Brooke Gladstone: I'm Brooke Gladstone with OTM's Midweek Podcast. In the wake of last Friday's decision by the Supreme Court to overturn Roe v. Wade, people, politicians, and healthcare providers are scrambling to figure out what's next. For one sector of the population, pregnancy was already fraught with extraordinary complications, no matter where they were based, women in the military.

According to a 2018 report by the US government accountability office, women made up a substantial 16.5% of active duty service members in the department of defense and the DOD wants to boost that number even more. Military women though, between the ages of 18 to 44 are more likely than their civilian counterparts to have unintended pregnancies. There's also research suggesting they're more likely to be sexually assaulted or experience intimate partner violence.

One study done in 2017 found that over a three-year period, 31% of military women reported a miscarriage. Overall for known pregnancies, the Mayo Clinic estimates 10% to 20% of pregnancies end in miscarriage, though they add it could be higher, but historically and even today there's little data on how or whether military service can affect fertility or why military women might be at higher risk of pregnancy complications.

What seems certain is that should the DOD want more women in the ranks, medical care will only become more essential. According to Kyleanne Hunter, a senior political analyst at the RAND Corporation and a Marine Corps combat veteran, the department had just begun to make those changes. Kyleanne, welcome to the show.

Kyleanne Hunter: Thank you so much for having me.

Brooke Gladstone: It sounds like participation of women is hugely expanding. Have there been changes in how the military handles pregnancy? How does it?

Kyleanne Hunter: There have been some really positive and significant changes to pregnancy policy over the past half a dozen years or so. There's administrative policies that go along with pregnancy in the military. These are typically designed to protect the pregnant woman. For example, women who work in aviation maintenance and around jet fuel quite a bit, or work in ordinance and around more toxic chemicals, there are administrative policies to reassign them to maintain their health and the health of their future child.

There's been a lot more education around those policies in a really positive and proactive way, as well as changes in policies when it comes to parental leave to encourage more time for both birthing parents, but also non-birthing parents. There's been policies as well that go beyond live births, which is incredibly important when we look at convalescent leave after miscarriage or stillbirth.

Brooke Gladstone: That sounds great, but the main rule is that a service member has to notify her commander that she's pregnant within two weeks of confirming pregnancy with a doctor. That seems to be rule number one, and it's problematic, right?

Kyleanne Hunter: Absolutely, and I was just about to get to the, "but here's the problematic part."

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Kyleanne Hunter: You have to alert your commander within two weeks of being confirmed by a doctor. First is even the fact that you have to have it confirmed by a medical professional. Then you have to notify your commander within two weeks. This provides even an issue for women outside of abortion who have pregnancies they want to keep. In every single focus group that I have done around pregnancy experiences and pregnancy policies, there are heart-wrenching stories of women who had to tell their commanders, got removed from their unit, miscarried, and now two weeks later they're back in their units not pregnant anymore and either have to share incredibly personal heart-wrenching stories with people or have the rumor mill start to go crazy.

Everything from, "Did she lie about being pregnant to get out of work? To get moved? Did she have an abortion? What's wrong with her that she miscarried?" There's all sorts of negative stigma that comes along with it. When we talk about abortion, this becomes even more of a challenge because even pre the Roe decision to get an abortion, the average wait time was about 20 days. If you find out you're pregnant, you want to terminate your pregnancy for whatever reason, which is frankly nobody's business, and you call to get an appointment and the average time is 20 days, that's beyond the two weeks. You still have to tell your commander that you're pregnant knowing that you want to terminate your pregnancy.

Brooke Gladstone: Now, when you talk about the wait time, you're not talking about doctors on-site because the Hyde Amendment prohibits the military's insurance policy from paying for abortions for doing them in almost every case. Rape, incest, life of the mother, those are exemptions. Basically, prior to the ruling last week, it was well within the rights of the military medical providers to tell you where you could go, here are the resources. How did that change?

Kyleanne Hunter: There's lots of questions and no one has answers to them. Military medical providers are unsure how much information they can share with service members who come to them and say, "Hey, I want to terminate my pregnancy." Are they going to be accused of aiding and abetting a woman seeking an abortion, which if you look at some of these vigilante laws, that's a real problem.

Do you also have victim advocates and sexual assault response coordinators in this unsure area as to what can we offer for resources for victims if they might become pregnant? There are concerns from commanders. If a service member goes to their commander and says, "I am pregnant, I plan on terminating it." Now that the commander knows, are they considered aiding and abetting? There's a lot of unknown, particularly because these are federal employees, military hospitals are federal property yet they're inside of state's jurisdictions. There's a lot of concern.

Brooke Gladstone: You noted that in 2017, part of the National Defense Authorization Act, there was a big push to privatize a lot of the medical care. You mentioned that Camp Lejeune a huge facility in North Carolina, there's one OB-GYN that services 200,000 people. Not just women service members, but also retirees and the dependence of spouses and so forth.

Kyleanne Hunter: This is just what's reported. We still don't know the full extent of the shortage of uniformed providers. If we're in a situation where women's healthcare options become more and more limited, the ever-shrinking number of OB-GYNs is going to be a problem.

Brooke Gladstone: We frame this as the consequences of overturning Roe for military personnel, but it isn't that niche, even though it isn't all that niche to begin with. These policies have an impact on a huge number of people. Who are we forgetting?

Kyleanne Hunter: If we're thinking about even just the DOD, we've got DOD civilians there, we've got the dependents, we've got all of the support staff that keep our bases running day in and day out, the cooks, and the people who clean buildings, the people who keep the lights on. There's large military installations and the entire apparatus that goes along with running them in states where abortion is now not legal. The impact is going to be vast.

Brooke Gladstone: Texas, Missouri, Kentucky, Louisiana, Oklahoma, they're all homes to major military installations. What happens in states where abortion bans triggered by the court ruling have already become much more restrictive? What are the service members' options?

Kyleanne Hunter: The primary option available to service members like any women is to go out of state. If we think about Fort Hood, Texas, a large base in the middle of Texas, it also is the base that has the highest likelihood of sexual assault. It also has a very large concentration of junior enlisted who are the most likely to experience an unintended pregnancy. The closest clinic that provides abortion is in Kansas and it's well over 500 miles away.

Brooke Gladstone: You priced this out, didn't you? You priced out the cost of leaving Fort Hood. Tell us about it.

Kyleanne Hunter: Yes. If you're at Fort Hood and you want to get an abortion from the closest place in Kansas, this is assuming that gas stays around 4.50 a gallon in Kansas and your car can get 20 miles per gallon, it's going to cost you over $130 each way, just to drive. If you look at hotels that are in and around close to the clinic, they're looking at between $130 and $150 a night. You're thinking a minimum of three nights to actually stay there

Brooke Gladstone: Because there's a waiting period for the abortion.

Kyleanne Hunter: You have to go in and get a consultation and then come back the next day and then you come and do it. Then they, recommend that you don't get in the car and drive for 10 hours, recover.

Brooke Gladstone: Then how much does the abortion itself cost?

Kyleanne Hunter: The average cost is around 750, but they can range from 500 to 1500, depending on the actual individual provider. The type of abortion, if there's any complications, if there's any aftercare that's needed, all those things just raise the price.

Brooke Gladstone: A little back of the napkin calculation between the gas, the three nights in the hotel, and let's say 750 for an abortion, that's upwards of $1,500. What's the after-tax salary of a junior.

Kyleanne Hunter: A junior enlisted is a little more than $$1,000 a month.

Brooke Gladstone: Wow.

Kyleanne Hunter: You've got more than a month's salary to get medical care, and then you've got time away. What the data show as well about women who seek abortions, a large percentage of them have families have other children. You have to think about childcare. This is often an experience as well, that you're going to want someone else to go with you. Now you've got another person that's there and time away, this is also assuming that there's no complications of any form. What this also excludes is any mental healthcare that might be needed.

The air force recently did a survey of women in the air force and they asked questions about abortion and care after. Very few, so like around 5% said that they received any sort of mental healthcare after. Yet almost all of them said that they would've benefited from the ability to get mental healthcare services, just to work through the process.

Brooke Gladstone: Just wondering what happens if you don't tell your commander, say you miscarry, or get an abortion, but it's outside of that two-week window where you have to notify him or her.

Kyleanne Hunter: It's hard often for these policies to be enforced if nobody knows. There is these sort of, if you miscarry or you choose abortion and nobody knows, well, then nobody knows, but there can be administrative action. It can be reduction in pay. It can be administrative sanctions that happen. There can be a loss of benefits. If you needed any sort of convalescent leave or additional medical care, but you didn't abide by the policy, it'll be much more difficult.

Brooke Gladstone: Now these focus groups that you convened, it was a couple of thousand service people, men as well as women.

Kyleanne Hunter: Yes.

Brooke Gladstone: Across about 28 military installations?

Kyleanne Hunter: Yes.

Brooke Gladstone: Can we talk about how this post-road discussion might play into any longstanding prejudices about women in the military for men in the military and the power structure in general?

Kyleanne Hunter: From focus groups, we see that women's healthcare in general, there's already negative stereotypes about women who get pregnant. There's already negative stereotypes about the fact that women have particular healthcare needs.

Brooke Gladstone: You referenced a male officer who participated in one of the focus groups who said that women were, "Another distraction." He said that if you have a group of people and preconceived notions of their capabilities as individuals, you're not focusing on the mission. It sounds like he's saying women are responsible for the consequences of anti-women prejudice.

Kyleanne Hunter: Unfortunately, a not too uncommon thought. It's the women's fault for being discriminated against it's the women's fault that men hold these negative views.

Brooke Gladstone: He went on to say that, "When females disappear to do their women health things like breast exams or pap smears or whatever they do," it's just one more distraction from the unit. All their "special treatment" just takes the focus away from what I need my people to do." It's pretty blatant. He's not saying prostate exams are special treatment.

Kyleanne Hunter: The military invests a lot of money to ensure that its people are healthy. You have to have annual physicals. You have to go to the dentist every year. You have to run a physical fitness test. There are screenings that are different for women and men. Women don't complain about the fact that erectile dysfunction can be covered as a condition. We don't see this as special treatment. This is biologically appropriate treatment. Yet if it continues, if the DOD allows it to continue to be framed in this way, it creates a very negative environment where women don't even have the option to succeed.

Brooke Gladstone: You've talked about the potential for cultural backlash. What's a likely cultural impact for women in the military. Following the repeal of Roe?

Kyleanne Hunter: The loss of privacy that we see can allow for more of these stereotypes to continue.

Brooke Gladstone: Stereotypes like what?

Kyleanne Hunter: Stereotypes like women are weaker, stereotypes like women get pregnant to get out of work, stereotypes like women have special treatment and don't belong because there's this very short window where they have to let commanders know. If they are looking to seek abortion care, it's going to be outside of that window. This can be construed as one more special treatment. If women do reduce the number of abortions they have, and actually have more children, women already get a bad rap for kids.

Brooke Gladstone: What happens next? The military in many ways, seem shielded from the rest of the population in its culture and in its regulations. How does a soldier fight for her rights on this one?

Kyleanne Hunter: The military does have the ability to do some things. There's the Hyde Amendment, which it require congressional action is still a limitation right now.

Brooke Gladstone: Yes. The Hyde Amendment that banned the military from paying for the kind of care that they might provide for a man with the erectile dysfunction.

Kyleanne Hunter: Right, so the Hyde Amendment ties the hands to an extent of what the DOD can actually do. The DOD, can't say, we're going to make abortions available at all military medical hospitals now, but they need to look at what policy actions can take place. The air force has been the first to classify abortion as not being voluntary, which opens up leave options.

Brooke Gladstone: That struck me as very important that it's not considered elective medical care anymore.

Kyleanne Hunter: Exactly. That's something the DOD can do. They can expand that, which opens up the ability for women to not have to use their PTO that they earn. They get leave given to them to go do this. They have to look at what counseling can be provided for military women. These are options that work within the Hyde Amendment.

If we look at the draft of the appropriations bill that came out of the house for DOD spending, there was a small provision in there essentially to guarantee that women would be able to take leave and that it could not be denied for them to seek abortion care. That's something. I think we're all watching to see how it plays out. This is unprecedented in how quickly a change impacts such a large swath of our military and the DOD is being very calculated in how it responds and I think that's important too.

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Brooke Gladstone: Kyleanne. Thank you very much.

Kyleanne Hunter: Thank you so much for your attention to this topic.

Brooke Gladstone: Thanks for checking out the Midweek Podcast. The big show will be posted on Friday as usual around dinner time and of course, on the radio in most places.

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