Free healthcare is a military benefit and major recruiting attraction. What could be the downside?

With limited expense comes limited options. Limited options can come at a staggering personal price, especially for women in service. And women’s health is critical to military recruitment, retention and our nation’s readiness to fight.

In 2020, after a long infertility journey, my husband and I were overjoyed to see our daughter’s heartbeat on the screen. My maternity care was initially directed to the civilian clinic of my choice, due to the lack of obstetric care on base. However, that changed when I relocated for my next assignment and my care was directed to my local military treatment facility. I was skeptical. I had heard anecdotal stories of poor maternal care on military installations, particularly the one I was assigned.

I requested a referral to a civilian practice during my first appointment but was informed that as an active duty service member, I could not be seen off-installation. Had I been the wife of a service member, I could have enrolled in Tricare Select to see an in-network obstetrician of my choice. But by law, active duty members must enroll in Tricare Prime, and Prime must direct referrals to local military installations when care there is available. I was stuck.

Unfortunately, I started experiencing worsening complications over several weeks — spotting, then bleeding, then passing clots — all dismissed as “normal” pregnancy symptoms. At 17 weeks, after waking up in soaked bedding, my trip to the base emergency room ended with me being kicked out. The ER doctor neither took my concerns seriously nor followed medical protocol to test for amniotic fluid. On follow-up, the OB counseled me against crying wolf and even wrote in my record that my water did not break — without ever conducting an exam.

Eight days later, my husband drove me an hour away to Walter Reed National Military Medical Center as I bled through my pants. The OB team there rushed down to the ER and immediately found there was zero amniotic fluid around my daughter. My water had broken a week prior. Three days shy of 20 weeks, her cord prolapsed, and I was given no choice but to wait for the pressure on the cord to claim her life.

I felt the moment she died. I didn’t need doctors to check, but they did. Her heart was silent.

After 17 hours of labor, I delivered my perfect little girl, Liliana. Her life had been claimed, in part, by delayed and inadequate care. The Tricare Prime system which held me hostage to limited options became complicit in her death. I will forever wonder if getting a referral off-installation could have altered the outcome — if other physicians or better equipment would have detected the placental abruption in time to give her a fighting chance.

Unfortunately, my experience is not an anomaly. Multiple studies indicate there is a larger number of obstetric complications at military hospitals compared to civilian care. Tricare’s own surveys consistently show dissatisfaction with on-base obstetric care, and less than half of 2,000 postpartum women would not be willing to recommend a military hospital to family or friends.

With over 222,000 women in active service (nearly 18% of the force) and around 12,000 babies born each year to active duty women, the implication of these studies is critical, given the confinement of obstetric care to the base.

Military hospitals have the “right of first refusal” (ROFR), which allows them to decide whether to treat a patient or send them to an in-network Tricare provider instead. While the policy can enhance the military medical education program, hone military providers’ skills, optimize clinics and contain health care costs, it does not prioritize women’s care and denies active duty women options for care.

In fact, the military hospital’s purpose is to ensure active duty readiness for military contingency operations, and Tricare Prime’s purpose is to support the operation of the military hospital. This system makes sense for most active duty medical care, but does it align with the unique needs of obstetric care?

Pregnant active duty women are automatically placed on limited duty and unable to deploy. Arguably, obstetric care has little to do with readiness for military contingency operations. Certainly, exceptions exist, such as for women who voluntarily pursue waivers to continue flying. In these cases, obstetric care should remain under the care of the military hospital. This is fitting to their personal choice and the military hospital’s purpose. However, given that active duty women have higher risks of preterm labor, intrauterine fetal death, and postpartum hemorrhage, women should otherwise have the autonomy to choose the obstetric care setting that best suits their needs.

Women comprise the fastest-growing demographic in the DOD and represent a higher percentage of the recruitable population, so reproductive healthcare is critical to recruitment and retention. In fact, the federally funded think tank Rand Corp. recommends addressing miscarriage rates among active duty women and improving standards of care to better meet women’s health care needs.

Yet evidence of substandard obstetric care and gaps in research on women’s health is a significant bulwark to overcome. Until such inadequacies are fully addressed, women in service should have more options for their obstetric care.

Fortunately, Tricare referral management already has a procedure to waive the ROFR. I have successfully received this waiver of ROFR for my subsequent pregnancies due to the circumstances of my first. However, a woman should not have to first lose a child for her referral request to be granted.

The ROFR waiver should be accessible and available without question to any woman in service who requests a referral off-installation for her obstetric care. When a woman signs up to defend her country’s freedoms, she should not be sacrificing her own freedom in pregnancy care decisions. Until such changes are made, the consequences of the current military health system and the autonomy forfeiture it forces can have tragic consequences, as I am all too familiar.

Amanda Rebhi is an active duty major in the U.S. Air Force, a 2024 strategic communication fellow at George Mason University and Liliana’s mother. The views expressed in this article are the author’s own and do not represent the views of the U.S. Air Force or DOD.

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