Selection, Initiation, Continuation, and Efficacy of Reversible Contraception Among Enlisted U.S. Service Women in Their First Term of Service From 2012 to 2020.

BACKGROUND: Pregnancy is the second most common cause of limited duty days among active duty service members in the U.S. Military. Pregnancy accounts for 10% of all days on restricted duty, despite impacting a minority of active duty service members. One out of five service women will experience an unintended pregnancy every year despite the availability of no-cost contraception and reproductive healthcare. Young, single, junior enlisted service women experience the highest rate of unintentional pregnancy. Previous studies have demonstrated service branch-based variability in selection, initiation, and continuation of specific contraceptive methods related to service branch culture and access to contraception during basic training. It is unclear if these differences impact overall contraception use or fertility rates among junior enlisted service women in their first term of enlistment. This study examines rates of contraceptive selection, initiation, continuation, and efficacy among junior enlisted service women in their first 4-year enlistment period, and the service branch specific variability in these outcomes. METHODS: This study is a secondary analysis of Military Healthcare Data Repository records from women who began basic training between 2012 and 2020 and remained on active duty for at least 12 months. We used Kaplan-Meier analyses to examine the effect of age and military branch on contraceptive continuation and efficacy. We used binomial regression for interval censored data, to assess the association of service branch with rates of contraceptive initiation, contraception use, births, and childbirth-related duty restrictions. RESULTS: We identified 147,594 women who began basic training between 2012 and 2020. The mean age of these women at the beginning of basic training was 20.4 ± 3.1 years. Women in the marines and navy had higher contraceptive initiation rates than women in the army or air force. Among women initiating a contraceptive pill, patch, or ring (short-acting reversible contraception), 58.3% were still using some form of hormonal contraception 3 months later. Among women initiating depot-medroxyprogesterone (DMPA), 38.8% were still using any form of hormonal contraception 14 weeks later. Long-acting reversible contraceptive methods, such as intrauterine or subdermal contraceptives, had higher continuation rates and less service-based variability in continuation and failure rates than short-acting reversible contraception or depot-medroxyprogesterone. The proportion of days on any form of prescription contraception during the first 4 years on active duty varied from 23.3% in the army to 38.6% in the navy. The birth rate varied from 34.8 births/1,000 woman-years in the air force up to 62.7 births/1,000 woman-years in the army. Compared with women in the air force, women in the army experienced 2,191 additional days of postpartum leave and 13,908 days on deployment restrictions per 1,000 woman-years. DISCUSSION: Service branch specific variability in contraceptive use is associated with differences in days of pregnancy-related duty restrictions during first 4 years on active duty among junior enlisted females. Robust implementation of best practices in contraceptive care across the military health system to improve contraceptive initiation and continuation appears to offer an opportunity to improve military readiness and promote the health and well-being of active duty service women, particularly in the army.

Brief report: Influence of mandatory contraceptive education emphasizing long-acting reversible methods on continuation rates among military recruits.

OBJECTIVES: Determine if the replacement of patient-initiated, individual contraceptive education with mandatory group contraceptive education, during US Navy basic training, was associated with decreased LARC continuation. STUDY DESIGN: Secondary analysis of administrative billing data from female military recruits who began basic training between September 2012 and February 2020. RESULTS: Servicewomen who started LARC method during rather than after basic training had higher continuation rates. Servicewomen who started training before the implementation of mandatory group education had higher IUD continuation than those trained after. CONCLUSIONS: Implementation of mandatory group contraceptive education during basic training was not associated with a decline in LARC continuation.

Effects of genotype and food on naltrexone exposure in adolescents.

Naltrexone (NTX), an opioid antagonist metabolized by aldo-keto reductase 1C4 (AKR1C4), is prescribed for psychiatric conditions like eating disorders with variable response. Systemic exposure is highly variable in adults, yet no data exist in children. The purpose of this study was to evaluate NTX exposure in adolescents with eating disorders. Adolescents aged 12-21 years with eating disorders underwent postdose blood sampling in the fasted and/or fed state. NTX and primary active metabolite, 6-ß-naltrexol, were determined by ultra-high performance liquid chromatography tandem mass spectrometry. Pharmacokinetic parameters were determined by noncompartmental analysis. DNA was genotyped for AKR1C4 missense mutations associated with decreased activity (rs3829125 and rs17134592). Linear mixed effects modeling was performed. In 21 participants, aged 16.9 ± 1.9 years (15-21 years), 81% female participants, maximum concentration (Cmax ) was 90.4 ± 129 nM/mg/kg, area under the concentration-time curve from zero to infinity (AUC0-∞ ) was 166 ± 154 nM h/mg/kg, and varied 63-fold and 21-fold, respectively. Compared with wildtype, those with AKR1C4 allelic variations (n = 7) displayed 3.2-fold higher AUC0-∞ , four-fold higher Cmax and delayed time to Tmax . Linear mixed effects modeling demonstrated a large effect of genotype on AUC0-∞ (Cohen's d -2.3) and Cmax (Cohen's d -1.4). Food effect was large for AUC0-∞ (Cohen's d 2.6), but highly variable and failed to reach significance for Cmax. The respective model accounted for 82% of the variance in NTX AUC0-∞ and 46% of the variance in Cmax . NTX systemic exposure is highly variable in adolescents with eating disorders and modulated, in part, by AKR1C4 genotype and food intake. These findings may, in part, explain the large degree of interindividual variability observed response to NTX.

Influence of military contraceptive policy changes on contraception use and childbirth rates among new recruits.

BACKGROUND: Unplanned pregnancy is a common problem among United States servicewomen. Variation among service branches in contraceptive education and access during initial training is associated with differences in contraceptive use and childbirth rates despite access to a uniform health benefit including no-cost reproductive healthcare and contraception. However, it is unclear whether changes in branch-specific contraceptive policies can influence reproductive outcomes among junior enlisted women in that service branch. OBJECTIVE: To assess the longitudinal effect of contraceptive policy changes on contraception use and childbirth rates among military recruits. MATERIALS AND METHODS: Secondary analysis was performed of insurance records from 70,852 servicewomen who started basic training between October 2013 and December 2016, assessing the longitudinal impact of a Navy policy change expanding contraceptive access during basic training implemented in January 2015, and a Marine Corps policy change restricting contraceptive access during basic training implemented in January 2016 on the following: contraception use (pills, patches, rings, injectable, implantable, and intrauterine) at 6 months, long-acting reversible contraception use at 6 months, and childbirth prior to 24 months after service entry. We used logistic and Cox regression models, adjusted for age group, to compare outcomes of women in the Navy and Marine Corps who started basic training before and after their service branch's policy change with outcomes among women in the Army and Air Force. RESULTS: Compared to the longitudinal difference observed among women attending Army or Air Force basic training, changing policies to increase contraceptive access during Navy basic training in January 2015 increased contraception use from 33.1% of sailors to 39.2% of sailors before and after the policy change (interaction term odds ratio, 1.31; 95% confidence interval, 1.22-1.41) and long-acting reversible contraception use 11.0% to 22.7% (odds ratio, 1.78; 95% confidence interval, 1.50-2.08). However, this policy change was not associated with a decline in childbirth rates among sailors (7.5% versus 6.1%) relative to the change among women in the Army and Air Force over the same time period (interaction term hazard ratio, 0.90; 95% confidence interval, 0.79-1.03). The January 2016 Marine Corps policy change decreased contraception use (29.6% to 24.4%; odds ratio, 0.78; 95% confidence interval, 0.70-0.88), long-acting reversible contraception use 14.6% to 7.3% (odds ratio, 0.39; 95% confidence interval, 0.31-0.48), and increased childbirth rates (8.0% to 9.6%; hazard ratio, 1.26; 95% confidence interval, 1.03-1.55) among Marines compared to outcomes in the Army and Air Force over the same time period. CONCLUSION: Basic training contraceptive policy influences contraception use among junior enlisted servicewomen. Implementing best practices across the military may increase contraception use and decrease childbirth rates among junior enlisted servicewomen.

Naltrexone Reduces Binge Eating and Purging in Adolescents in an Eating Disorder Program.

Objective: Little evidence exists for pharmacologic treatment of binge eating and purging in adolescents with eating disorders. Given the role of the opioid reward system in compulsive binge eating and purging, naltrexone, an opioid antagonist, may be effective in reducing these behaviors. Previous studies have demonstrated that naltrexone reduces binge eating and purging in adults, yet evidence for its use in adolescents is lacking. This case series describes naltrexone utilization, response, and safety in adolescents with eating disorders. Methods: A retrospective chart review of adolescent patients prescribed naltrexone at an academic eating disorder program was completed. Results: Thirty-three adolescents aged 15.3 ± 1.49 years, 94% female gender identity, were treated with naltrexone with the most common expected outcome "to reduce vomiting." Naltrexone was prescribed for 129 ± 125 days. Over half of patients (52%, n = 17) had liver function tests during follow-up, all of which were within normal limits. Three patients (9.1%) experienced nausea related to naltrexone. Just over half of adolescents (67%; n = 22) had documentation of positive naltrexone response (e.g., reduced purging or urge to purge). The mean Clinical Global Impressions-Improvement score was 2.7 ± 1.3 (2 = much improved; 3 = minimally improved). Conclusions: Naltrexone is safe, well tolerated, and effective for the treatment of adolescents with binge eating and/or purging as part of a comprehensive eating disorder treatment plan. Further study is necessary to confirm the effectiveness of naltrexone prospectively and evaluate factors contributing to naltrexone response vs. nonresponse to promote an individualized approach to treatment of binge eating and purging behavior.

Contraceptive use and childbirth rates by service branch during the first 24 months on active duty in the United States military from 2013 to 2018: a retrospective cohort analysis.

OBJECTIVE: To measure the association of military branch-specific contraceptive education and access policy during basic training with contraceptive use and childbirth among new recruits. STUDY DESIGN: Secondary analysis of insurance records from 92,072 active duty servicewomen who started basic training between 2013 and 2017. RESULTS: Exposure to reproductive health education and access to contraception during basic training differ by military branch. Highly effective contraception use (pills, patch, ring, shot, implants or intrauterine contraception) at 6 months on active duty [Army (18.1%), Air Force (27.4%), Marines (26.5%) and Navy (37.6%), p<.001], long-acting reversible contraceptive method use (implant or intrauterine) at 6 months [Army (2.0%), Air Force (3.7%), Marines (11.0%) and Navy (19.6%), p<.001] and childbirth in the first 24 months of service [Army (11.1%, 95% CI 10.7-11.5), Air Force (6.0%, 95% CI 5.6-6.4), Marines (8.4%, 95% CI 7.8-9.0) and Navy (6.7%, 95% CI 6.3-7.1)] varied by service branch. After adjusting for age at basic training and contraceptive use at 6 months on active duty, childbirth rates differed among all branches. The Army (hazard ratio 1.86, 95% CI 1.71-2.01), Marines (1.48, 95% CI 1.33-1.65) and Navy (1.24, 95% CI 1.13-1.35) all had a higher risk of delivery than the Air Force. CONCLUSION: Variation in branch-specific contraceptive education and access policy during basic training is associated with differences in rates of contraceptive use at 6 months on active duty and childbirth prior to 24 months on active duty. This occurs despite all recruits having access to an identical medical benefit including no-cost access to contraception after completing initial training. Further study is needed to determine the etiology of these differences. IMPLICATIONS: Guidelines for contraceptive education and access during basic training, highly effective contraception use after 6 months of service and childbirth in the first 24 months of service vary among branches of the United States military. Reducing this variability may reduce childbirth rates and improve the reproductive health of junior enlisted servicewomen.

All Military Adolescents Are Not the Same: Sexuality and Substance Use among Adolescents in the U.S. Military Healthcare System.

Data examining sexuality and substance use among active duty and military-dependent youth is limited; however, these psychosocial factors have military implications. Adolescents and young adults aged 12-23 were recruited from an active-duty trainee clinic (n = 225) and a military pediatric clinic (n = 223). Active duty participants were more likely to be older, male, White, previous tobacco users, and report a history of sexual activity and less contraception use at their most recent intercourse, compared to the dependent group. Over 10% of all participants indicated attraction to members of the same gender or both genders. In logistic regression analysis, non-White participants were less likely to use contraception compared to White participants. Adolescents and young adults seen in military clinics frequently engage in high-risk behavior. Clinicians who care for military youth should assess their patient's psychosocial history. Further study of this population is warranted to identify factors that may influence risk and resilience.

The impact of marijuana policies on youth: clinical, research, and legal update.

This technical report updates the 2004 American Academy of Pediatrics technical report on the legalization of marijuana. Current epidemiology of marijuana use is presented, as are definitions and biology of marijuana compounds, side effects of marijuana use, and effects of use on adolescent brain development. Issues concerning medical marijuana specifically are also addressed. Concerning legalization of marijuana, 4 different approaches in the United States are discussed: legalization of marijuana solely for medical purposes, decriminalization of recreational use of marijuana, legalization of recreational use of marijuana, and criminal prosecution of recreational (and medical) use of marijuana. These approaches are compared, and the latest available data are presented to aid in forming public policy. The effects on youth of criminal penalties for marijuana use and possession are also addressed, as are the effects or potential effects of the other 3 policy approaches on adolescent marijuana use. Recommendations are included in the accompanying policy statement.

Adolescent caesarean delivery in the US military health care system.

OBJECTIVES: Determine cesarean delivery (CD) rates and associated demographics among military dependent teenagers. METHODS: United States military health care claims records of live births from 2003-2006 to 13- through 19-year-old dependent children were analyzed using logistic regression. RESULTS: The CD rate rose from 17% in 2003 to 20% in 2006. Rates were significantly higher for ages 18 and 19, for African American sponsors' children, and those who gave birth in a civilian facility. Rates did not differ significantly by sponsor's military rank. CONCLUSIONS: Teenagers in the military health care system have increasing rates of CD. Independent demographic risk factors for teenage CD include age > 17 years, sponsor's race African American, and delivery at a civilian facility.

Births to adolescents in the U.S. military healthcare system.

PURPOSE: To describe the rate and sociodemographic profile of live births to adolescents having U.S. Department of Defense healthcare coverage because of parental military service. METHODS: All live births identified from the M2 database during 2003-2006 to 10- to 23-year olds in this population were stratified and compared. RESULTS: Birth rates rose in the 18- to 19- and 20- to 23-year-old groups over the 4 years studied (p < 0.05). Daughters of active duty personnel had higher live birth rates than daughters of retirees (7.1 vs. 6.1 age 15-17; p < 0.05). Birth rates differed among dependents of junior enlistees, senior enlistees, and officers (7.1, 9.4, 3.8, respectively; p < 0.0001). CONCLUSIONS: Adolescent dependents in this system have an increasing, though low, live birth rate. Those with active duty sponsors have a significantly higher rate than their age-matched peers with retired sponsors. Further study is warranted to identify factors unique to this population that may influence birth patterns.

Pediatric wartime admissions to US military combat support hospitals in Afghanistan and Iraq: learning from the first 2,000 admissions.

BACKGROUND: Humanitarian and civilian emergency care accounts for up to one-third of US military combat support hospital (CSH) admissions. Almost half of these admissions are children. The purpose of this study is to describe the features of pediatric wartime admissions to deployed CSHs in Iraq and Afghanistan. METHODS: A retrospective database review was conducted using the Patient Administration Systems and Biostatistics Activity. Details of 2,060 pediatric admissions to deployed CSHs were analyzed. RESULTS: Nontraumatic diagnoses were responsible for 25% of all pediatric admissions. Penetrating injuries (76.3%) dominate the trauma admissions. The primary mechanisms of injury were gunshot wound (39%) followed by explosive injuries (32%). Categorizing the injuries by location revealed 38.3% extremity wounds, 23.6% torso injuries, 23.5% head, face, and neck injuries, and 13.3% burns. More than half of the children required two or more invasive or surgical procedures, 19.8% needed a transfusion, and 5.6% required mechanical ventilation. The mortality rate was 6.9%. The primary cause of death involved head trauma (29.5%) and burns (27.3%), followed by infectious diagnoses (7.2%). The case fatality rate for head injury and burn patients was 20.1% and 15.9%, respectively, in contrast to the fatality rate for all other diagnoses at 3.8% (p < 0.01). Excluding emergency department deaths, mortality rates for Afghanistan (6.2%) and Iraq (3.9%) significantly differ (p < 0.02). CONCLUSION: Pediatric patients account for approximately 10% of all CSH admissions in Afghanistan and Iraq. Burns and penetrating head injury account for the majority of pediatric mortality at the CSH.

Adolescent pregnancy in the U.S. military: what we know and what we need to know.

Adolescent pregnancy is a significant public health problem in the United States, but little is known about this condition in military-affiliated populations. This article reviews what is known about adolescent pregnancy among (1) dependent children of active duty and retired personnel and (2) active duty military personnel. Sparse and conflicting evidence exists regarding the prevalence of, the risk factors for, and the impacts of pregnancy in the dependent child population. Limited evidence regarding active duty service members reveals risky behavior by young military personnel, failure to effectively use contraception, and resulting pregnancies that consume military resources and diminish deployability and retention. We suggest research questions for further study that could lead to interventions targeting unintended adolescent pregnancy and its attendant tolls on health, budgets, military readiness, and fighting strength.

Screening military dependent adolescent females for disordered eating.

Eating disorders are increasing in frequency among adolescents. The active duty military population has a high prevalence of eating disorders. This study, conducted at a major medical center, determined the prevalence of disordered eating among military dependents and the correlation between adolescent and parent eating behaviors. Three hundred forty adolescent and parent pairs completed the Eating Attitude Test-26 question-based survey. Twenty-one percent of the adolescents and 26% of the parents met the criteria for disordered eating, with a strong correlation between at-risk parents and their adolescent daughters. Overall, the rate of disordered eating in this military sample was significantly higher than the comparable civilian population. Military families should be considered at high risk for disordered eating and eating disorders. Screening for disordered eating should be incorporated into routine practice to identify at-risk individuals.

Tobacco use cessation for adolescents.

Adolescent tobacco users are unique. Thus far, effective interventions for adult tobacco users have been disappointing when applied to adolescents. This article reviews current evidence regarding adolescent tobacco use cessation interventions, explores under-researched areas in tobacco use cessation for adolescents, and offers assistance with treating adolescent tobacco users across the spectrum of use. A means of assessment and treatment of the adolescent smoker is proposed, and cases are included to assist the practitioner with treatment of the experimental tobacco user, the "adolescent-type" intermittent user, and the daily "adult-type" of adolescent tobacco user.