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CONTEXT: As of 2023, women constitute an average of 17.5% of all active-duty military personnel, totaling nearly 229,000. An additional 231,741 women (21.4%) serve in the Selected Reserve and the National Guard. DOD also employs ~224,000 civilian women (32%)—for a total of 684,741 women across the Department of Defense. https://www.gao.gov/productsgao-23-105284#)

Women were first granted the ability to serve as permanent members of the military under the Women's Armed Services Integration Act of June 12, 1948. The combat exclusions established by the Act were lifted gradually, starting in 1993. The final ban on women in direct ground combat roles was lifted on January 24,2013. Today, women are indispensable in the US military and DOD at large. As 51% of the US population—statistically better educated and less prone to crime than their male counterparts—women also constitute a key recruitment pool. 

Reproductive health is, naturally, a key issue for all women and their families. It is also a political lightening rod in the wake of the controversial—and, often, mischaracterized—SCOTUS decision (Dobbs v. Jackson) to overturn Roe v. Wade. The 1973 Roe court had inferred the existence of a federal constitutional right to abortion, within limits. The 2022 Dobbs court disagreed, ruling instead that abortion access is not addressed by the US Constitution and is not among the powers relinquished by the states to the federal government. Therefore, SCOTUS ruled that under the Tenth Amendment the regulation of abortion access is reserved to the states.

Following—and even before—Dobbs, some states have enacted laws severely restricting abortions, while others have legislated unlimited access. This transformation inevitably impacts military women, stationed on installations across our great Nation and abroad.

Ready access to contraceptives and healthcare is important for all women—civilian and military.  Everyone should be encouraged to make wise choices and exercise control in all aspects of their lives, to include their intimate relationships. Military women—entrusted with lethal actions—should be particularly responsible and mature in all matters—to include their physical, mental and reproductive health.

Abortion should remain LEGAL, RARE AND SAFE. Thousands of women have died over the centuries in illegal, botched, “back alley” abortions. Many more suffered life-long physical and mental injuries. With today’s widely available contraceptives, unwanted pregnancy could—and should—be easily prevented. Better education should make abortion rare—the exception rather than the rule in women’s reproductive health care. 

KEY ISSUES: While abstinence is the only sure guarantee against unwanted pregnancy—and should be advocated by parents and schools—it is not a realistic substitute for birth control and, in extremis, abortion, particularly in our promiscuous society, where graphic pornography is a keyboard click away and children as young as 10 reach puberty. 

Adoption should be made more attractive for girls and women who are ready to carry a pregnancy to term but are unable or unwilling to raise a child. Adoption should also be made easier for the millions of couples unable to conceive, but eager to provide a loving home for those children. Prospective grandparents—both partners’ parents—should be given priority consideration. 

Abortion should never be deemed a preferable method of birth control. Rape, incest and maternal health should always be allowable exceptions. 

The sanctity of human life is a core value in all major religions. The Catholic Church and some Shia Muslim sects are alone in prohibiting all abortions (as well as all contraceptives). 

The Judeo-Christian tradition—the foundation of our Republic—places the life, health and future fertility of the mother ahead of the unborn fetus. So does the vast majority of medical professionals. All life is sacred. But if a life must be sacrificed, the wellbeing of the giver of life—the mother—should take precedence. 

FACTS AND FIGURES: How many abortions are there in the U.S. each year? An exact answer is hard to come by. The Center for Disease Control (CDC) and the highly reputable Guttmacher Institute (https://www.guttmacher.org/) have each tried to track abortions for 50 years. Unfortunately, they use different methods and publish different data. The CDC compiles data voluntarily reported by states’ central health agencies, including separate figures for New York City and the District of Columbia. Its latest totals do not include figures from California, Maryland, New Hampshire, or New Jersey, which did not report to the CDC. Guttmacher compiles its figures after contacting every known abortion provider–clinics, hospitals and physicians’ offices–across the US. It uses questionnaires and health department data, then provides estimates for abortion providers who don’t respond. Guttmacher’s figures are higher than the CDC’s, mainly because they include data and estimates from all 50 states and D.C.

The last year for which the CDC reported a yearly national total for abortions is 2021: 625,978 abortions in the 46 states with available data plus the District of Columbia—up from 597,355 in those states and D.C. in 2020. The corresponding figure for 2019 was 607,720.

The last year for which Guttmacher reported a yearly national total was 2020. It stated there were 930,160 abortions that year in all 50 states and D.C., compared with 916,460 in 2019.

The annual number of US abortions rose for years after Roe v. Wade legalized the procedure in 1973, reaching a peak in the late 1980s-early 1990s. Since then, abortions have generally decreased at what the CDC called “a slow yet steady pace.”

Guttmacher says that in 2020 there were 14.4 abortions in per 1,000 women aged 15-44. Its data show that the rate of abortions has been declining since 1981, when there were 29.3 abortions per 1,000 women in that same age range.

The total number of abortion providers has declined dramatically since the 1980s. In 1982, according to Guttmacher, there were 2,908 facilities providing abortions, including 789 clinics, 1,405 hospitals, and 714 physicians’ offices. Between 2017 and 2020, the number of clinics was virtually unchanged, from 808 in 2017 to 807 in 2020. However, there was substantial variation across states: The number of clinics increased 11% in the Midwest, with 10 more clinics in 2020 than 2017, and 6% in the West, with 18 more clinics in 2020 than 2017. The number of clinics decreased by 9% in the Northeast, with 22 fewer clinics in 2020 than 2017, and 3% in the South, with 6 fewer clinics in 2020 than 2017. (The CDC does not track the number of abortion providers).

The CDC divides abortions into two categories: “surgical abortions” and “medication abortions.” Since the Food and Drug Administration first approved “abortion pills” in 2000, their use has steadily increased. The CDC says 56% of abortions in 2021 involved pills, up from 53% in 2020 and 44% in 2019. Its figures for 2021 include D.C. and 44 states that provided data. Guttmacher, which analyzes these data every 3 years, reported that 53% of abortions involved pills in 2020, up from 39% in 2017.

The two pills commonly used together for medication abortions are mifepristone, which, taken first, blocks hormones that support a pregnancy, and misoprostol, which then causes the uterus to empty. According to the FDA, medication abortions are safe until 10 weeks into pregnancy.

It is useful to differentiate between emergency contraception (EC) and medication abortion. EC stops pregnancy from happening. The abortion pill ends an existing pregnancy. EC is available over the counter (under the brand name Plan B). Medication abortion requires a clinical consultation (via tele-health or a clinic). EC can be used up to 72 hours after unprotected sex, while an abortion pill can be used between 4-11 weeks after the last menstrual period. 

In the District of Columbia and the 46 states that reported age data to the CDC in 2021, the majority of women who had abortions (57%) were in their 20s, while 31% were in their 30s. Teens (12-19) accounted for 8%, while women aged 40-44 accounted for 4%. The vast majority of women who had abortions in 2021 were unmarried (87%), according to the CDC.

In the District of Columbia, New York City (but not the rest of New York) and the 31 states that reported racial and ethnic data to the CDC, 42% of all women who had abortions in 2021 were non-Hispanic Black; 30% were non-Hispanic White; 22% were Hispanic; and 6% were of other races.

Looking at abortion rates among those aged 15-44, there were 28.6 abortions per 1,000 non-Hispanic Black women in 2021; 12.3 abortions per 1,000 Hispanic women; 6.4 abortions per 1,000 non-Hispanic White women; and 9.2 abortions per 1,000 women of other races, the CDC reported from those same 31 states, D.C. and New York City.

For 57% of women who had abortions in 2021, it was the first time they have had the procedure, according to the CDC. For 24%, it was their second abortion. For 11% it was their third, and for 8% it was their fourth or more. These CDC figures include data from 41 states and New York City.

The reasons for abortion are as varied as the women seeking them. The CDC does not track this information. Per Guttmacher, rape, incest, or complications making the pregnancy unviable account for only 3% of the total. 

The vast majority of abortions occur during the first trimester of a pregnancy. In 2021, 93% of abortions occurred during the first trimester—at or before 13 weeks of gestation, according to the CDC. An additional 6 occurred between 14-20 weeks, and about 1% were performed at 21 weeks or more. (These CDC figures include data from 40 states and New York City.)

About 2% of all abortions involve some type of complication for the woman. Most complications are considered minor, such as pain, bleeding, infection, and post-anesthesia issues. Per the CDC, case-fatality rates–that is, how many women die from abortion-related complications for every 100,000 legal abortions—were 0.45 deaths, the lowest ever during the most recent period examined (2013-2020).

In 2020, the last year for which the CDC has information, 6 women died due to complications. Since 1990, the annual number of deaths due to legal abortion has ranged from 2-12. Abortion is safe and should remain so. (https://www.pewresearch.org/short-reads/2024/03/25/what-the-data-says-about-abortion-in-the-us/#how-many-abortions-are-there-in-the-us-each-year).

These statistics don’t address the inevitable emotional toll and the sometimes-lingering psychological impact of terminating a pregnancy: the profound grief associated with a spontaneous miscarriage is often compounded by guilt, regret, and PTSD-like symptoms caused by the heart-wrenching decision to abort a baby.

Later-term abortions are particularly abhorrent and traumatic, as the fetus is not only a fully formed human being, but also capable of survival outside the womb. According to recent Gallup polling, 70% of Americans oppose abortion in the third trimester and 55% oppose it in the second trimester.  https://news.gallup.com/poll/321143/americans-stand-abortion.aspx 

The reasons for later-term abortions vary. Some women don’t realize they are pregnant until after the 12th week: some are still menstruating; others are on medications that cause cycle changes.  

Another reason some women seek abortion past the 12th week is the need to gather the money to pay for the procedure. Nearly 75% of abortion patients live at—or below—the federal poverty level. The Federal government and 33 states prohibit Medicaid to pay for abortions.  And, past the 12 weeks mark, the cost increases, as clinical care becomes more complex, further compounding the financial burden.  

Most often, the later-term abortion decision is based on the mother’s or the baby’s health. Some complications do not onset until later in pregnancy. Issues with the fetus are often not diagnosable until later as well. There is no CDC data on how frequently a pregnancy threatens the mother’s life, because this care occurs mainly in hospital settings, which do not advertise that they perform abortions. Likewise, treating physicians rarely discuss these issues publicly. 

Now that abortion is banned in some states—and the penalty for violating the ban is jail time for the physician and legal consequences for the institution—ready access in life-threatening circumstances is much harder. https://www.american.edu/cas/news/roe-v-wade-overturned-what-it-means-whats-next.cfm. 

ABORTIONS IN THE MILITARY: All the data presented above pertain to the general US population. There are no publicly available statistics for abortions among servicewomen. Therefore, issues unique to the military are addressed below premised on the assumption that the armed forces reflect the society they serve. 

10 U.S.C. 1093(a) states that “funds available to the Department of Defense may not be used to perform abortions except where the life of the mother would be endangered if the fetus were carried to term, or in a case in which the pregnancy is the result of an act of rape or incest.”

Yet on Oct 20, 2022, DOD issued a memorandum titled “Ensuring Access to Reproductive Health Care,” authorizing funds and time off for pregnant servicewomen to travel to facilities that offer abortions. The Under Secretary of Defense issued an implementing memorandum, “Administrative Absence for Non-Covered Reproductive Health Care” on Feb 16, 2023. On the same day, Headquarters Defense Human Resources Activity issued a memo authorizing travel and transportation allowances for the non-covered abortion care.

The memorandum directs DOD to: 

Not/not require women to inform their chain of command until 20 weeks after conception. 

Allow administrative absence of 21 days (no loss of pay, nor leave charged) “to receive, or to accompany a dual-military spouse or a dependent who receives non-covered reproductive health care.” 

Grant follow-on convalescent leave as recommended by the health care provider.

Provide “travel and transportation allowances” to obtain this non-covered care.

Travel and transportation allowances include transportation costs, per diem and lodging. It is a fair question whether tax dollars should pay for expenses associated with non-covered abortions (i.e., when the life of the mother isn’t endangered, and the pregnancy isn’t the result of rape or incest). It is an intuitively obvious recommendation that, except in cases of acute financial hardship—unfortunately not atypical among junior military personnel, many of whom face food insecurity—the burden should be on the individual, not DOD and, by extension, the American taxpayer. 

It is also a fair question how often out-of-state travel is even necessary when the “abortion pills”—as noted above, the means by which most abortions are performed in the US—are readily available via tele-health. 

What’s not a question is that the current DOD policy impacts readiness by taking personnel off duty for extended periods of time—often on short notice. It is noteworthy that DOD does not allow administrative absence or travel and transportation allowances for any other non-covered medical procedure. 

Delayed notification about the pregnancy to the chain of command is even more thorny. The obfuscation could lead to duty assignments harmful to the mother and the fetus, with unforeseeable long-term consequences and costs for both. Moreover, concealing a pregnancy until the 5th month fosters distrust within the unit and the chain of command. 

Last but certainly not least, when a woman fails to perform her duties due to an advancing but concealed pregnancy, she is placing her entire team—not just herself and her unborn baby—at grave peril. With lives and mission in the balance, this is an unacceptable risk. 

Thus, it is the servicewoman’s responsibility to seek medical advice expeditiously, not only in order to avoid later-term abortions, but also to ensure that the pregnancy doesn’t adversely impact the unit’s combat readiness and operational capability. Having readily available, safe and discreet reproductive services would go a long way to avoid placing service members in desperate situations.

Since the last case of immaculate conception dates back to the Bible, it is also fair to assume that the vast majority of unwanted pregnancies among servicewomen result from unprotected sex with their military teammates. Those men bear equal responsibility for the ensuing pregnancy—an issue that has been swept under the rug for way too long.

RECOMMENDATIONS: 

1. THE CURRENT DOD POLICY SHOULD BE REEVALUATED AND RESCINDED. EXCEPT IN CASES OF ACUTE FINANCIAL HARDSHIP, DOD MONIES SHOULD NOT COVER COSTS ASSOCIATED WITH ABORTION—EXCEPT IN CASES OF RAPE, INCEST AND MATERNAL HEALTH, AS PROVIDED IN THE LAW. 

2. THE DELAYED NOTIFICATION OF THE CHAIN OF COMMAND CARRIES UNACCEPTABLE RISKS TO MISSION AND PERSONNEL AND SHOULD BE RESCINDED IMMEDIATELY. 

Dr Lani Kass served in the Department of Defense with honor and distinction for nearly 30 years. These views are her own.