preferences
paragraphs: According to DOD officials, some women beneficiaries were dissatisfied  with the care they received or were reluctant to seek available care  because of certain expectations about the type of provider they should see  and the setting in which they should receive their care. Several DOD  officials told us that some women expressed dissatisfaction or reluctance  to seek care from a provider who they perceive to be inexperienced or  insensitive to women’s issues or who is male. These officials also told us  that some women prefer or expect to see a doctor who specializes in  obstetrical and gynecological care for their gynecological examinations.  This preference or expectation is generally the result of their believing that  specialists are better qualified than generalists, such as internists or family  practice doctors. According to DOD officials, while obstetrical and  gynecological specialists are needed for some procedures, generalists,  physician assistants, or nurse practitioners can provide routine care and  perform preventive tests. According to beneficiary representatives from  DACOWITS and NMFA, women also expressed dissatisfaction with the  lack of continuity of care because they did not see the same provider from  visit to visit. Finally, DOD officials also said that active duty women noted  that they were reluctant to seek care from a provider who is a peer or  junior in rank, or is someone with whom they socialize. This can be a  particular problem in some deployed settings where the number of medical  staff is limited.
DOD officials also reported that women have preferences for where they  receive their maternity care. According to DOD officials, some women  prefer to have their babies delivered in civilian hospitals instead of MTFs.  Additionally, results from a DOD survey on inpatient care during childbirth  at selected MTFs show that some women reported problems with  obstetrical care received at MTFs. According to survey results from 2000,  26 percent of women beneficiaries reported dissatisfaction with obstetrical  care at the MTF, compared to the civilian hospital average of 22 percent.  These women reported that their dissatisfaction related to coordination of  care, physical comfort, respect for patient preferences, emotional support,  involvement of family and friends, and information and education. (See  app. II for recent legislation and initiatives by the military branches to  address these concerns.)
section_title: Commanders and Beneficiaries May Lack Understanding About Women’s Health Care Needs
paragraphs: DOD officials told us that reports from the field have indicated that some  line commanders, including officers and senior enlisted personnel, may not  understand the importance of women’s health care. These officials also  said in some cases, women beneficiaries also lacked an understanding of  their health care needs. Specifically, DOD officials said that some  commanders and beneficiaries lack knowledge about women’s health  issues, the health care services available to women through DOD, when  this care should be accessed, and the need for such care. For example,  some women beneficiaries do not understand the importance of physical  exams and preventive screenings such as Pap smears and mammograms.  This can be especially problematic for women—both active duty and family  members—who are young and away from their families or other sources of  support who might provide health care guidance and teach them the  importance of primary and preventive care.
In some cases, beneficiaries and commanders have not been adequately  trained about the importance of women’s basic health care and its effect on  readiness. For example, according to DOD officials, neither the Army nor  the Air Force has a program to train line commanders about women’s  health care, although the Navy has some efforts to train its leaders about  these issues. DOD officials said that, lacking this understanding, some  commanders may be reluctant to allow active duty members—both men  and women—time away from their duty station to obtain health care  services—especially if the commander perceives that their time away will  negatively affect the primary mission. For active duty women, explaining  their specific ailment to their commanding officer (usually male) or  appearing like they need special treatment may make them reluctant to  seek the care they need.
section_title: Concluding Observations
paragraphs: DOD offers a full range of health care services for women beneficiaries  through the TRICARE benefit. In general, TRICARE-covered benefits for  women reflect national clinical guidelines developed by ACOG and are  comparable to widely used FEHBP health plans. In addition, the TRICARE  benefit requires some beneficiaries to share in the cost of their health  care—a characteristic also found in the FEHBP plans we reviewed. These  copayments vary depending on the plan option and providers selected.
Overall, DOD data indicate that women beneficiaries are satisfied with the  TRICARE health care benefit, but some have concerns about the care  available to them. Generally, these concerns stem from where the  beneficiary is located—overseas, in remote areas, or in deployed settings— and beneficiaries’ expectations about the type and source of care that  should be available. Concerns can also stem from the attitudes and the  climate established by the command personnel. We did not, however,  determine the prevalence of any of these concerns. Additionally, we note  that some concerns are relevant only to women, but others pertain to men  as well.
section_title: Agency Comments
paragraphs: We provided DOD a draft of our report for its review. In its comments, DOD  agreed with our findings, noting that our portrayal of DOD’s health care  benefit for women was accurate. DOD also provided technical comments,  which we incorporated where appropriate. (DOD’s comments appear in  app. III.)
We are sending copies of this report to the Secretary of Defense,  appropriate congressional committees, and other interested parties. We  will also make copies available to others upon request. If you or your staff  have questions about this report, please contact me at (202) 512-7101.  Other contacts and staff acknowledgments are listed in appendix IV.
section_title: Scope and Methodology
paragraphs: Our review focused on issues related to health care provided by the  Department of Defense (DOD) that are specific to women, including  preventive and reproductive care. To address the key questions, we  analyzed pertinent documents (including policies, procedures, and survey  results) and interviewed officials from  DOD’s Health Affairs’ Office of Clinical and Program Policy,  DOD’s TRICARE Management Activity (TMA),   the Surgeons General Offices for the Air Force, Army, and Navy, and  the American College of Obstetricians and Gynecologists (ACOG).
We reviewed selected health care plans under the Federal Employees  Health Benefits Program (FEHBP) to compare the covered benefits with  those provided by TRICARE. We selected BlueCross and BlueShield  Service Benefit Plans, a fee-for-service and preferred provider plan with the  largest number of participants in FEHBP, and Kaiser Foundation Health  Plan of the Mid-Atlantic States, Inc., one of the FEHBP’s largest health  maintenance organization (HMO) plans. In addition, we reviewed  completed studies addressing military health care, including those we  conducted and those conducted by DOD. We also conducted a site visit to  Walter Reed Army Medical Center to review the in vitro fertilization  services offered at this military treatment facility (MTF).
To further address these questions, we agreed with the committees of  jurisdiction to conduct a high-level review to obtain DOD beneficiaries’  perceptions on women’s health care services and identify potential  concerns about women’s health care in DOD. To do this, we interviewed  DOD headquarters officials and relied on two DOD surveys:  a DOD-wide  health care survey on beneficiary satisfaction and a survey targeted at  inpatient care during childbirth at selected MTFs. Both of these surveys are  from 2000—the most recent data available. We also conducted interviews  with  the Defense Advisory Committee on Women in the Services  (DACOWITS), a group that advises the Secretary of Defense on issues  concerning active duty women, including health care, and   the National Military Family Association (NMFA), an advocacy group  that obtains beneficiary views on issues concerning military families,  including health care.
To supplement these interviews, we relied on our past work on DOD health  care.
We did not independently validate the information we received from DOD,  DACOWITS, or NMFA, nor did we determine the prevalence of beneficiary  concerns. Additionally, while our review focused on health care for women  beneficiaries, some of our findings pertained to men as well, which we have  noted in our report where appropriate. Our work was conducted from  November 2001 through April 2002 in accordance with generally accepted  government auditing standards.
section_title: DOD Policies And Initiatives To Improve Women’s Health Care
paragraphs: Over the past decade, DOD has taken a number of steps to improve its  women’s health care services in response to several factors, such as  legislation and beneficiary concerns. Notably, in 1990, DOD added women’s  health as a responsibility of its Office of Clinical and Program Policy to  formulate DOD-wide policy related to women’s health issues and to  coordinate women’s health care activities initiated by the three branches of  the military. In addition, DOD has established several DOD-wide policies  to clarify TRICARE’s benefits for women. DOD has also implemented  specific initiatives that affect health care provided to women beneficiaries,  including maternity care and breast cancer care. Similarly, the three  branches of the military have developed initiatives targeted to meet the  specific needs of women patients. Many of these efforts aim to better  educate leaders and beneficiaries about the importance of women’s health  care services to readiness.
subsections: section_title: DOD-wide Policies and Initiatives
paragraphs: Since 1992, DOD has refined and enhanced some of its policies and  implemented several initiatives related to women’s health care. Many of  these efforts were undertaken to respond to findings in the medical  community and concerns by the Congress, DACOWITS, and beneficiaries.  Key efforts are listed below.
In 1992, in response to DACOWITS concerns, DOD issued a policy  regarding obstetrical care, stating that epidural analgesia would be an  option to women for normal vaginal deliveries. According to DOD  officials, this policy was based on the medical community’s findings that  epidural analgesia was the most effective method to control pain during  labor and delivery, and allowed for an alert, participating mother.
In the early 1990s, DOD began to develop and implement the Breast  Cancer Initiative to improve early diagnosis, education, and prevention  of breast cancer for women beneficiaries. Funds were allocated through  the surgeons general of each branch of the military to the local level for  beneficiary access to breast cancer screening, diagnosis, and treatment;  training of primary care managers; and education programs.
In 1993, also in response to DACOWITS concerns, DOD established a  policy to clarify its standards for (1) access to and timely notification of  the results of Pap smears and mammograms and (2) the availability of  obstetrical and gynecological appointments for active duty women.
In 1994, the National Defense Authorization Act (NDAA) authorized  DOD to establish a Defense Women’s Health Research Center at a  selected medical treatment center to coordinate research conducted  under DOD, the Department of Health and Human Services, and other  federal agencies on women’s health issues that are related to military  service. The center researches women’s health care issues such as the  effect on women of exposure to toxins and other environmental  hazards; combat stress and trauma; and mental health, including post- traumatic stress disorder and depression.
In 1995, DOD issued a policy refining the clinical preventive services  benefit for all TRICARE Prime enrollees based on the collective  expertise of military preventive medicine and to be more consistent  with nationally recognized standards for preventive services. These  preventive services include the following screenings specific to women:  breast cancer (physical exam and mammography); cancer of female  reproductive organs (physical exam and Pap smear); Hepatitis B for  pregnant women; and counseling about breast self-examination for  cancer surveillance.
In 1998, DOD refined its policy on assigning primary care managers  (PCM) to beneficiaries enrolled in TRICARE Prime. PCMs coordinate  enrollees’ care and refer them to the appropriate specialists, if needed.  This policy states that women enrolled in TRICARE Prime shall have the  option to choose a PCM who has advanced training in women’s health  issues.
In 2002, NDAA included a provision that will make it easier for  TRICARE Standard beneficiaries to obtain civilian maternity care  without prior approval from the MTF. DOD is required to implement this  provision on the earlier date of either of the following:  the date that a  new TRICARE Standard contract takes effect or December 28, 2003.
section_title: Specific Initiatives by Each Branch of Service
paragraphs: In addition to these DOD-wide efforts, the branches of the military have  implemented a number of women’s health care initiatives—some of which  have been developed by one branch of the service and then adopted by the  others. Some of these initiatives aim to improve health care for women,  while others focus on providing education to leaders and women  beneficiaries to emphasize the importance of women’s health to DOD’s  readiness mission. Other education initiatives focus on the importance of  family planning and maternity wellness.
Over the past several years, the Army, Navy, and Air Force have each  implemented initiatives aimed at improving health care for their women  beneficiaries. For example, in November 2001, all Army MTFs began using  liquid-based cytology to read Papanicolaou (Pap) smears which is a faster  test than the standard Pap test. According to Army officials, the use of  liquid-based cytology will address the readiness concerns identified during  the Gulf War. Specifically, women who had received Pap smears in their  predeployment screening and were found to have abnormal test results  after being deployed were usually returned to Europe or the United States  for additional testing or treatment. With the faster test, the Army expects to  avoid the cost of returning soldiers from a deployment and the need to  back fill these deployments. Both the Navy and the Air Force are also using  the liquid-based cytology Pap test in some locations.
The Navy’s Perinatal Advisory Board (formerly, the Birth Product Line) has  been working to keep deliveries “in house” by improving the birth  experience at MTFs. Since its inception in 1997, the board has been  assessing patient satisfaction and health care concerns at MTFs worldwide,  including why some women choose MTFs and why others choose civilian  facilities to deliver their babies. Every Navy MTF worldwide is in the  process of implementing “family-centered care” to better coordinate care  within the facility and to involve the family in the continuum of care from  prenatal through postpartum. The Army and the Air Force have also begun  to focus on obstetrical care at their MTFs.
The Air Force also has several other initiatives related to improving  women’s health care. For example, in 2000, the Air Force began pilot  testing “Project Athena” at Aviano Air Force Base in Italy, to provide  specialty care in areas—such as obstetrics and gynecology—where it does  not have sufficient patient populations to permanently assign several  specialists. While Aviano’s workload was sufficient to support one  obstetrical and gynecological doctor, it was not enough to support two,  although more than one was needed at times. To meet these needs, the Air  Force assigned one obstetrical and gynecological specialist full-time, and  rotates other specialists to the MTF on temporary assignments—usually 90  days. In addition to providing patients access to specialized care, these  rotations have given specialists enough work to keep their skills current.  The Air Force has expanded this initiative of rotating obstetrical and  gynecological doctors to another location—Misawa Air Force Base in  Japan.
Some of the military branches’ health care initiatives for women were  developed by one branch and then adopted by the others. For example, the  Army and the Air Force have developed deployment readiness guides for  active duty women and their leaders. The need for such guides was  demonstrated in 1999, when we reported that 51 percent of women  deployed to Bosnia stated that they had not received any information on  women-specific health care and hygiene practices in the field prior to  deployment. The Army’s Female Soldier Readiness Guide—which covers  areas such as field needs, health care preventive measures in the barracks,  and pregnancy—suggests strategies for leaders and soldiers to ensure  female readiness. The Air Force’s Female Airman Readiness Guide is  based on the Army’s readiness guide and, like the Army guide, aims to  enable military leaders to effectively manage women in the Air Force by  addressing topics such as hygiene in the field and pregnancy counseling.
Each military branch is also developing systems for tracking women’s  routine gynecological exams, including Pap smears. Currently, the Air  Force reviews the health needs of active duty women and men annually  during a preventive health appointment and makes recommendations for  further care based on their medical history. For example, during this annual  visit, active duty women are told when they are due for their next  gynecological exam. In addition, the Army is working on an Army-wide  initiative to track active duty women’s Pap smears so they can notify them  of their annual exams, thereby helping to ensure they receive needed care.  This initiative is in the planning stages and has not been implemented,  although in the meantime some individual installations have tracking  processes in place. Similarly, the Navy has no Navy-wide mechanism for  tracking annual exams for women, although there is some tracking of Pap  smears at the MTF level.
Many of the Army’s, Navy’s, and Air Force’s education initiatives aim to  educate leaders and beneficiaries about health care services for women,  including family planning and pregnancy wellness. According to Army  officials, unplanned pregnancies can disrupt work and training situations.  Army officials told us various studies show that more than half of births to  active duty women in the Army are from unplanned pregnancies. In  response, the Army has developed several initiatives to provide  beneficiaries with the knowledge to make informed decisions about having  children and taking appropriate care measures while pregnant.
The Center for Health Promotion and Preventive Medicine (CHPPM) is  developing a Personal Responsibility Program, including an Army- specific curriculum for soldiers. Its purpose is to provide soldiers with  better skills for reducing unplanned pregnancies, including education on  reproduction and contraception as well as meshing family planning with  career and financial planning. Following pilot testing, this program may  be implemented Army-wide.
The Army’s Office of the Deputy Chief of Staff for Personnel convened a  multidisciplinary work group that is looking at many aspects of  parenthood and its effects on readiness, including unplanned pregnancy  and physical training for women after birth. Its intent is to develop a  comprehensive reference manual for military leaders to use in managing  the myriad issues connected to parenthood.
CHPPM, with the assistance of a contractor, is developing a certification  program for physical training during pregnancy and postpartum. The  intent of this program is twofold:  to provide Army certification in  pregnancy fitness and to provide a safe, standardized program for  pregnant and postpartum soldiers. Most women may exercise safely  throughout pregnancy within ACOG guidelines and under the advice of  their health care provider. Exercise during pregnancy helps prevent  unwanted body fat gain and promotes a faster return to physical  readiness levels. According to Army officials, one Army study suggested  that active duty women who participated in a pregnancy wellness  program were more likely to pass the postpartum height/weight  requirements than those who did not participate in a structured physical  fitness program. In addition, they told us that other studies showed that  the caesarian section rate was lower among fitness program  participants than the national average, and there were no increases in  adverse outcomes to either the pregnant soldiers or their fetuses or  infants. They also said that preliminary Army data from the initial pilot  program indicate that there is a beneficial effect on labor and that  military readiness is promoted following a regular special exercise  program.
The Navy and Air Force have also developed initiatives on family planning  and pregnancy wellness. For example, the Navy’s Environmental Health  Center developed a program called the Sexual Health and Responsibility  Program (SHARP) to provide sexual health and responsibility training  Navy-wide to both leaders and active duty members through the Internet  and CD-ROMs. In addition, the Navy’s CHOICES program provides sailors  with education on sexually transmitted diseases, pregnancy, relationship  building, and sexual responsibility. The goal of the program is to assist  sailors in making better choices, which will reduce the number of  unplanned pregnancies. CHOICES is available at selected commands,  including in San Diego where the Deployment Program Manager of the  Fleet Family Services Center has indicated that male and female sailors at  Naval Station San Diego, including all shipboard personnel, are required to  attend this program. The Navy’s recruit training also includes a component  on conception and contraception. Specifically, in the seventh week of basic  training both females and males attend a program called Recruit Education  to Achieve Health (REACH) that includes training on sexual responsibility,  family planning, and emergency contraception. The Air Force supports the  use of doulas—specially trained women to help other women, particularly  first-time mothers, during pregnancy and childbirth—as long as this does  not interfere with providing care. A national society of doulas has offered  their services free of charge to women beneficiaries. According to Air  Force officials, this service could be particularly beneficial to women  whose husbands have been deployed.
The branches of the military have provided education on women’s health  through targeted web sites or a CD-ROM. For example, a Navy website  provides information about dysuria, family planning, and emergency  contraception. It also provides information on the breast care centers at  the National Naval Medical Center in Bethesda and the Naval Medical  Centers at San Diego and Portsmouth. The Navy also developed the  Operational Obstetrics and Gynecology CD-ROM to serve as a self- contained resource on obstetrical and gynecological care for health care  providers of all levels from corpsman through physician providers who are  deployed and ashore, stationed away from an MTF or other hospital.  According to Navy officials, the fact that it does not require Internet access  is crucial during deployment. The CD-ROM is a refresher on the full range  of women’s health care from Pap smears, family planning, gynecological  emergencies, and obstetrical care through menopause. It also includes  DOD-wide medical instructions pertinent to all three military branches and  copies of the female readiness guides for the Army and Air Force. The CD- ROM has been distributed to the Air Force, Army, Coast Guard, and various  international military medical forces.
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