Athena Thriving II

A Unit Guide to Leading Pregnant and Postpartum Soldiers

by

The United States Army has come a long way since the days of the Women’s Army Corps, an era when regulations mandated involuntary separation for pregnant women, while reporting them as having a “sickness; not in the line of duty.” While progress has been encouraging since World War II, we can continue to do better. Frustrating incidents of ignorance, stigmatization, discrimination, and substandard leadership and care of pregnant and postpartum soldiers still occur. These incidents occur despite the success and grit of numerous Army women who have sacrificed for our nation and excelled in their duties while carrying and raising children. 

Photo courtesy of Julie Edler Photography

This guide is a follow-up to “Athena Thriving: A Unit Guide to Combating Gender Discrimination in the Army.” It is intended to educate, provide references, best practices, and practical solutions for supporting Army women, their partners and support systems, and their children so that they may thrive in their service to our nation. Our intent is to provide all updated pregnancy, postpartum, and lactation policies in a common area for soldiers’ and leaders’ knowledge and stewardship. Understanding how to practically apply these policies and best practices is critical in putting “People First.”

“The Army must continue to put people first by fostering a culture of trust that accepts the experiences and backgrounds of every soldier and civilian. Our diverse workforce is a competitive advantage and the Army must continue to offer fair treatment, access and opportunity across the force.” -Gen. James C. McConville, Army Chief of Staff, 25 June 2020

Leaders at all levels must do more to understand and properly lead our pregnant and postpartum women. To do less is corrosive, a dereliction of duty, and ultimately detrimental to our goals of becoming the most inclusive and effective Army the world has ever seen.   

Table of Contents

Introduction

Women comprise 51% of American society, but only 18% of the Army and are 28% more likely to leave service than their male counterparts. Of the six major factors leading women to leave the service (work schedules, deployments, organizational culture, family planning, sexual assault, and dependent care), two are directly tied to pregnancy while in uniform and the others are tangentially related. These issues do not just affect a small section of women; 98% of active duty women are of childbearing age. In other words, one of our critical sources of talent is already underrepresented, and our inability to afford them the equal opportunity to raise a family is driving them out of service at an elevated rate. Additionally, 30% of recruits have a parent who served in the Army, so failing to support mothers in uniform might have long-term impacts on recruiting efforts. When we fail to care for our talented professionals as they navigate the challenges of growing and caring for their families, we lose significant potential and harm our long-term readiness.

Our vision is an Army in which policy, practice, culture, and leaders build a supportive environment where soldiers do not have to choose between their families or a successful career. 

Motherhood is not a limiting factor in what women can achieve professionally, but lack of support is. Pregnancy is a major life-cycle event for soldiers. It is not a disease, illness, disability, or an affliction. Pregnancy is a limited time frame in a female soldier’s career when she is on profile. Pregnancy does not lessen the value of a soldier. Pregnant soldiers demonstrate outstanding character, commitment, competence, and fulfill their duties faithfully and honorably. Leaders who fail to cultivate command climates that accept the temporary nature of a woman’s pregnancy, and fail to treat their soldiers with dignity and respect do lasting damage to the institution both practically and ethically by enabling gender discrimination. Those that succeed at creating positive command climates in this regard improve the command climate for ALL the soldiers in the unit — women and men.

Supporting pregnant women is not only the right thing to do — it’s the law. The Department of Defense (DoD) Equal Opportunity Policy (DoD Instruction 1350.02) states the following and requires leaders to ensure that:

“Service members are treated with dignity and respect and are afforded equal opportunity in an environment free from prohibited discrimination on the basis of race, color, national origin, religion, sex (including pregnancy), gender identity, or sexual orientation.”

Pregnant soldiers are entitled to equal opportunity to participate as much as possible in all unit activities. If possible, they should continue serving in their role, but no matter what they should contribute to mission accomplishment as a valuable member of the team. Leaders must be deliberate in maintaining their inclusivity on the team by assigning them meaningful, engaging work within their capabilities. While every pregnancy is an individualized experience, pregnant soldiers desire and deserve opportunities to continue contributing to the team in a fulfilling way. Enabling this might require leaders to change the environment in which they work or the duties they perform given safety considerations, but the soldier should not be isolated from their team. 

It is also important to note that the modern Army is diverse. The military family is no longer represented by the traditional stereotype of the nuclear family. Single parents, same-sex parents, dual-military married, dual-military unmarried, dual-military with one active soldier and one reserve/guard soldier, families with adult dependents, soldiers with guardianship of their siblings or parents, and other unique circumstances exist. Leaders must consider a multitude of “family” variations and be well versed in the regulations and policies for each. By following the regulations, policies, and recommendations in this guide, Army leaders will make great strides towards inclusivity and increased cohesion with our amazing women who make our force stronger. Back To Top

Family Planning

Leaders should proactively address personal and family goals with an open mind through the regular counseling process as a component of holistic soldier fitness and well-being. Engaging in open, mature dialogue on what are often seen as “taboo” topics between mixed genders is critical to creating a climate of trust and cohesion. The more we have these conversations, the more we will decrease the stigmas, and the more comfortable and normalized the dialogue will become. Leaders are encouraged to shape these discussions around the full spectrum of personal and professional goals to the extent the soldier is comfortable sharing. For example, leaders can ask, “what are your personal goals, and how can I best support you?”

Photo courtesy of Amanda Hughes Photography, LLC

Leaders should work to develop a trust relationship before directly broaching the subject of family planning, as some women (and men) might understandably meet these questions with skepticism. This level of trust must be earned over time. Women in the Army face difficult decisions when choosing if and when to have children due to unique challenges and demands of the profession. While 98% of women in the Army are in their childbearing years, leaders should also not assume that all women wish to become pregnant or have children. This is a common form of sexism that is unhelpful in promoting equality and team cohesion. Questions probing why a woman does not want children, or suggesting that she is too important to the mission to lose for the length of a pregnancy, are inappropriate. Interviews for jobs or educational opportunities are not an appropriate time to ask what a soldier’s family plans are, because this can easily lead to gender discrimination and even unintentional prejudices against mothers when considering potential candidates for opportunities. However, the empathetic support of leadership throughout a soldier’s tenure within an organization can greatly enable family planning, reduce stress, and retain talent. 

If a soldier decides to discuss pregnancy as part of her goals, the leader should offer to help the soldier develop a comprehensive plan that considers operational requirements, deployments, fertility challenges, options for limited duty, maternity leave, postpartum recovery, and the family care plan (if applicable). However, the leader should aim to do so and provide information without applying additional pressure on the soldier to fit it into an “ideal” or “perfect” time; there are windows that are less challenging than others, but “perfect timing” does not exist. Furthermore, many soldiers experience fertility challenges and stressors because no timing is guaranteed even when actively trying to conceive. Conversely, not all families are planned; unexpected pregnancies happen. Any discovery of pregnancy, regardless of timing, should be met by leadership with empathy, compassion, understanding, and support. To do otherwise adds unnecessary stress to an already stressful situation. 

If the soldier has no plan for pregnancy or declines to offer any family goals, leaders should encourage them to explore unit support assets, such as medics, Military Family Life Counselors (MFLC), the chaplain, the Women’s Wellness Clinic (WWC), or unit primary care provider in order to obtain information on available family planning resources. Family planning and contraceptive needs are a personal aspect of soldiers’ lives, and should be treated as confidential healthcare information. Leaders should only provide advice if specifically asked by the soldier. Lastly, leaders should not assume that their soldiers arrive with a comprehensive level of understanding on these topics, as they come from a wide variety of backgrounds and upbringings. Unit providers can help with instruction on sexual health and reproductive topics.

Lastly, Section 718 of the 2016 NDAA and Defense Health Agency Instruction 6200.02 requires military treatment facilities to provide comprehensive contraceptive counseling and access to the full range of contraceptive methods for pregnancy prevention and menstrual suppression. Soldiers deserve access to this standard of care for family planning, as well as further information on fertility-awareness based methods and tools to support reproductive health and goals to both conceive or avoid pregnancy. Encourage your female soldiers to advocate for themselves and request a different provider or second opinion if they are not comfortable with their assigned primary care manager. Back To Top

On Fertility

Fertility is a critical aspect of family planning. With early career pressures, some soldiers may feel compelled to postpone family planning and put things on hold, increasing the risk of fertility issues. Additional risk factors associated with higher rates of infertility among military women include stress, exposure to toxins, use of psychiatric medication, and higher rates of sexual trauma. There are several environmental considerations for conception, and further information may be provided by Occupational Health Hazard Assessments available in unit Material Safety Data Sheets (MSDS). Although military women of various demographic backgrounds may experience fertility issues, infertility rates are highest among women in their 30s, senior enlisted/officers, married women, and non-Hispanic black women.

Photo courtesy of Beauty Captured by Brittany

Pre-deployment counseling should address considerations of fertility preservation, including cryopreservation (freezing either sperm or eggs). These services are not covered by TRICARE (despite a DoD pilot a few years ago), but as combat operations carry a heightened risk of compromising fertility through genital injury or exposure to toxic chemicals, soldiers should consider their potential long-term family goals before deployment. Many fertility clinics offer discounted options for military members seeking fertility preservation options prior to deployments.

In general, TRICARE does not provide assisted reproductive services or noncoital reproductive technologies (including artificial insemination, Intrauterine Insemination [IUI], In Vitro Fertilization [IVF], or Gamete Intrafallopian Transfer [GIFT]). TRICARE does offer certain types of infertility assessment, testing, and care when used in conjunction with natural conception. In other words, they may cover the cost of assessing a soldier’s infertility, but it is up to that soldier to finance their own treatment or solution. The DoD has also contracted for limited fertility services at reduced rates (generally a 20-30% discount) at a subset of military treatment facilities: Walter Reed (WRNMMC), Tripler (TAMC), Womack (WAMC), Madigan (MAMC), Joint Base San Antonio (SAMMC), and Naval San Diego (NMCSD). 

TRICARE does make an exception for soldiers who have sustained injury or illness on active duty that led to their loss of reproductive ability, but even this exception requires both a lawful spouse and a soldier’s own gametes to qualify for eligibility. Again, soldiers who sustained combat injury to their reproductive systems are unlikely to be able to provide their own sperm or eggs as a result of said injury, so absent the soldier personally financing the freezing of their own sperm or eggs prior to deployment (see the recommendation on pre-deployment fertility counseling above), they are unlikely to be able to take advantage of this exception.

These policies affect same-sex couples uniquely. Lesbian couples may be able to use one partner’s eggs fertilized with donor sperm, but are not eligible for “sharing” a pregnancy (where both partners fertilized eggs are implanted through IVF in one partner who gestates the child). Homosexual men, needing both donor eggs and a surrogate to achieve a pregnancy, are completely left out of even the limited available fertility options. Additionally, as they would likely not engage in “natural conception” they may be denied access to even the diagnostic fertility services (such as semen or hormone analysis) typically available through TRICARE.

The process of fertility treatments can be time consuming, expensive, and emotionally and mentally exhausting. These factors include their partners, some of which might be men or women in your unit. It is imperative that leaders are cognizant of medical issues surrounding fertility. We may not be able to solve organizational challenges to improve access to care; but we can provide empathy and support to our soldiers and partners struggling with infertility. Given the disruptive nature of Permanent Change of Station (PCS) moves and the detrimental effects they may have on infertility treatment and intensive appointment sequences, soldiers and leaders might consider requests for stabilization through both medical and Human Resources Command (HRC) channels. Back To Top

On Surrogacy

Surrogacy is not covered by TRICARE or subsidized by the DoD. Army policy does not authorize soldiers to act as surrogates (AR 600-8-10). A soldier whose spouse serves as a surrogate and gives birth is not entitled to primary or secondary caregiver leave. When a soldier or dual military couple uses a surrogate and the member(s) become legal parents or guardians of the child, the event will be treated as an adoption. The soldier(s) will be entitled to either primary or secondary caregiver leave. Surrogacy laws are complex and carry serious long-term ramifications; leaders should encourage their soldiers to seek counseling from a Judge Advocate General (JAG) or a family law attorney before entering into any surrogacy contracts or arrangements. Back To Top

On Adoption

For some, adoption is available as a method for family planning. Soldiers adopting children under the age of 18 can apply for up to $2000 reimbursement per child, not to exceed $5000 per calendar year, under the DoD Adoption Reimbursement Policy. In order to qualify for the reimbursement, soldiers must be serving on continuous active duty for at least 180 days and the adoption must be finalized while on active duty. In addition, the claim must be submitted while on active duty and within two years of the date the adoption was finalized. Other qualifying restrictions apply including the type of adoption agency and specific reimbursable expenses. For additional information, see DoDI 1341.09 and MyArmyBenefits. Adoptive parents are eligible for primary or secondary caregiver leave. Back To Top  

Ensuring Safe and Healthy Pregnancies

A unit’s command climate towards pregnancy drives potential success or failure in supporting pregnant women. Units where pregnancy is treated as an impediment to readiness, an injury to be overcome, or a nuisance in achieving the mission might be less likely to enable safe and healthy pregnancies, and will instead inhibit optimal soldier performance and team cohesion. Women are already under immense stress to balance personal fulfillment of family goals, biological realities of fertility, and professional goals. Leaders who complicate these difficult decisions with negative attitudes or unequal treatment toward pregnant soldiers increase the likelihood and risk women will either delay medical care confirming pregnancy, finance medical care out of their own pocket, or simply refuse to inform their command of their pregnancy. Leaders set the tone of the organization through routine counseling and messaging long before the announced pregnancy, and then continue to support the pregnant service member throughout her journey. Back To Top

On Pregnancy Counseling

Women who suspect they are pregnant should seek medical confirmation from their healthcare provider. Commanders who suspect a soldier may be pregnant are authorized to order the soldier to report for diagnosis by a medical provider, but our hope is that by applying the recommendations in this guide leaders will build trust relationships with soldiers that will not necessitate this. Upon confirmation of pregnancy, the provider will issue the soldier a physical profile for the expected duration of the pregnancy and instruct the soldier on follow-up care and appointments. The standard profile will cover workplace limitations and avoidance of specific occupational hazards. The provider will note any major complications known at time of diagnosis, and duty implications of those considerations. These complications may change and require updates to documentation as the pregnancy proceeds. The physical profile will serve as the official notification to the command confirming pregnancy. Commanders are not authorized to disregard the restrictions listed on the profile. 

Photo courtesy of Autumn Trinity Photography

Commanders are required to counsel all pregnant soldiers on their pregnancy. This should take place as soon as possible after the unit is informed about a medically-confirmed pregnancy test. The pregnancy counseling must address rights and regulations such as Equal Opportunity (EO) policy, parental leave, options for retention and separation, available prenatal care, maternity clothing and uniforms, housing, assignments, family care plans, information on childcare providers (including Child Development Centers [CDC] and available subsidies), enrollment in the Pregnancy and Postpartum Physical Training (P3T) Program, and lactation support needs. An example checklist can be found in AR 635-200 figure 8-1. The goal of the chain of command in this counseling session should be to empower a soldier with support and resources, as well as an understanding of responsibilities and options since this is a critical time in her personal and professional life. Ensuring open dialogue will prevent misunderstandings and allow for proactive planning. This counseling should be detailed and specifically tailored for each pregnant soldier, regardless of rank. Lastly, commanders should approach this counseling with a positive attitude, which might make the difference between pursuit of separation or continued service.

This initial counseling is a good opportunity for the commander to discuss the soldier’s comfort level with other members in the organization knowing that she is pregnant. Who, at a minimum, in the chain of command needs to know? Is the soldier comfortable with those leaders sharing with others? Who in the chain of command has Health Insurance Portability and Accountability Act (HIPAA) authorization waivers to know about the pregnancy? Does she have a history of miscarriages or want to keep the news on a need-to-know basis until the 2nd trimester? This is a deeply personal decision for the soldier and depends on a variety of individualized factors; it is important that leaders honor the soldier’s wishes in order to maintain trust.

Commanders should seek to accommodate and support soldiers and families through this initial counseling, but active duty women may choose to pursue administrative separation. Specific details for administrative separation of enlisted women can be found in AR 635-200, chapter 8. Officers may request voluntary release from active duty or tender resignation, but officers with an Active Duty Service Obligation (ADSO) must request a waiver of their ADSO which may complicate the release process. Specific details for officers may be found in AR 600-8-24, chapters 2 and 3. Women who request this type of administrative discharge may continue to be eligible for medical coverage for themselves and their newborn at a military treatment facility, but should check with TRICARE and the Military Treatment Facility (MTF) to confirm. They may also be eligible for care at a Veterans Administration (VA) hospital, but should check with their local facility to ensure eligibility. These soldiers are also required to complete a modified version of the Transition Assistance Program (TAP). 

COL Martin and her two children, Blake and Katherine Martin.

The counseling process for Army National Guard and Army Reserve soldiers varies slightly from active duty. Soldiers must be counseled in accordance with AR 135-91. Pregnant women may not enlist. A woman that becomes pregnant after enlistment but before entry to Initial Active Duty for Training (IADT) may either request a discharge or delay IADT until the pregnancy is no longer a factor. Specific guidance can be found in AR 135-178 chapter 6. Officers who become pregnant before entry to initial active duty or active duty training may either tender resignation, delay active duty or active duty training until pregnancy is no longer a factor, or request immediate active duty status through HRC. Specific guidance can be found in AR 135-91, chapter 4.

Later counselings are also a good opportunity to manage expectations with the chain of command during and after the birthing event. Many leaders are familiar with the typical report up to their leadership: “Baby Smith born at 1015, 7lb8oz. Girl.” This group has heard of some units requiring by-the-minute reporting on the laboring soldier (leading to such uncomfortable circumstances as the platoon leadership in the maternity waiting room sending up reports). A better solution for accountability is to receive an update from the soldier as she is going into labor, then waiting until the parents have had the opportunity to meet their new child and recover from a significant medical event. Similarly, while leaders will often want to visit the new family at the hospital, it is important to ask the family about visits both before and after delivery, rather than overwhelm them with official visitors during a crucial bonding, recovery, and adjustment period. Back To Top 

On Workplace Restrictions

While there are some standard workplace restrictions required for the occupational and environmental health of the soldier, a woman who is experiencing a normal pregnancy may continue to perform military duty until delivery within the limits of the standard pregnancy profile. Only those women experiencing unusual and complicated problems will be excused from additional or all duty, in which case they may be hospitalized or placed sick in quarters. Medical personnel assist unit commanders in determining duties. A pregnant soldier is not placed sick in quarters solely on the basis of her pregnancy, unless there are complications present that would preclude any type of duty performance. These complications may include (but are not limited to) hypertension, pre-eclampsia, gestational diabetes, lower extremity swelling, preterm labor and hyperemesis gravidarum (excessive vomiting during pregnancy).

Specific workplace restrictions should be addressed by the medical provider through the pregnancy profile. Commanders and soldiers should be aware of which operations under their command pose occupational health hazards. A full list of workplace limitations and hazards is found in DA PAM 40-502 chapter 4-9, and will be issued by the healthcare provider or profiling provider. Providers may add restrictions depending on individual situations but they can never take away from what is directed by regulation. The soldier and leadership can receive additional information from their servicing Occupational Medicine Clinic to provide a full assessment if there are further concerns not adequately addressed in AR 40-502, DA PAM 40-502, or screened by the soldier’s first visit to their provider. 

The intent of these provisions is to protect the health of the soldier and fetus while ensuring productive employment of the soldier. These are not minor inconveniences for the command; they are science-based restrictions intended to ensure the health and safety of both the mother and child. Pregnancy profile limitations, like all profile limitations, cannot be ignored. If a commander has questions or concerns regarding the profile, they are encouraged to communicate with the profiling provider. Standard restrictions include exposure to toxic chemicals, whole-body vibrations, immunizations and other chemical agents, and overwork. Soldiers with complicated pregnancies or compromised health histories may have additional restrictions. Highlights from standard occupational and environmental health restrictions are below, but leaders are encouraged to clarify any restrictions with the assigning healthcare professional. Back To Top

Restrict exposures to toxic compounds

Prenatal exposure to military fuels has been shown to result in immunosuppression and reduced cognitive function. Lead exposure may result in miscarriage, stillbirth, and lifelong degredation of a child’s central nervous system. Lead passes from the mother to child in multiple ways – there is no safe amount of lead. Prenatal exposure to carbon monoxide, diesel exhaust, and other particulates may result in low birth weight and delayed mental and physical development. DoD policy restricts pregnant women from assignments such as fuel handling, indoor firing ranges, and positions with routine exposure to exhaust and other chemical compounds. These restrictions do not generally apply to pregnant soldiers performing Preventive Maintenance Checks and Services (PMCS) on military vehicles using impermeable gloves and coveralls, nor does it apply to soldiers who do work in areas adjacent to the motor pool bay (for example, administrative offices) if the work site is adequately ventilated. Back To Top

Restrictions to excessive vibrations

Whole body vibrations have been linked to preterm birth and miscarriages. These occur in helicopters and larger ground vehicles (greater than 1 1/4 ton) when the vehicle is driven on unpaved surfaces. At 20 weeks of pregnancy, the soldier must not ride in, perform PMCS on, or drive in vehicles larger than light medium tactical vehicles, due to concerns regarding balance, vibrations, and possible hazards from falls. Back To Top

Restrictions on heavy lifting and excess weights

Sustained periods of work while engaging in heavy lifting has been linked to lower birth weights and increased risk of preterm birth or miscarriage. Additionally, pregnant women are more likely to be injured while lifting weights such as Load Carrying Equipment (LCE) or body armor due to changing ergonomics caused by physical changes in size, weight distribution, and balance. Wearing individual body armor and/or any other additional equipment is not recommended and must be avoided after 14 weeks of gestation. Back To Top

Restrictions on immunizations and other chemicals

Some vaccines and chemicals may pass through the mother’s blood barrier and affect the developing child. Pregnant women are exempt from all immunizations except influenza and tetanus-diphtheria and from exposure to all fetotoxic chemicals (including chemical and riot control agents) noted on the occupational history form. Women should make decisions on additional vaccines in consultation with their providers and information available from the Center for Disease Control (CDC).

There is currently limited data on the safety of COVID-19 vaccines during pregnancy because it was not studied among pregnant people. Getting vaccinated is a personal choice, and any of the currently authorized COVID-19 vaccines can be offered to people who are pregnant or breastfeeding. Pregnant women are at increased risk for severe illness from COVID-19 compared to non-pregnant people. Additionally, pregnant people with COVID-19 might be at increased risk of adverse pregnancy outcomes, compared to pregnant women without COVID-19. Although there is limited data available on the safety of COVID-19 vaccines in pregnant women, clinical trials and safety monitoring systems are in place to gather information. Most of the pregnancies in these systems are ongoing, so information is not yet available on the outcomes of those pregnancies. The CDC and Federal Drug Administration (FDA) report the need to continue to follow pregnancies long-term to understand effects on pregnancy and infants. The CDC’s V-Safe program monitors vaccine complications including data on pregnant women, and encourages consideration of participation in the V-Safe Pregnancy Registry for those who are pregnant and receive a COVID-19 vaccine. If soldiers have questions about the vaccine for pregnancy or breastfeeding, they are encouraged to open a conversation with their healthcare provider on likelihood of exposure to the virus, risks of COVID-19 to the pregnant soldier and potential risks to the fetus or infant, and what is known about the vaccine. Back To Top

Restrictions on field duty and other training requirements

Poor sanitation has been linked with low birth weight, preterm birth, and miscarriage. Additionally increased stress and lack of sleep are linked with poor maternal health and negative fetal outcomes. Pregnant women are generally exempt from participation in field duty, standing at parade rest or attention for longer than 15 minutes, swimming qualifications, drown proofing, and weapons training after 20 weeks by DA PAM 40-502, but these restrictions can be discussed between the woman, her commander, and healthcare provider. For example, healthy pregnant women who drive out to the field in non-tactical vehicles such as Transportation Motor Pool (TMPs) or Privately Owned Vehicles (POVs) for daily shift work may be perfectly capable of supporting field exercises beyond 20 weeks in such a manner that respects medical concerns and mitigates any risks, and this is recommended to be considered through open dialogue with the soldier and medical team to provide opportunities for the soldier to continue receiving equal opportunity to meaningfully contribute to the mission and feel included as a valued member of the team, especially if the soldier wants to take part. Back To Top

Restrictions on work hours

As described above, increased physical and mental stress can have negative outcomes for both the mother and fetus. For uncomplicated pregnancies, beginning at 28 weeks of pregnancy, the soldier must be provided a 15-minute rest period every 2 hours. Her duty week should not exceed 40 hours and the soldier should not work more than 8 hours in any one day (so no 24 hour duty such as charge of quarters or staff duty). The 8-hour work day DOES include the time spent in P3T and the hours worked after reporting to work or work call formation, but does NOT include the Physical Training (PT) hygiene and travel time. For soldiers with complications, these restrictions may be moderately or significantly increased, depending on the nature of complications. 

Medical fitness standards for flying duty

Reference (AR 40-501, Ch 4)

Uncomplicated pregnancy is not disqualifying, but there are flying duty restrictions. Applicants already in the military are disqualified until fully recovered and at least 6 weeks postpartum.  New accessions to the military are disqualified until 6 months after the completion of the pregnancy. Unresolved complications of pregnancy may be disqualifying and are  evaluated on a case by case basis. In uncomplicated pregnancies, flying is restricted to  synthetic flight simulator training during the entire pregnancy; or multi-crew,  multi-engine, non-ejection seat fixed wing aircraft during weeks 13 through 24 of  gestation. The requirement for physiological training is waived during pregnancy.

Photo courtesy of Jenna Hough Photography

Soldiers should not be placed in the position of having to choose between violating their profiles and contributing to the unit in a meaningful way. AR 40-502 says “Common sense, good judgment, and cooperation must prevail between policy, the soldier, and the soldier’s commander to ensure a viable program.” Soldiers should not be automatically removed from an assignment or job due to pregnancy. In some instances, the maximum use of a pregnant soldier may require some creative thinking or temporary internal reassignments within a unit. Commanders should understand the soldier’s medical restrictions, compare them with the job requirements, and work with the soldier to find reasonable accommodations as needed. Lastly, by including pregnant soldiers in planning and operations, leaders ensure they can seamlessly reintegrate into their previous duty positions when returning postpartum. 

For Reserve and National Guard soldiers not on active duty, pregnant soldiers will continue to perform duties in accordance with their pregnancy profile as described above. Performance of duty will continue until it is no longer considered feasible by her unit commander. In making this decision, the unit commander will consider the written statement of the soldier’s attending physician. When the decision is made, the soldier will be excused from Inactive Duty Training (IDT) periods. Normally, the prenatal leave period will not exceed four weeks. If the soldier wishes to be excused earlier, she will submit a written request to her unit commander for approval. Her request must include her physician’s written statement. The unit commander may extend the prenatal period beyond 4 weeks. This extension is based on the commander’s decision that the soldier is not physically able to continue in duty status. For more information, see AR 135-91.

Photo courtesy of Madison Jones Photography

The profiling process for remote active duty, Reserve, and National Guard soldiers is different than for soldiers located near a MTF. These soldiers must fill out a profile packet and submit it to their respective profiling agency. Soldiers should work with their unit administrators to assist with the process. Because it can often take a bit of time for a soldier to receive a profile, lack of a profile does not negate the restrictions outlined in AR 40-502 and DA PAM 40-502. Upon diagnosis of pregnancy, the restrictions outlined in these regulations must always be adhered to, even if the profile hasn’t been processed yet. For soldiers in remote locations, the nearest MTF is required to support all soldiers, and can be done telephonically. Additionally, the U.S. Army Reserve Medical Management Center has an easy to use profile request packet. Back To Top  

On Pregnancy Loss

Unfortunately, early loss of pregnancy (miscarriage) happens in up to 31% of pregnancies. The soldier’s command and leadership should treat miscarrying soldiers with dignity and respect, honoring the significance of the loss and the deeply painful and personal physical, mental, and emotional process of the miscarriage. Leaders should provide compassionate support, care, and resources for the soldier and family accordingly. Engage with providers when available to understand how to empathetically approach recovery for soldiers experiencing pregnancy loss. This same care should be taken with the soldier’s partner, or our soldiers whose partner miscarries as they grieve for the loss and care for their loved one. Utilizing resources such as the chaplain, MFLC, Family Advocacy Program (FAP), counseling through Military One Source, or behavioral health is critical in providing proper holistic support.

Soldiers choosing to end their pregnancy electively must do so in an off-post medical clinic as these procedures cannot be performed in MTFs except in rare cases, nor are they covered by TRICARE. These soldiers should be treated with dignity and respect in the same manner as any soldier with an early pregnancy loss. Soldiers who choose this path should be encouraged to seek follow-up care with their provider as there can be additional effects that are not initially apparent after the procedures. 

Photo courtesy of Images by SB

Soldiers who experience pregnancy loss before 20 weeks are not eligible for maternity convalescent leave, but may be authorized regular convalescent leave. This leave period is limited to 30 days but may be extended by the first O-5 in the chain of command in consultation with the soldier’s providers. While Army regulation provides clear guidance for soldiers with a pregnancy loss beyond 20 weeks, prior to 20 weeks, it is determined by the commander with reference to the medical provider’s guidance. In cases when a baby is stillborn or the covered member suffers a miscarriage, convalescent leave (other than maternity convalescent leave) may be granted. For pregnancies lasting 20 or more weeks, six weeks- the normal maternity convalescent leave period- is still appropriate for the physical recovery of the mother. The commander should work with the medical provider to determine the appropriate amount of time if pregnancy was less than 20 weeks, taking into consideration both the physical AND mental health of the mother. The soldier may need a longer recovery period and commanders need to understand that with any pregnancy loss, it is a process, not a single event. There is likely tremendous grief that must be acknowledged along with physical, mental, emotional, and spiritual recovery for both partners in the relationship (if applicable). This group recommends at least ten days of convalescent leave before returning to duty. Lastly, the Family Servicemembers’ Group Life Insurance (FSGLI) program contains benefits for families who suffer late pregnancy loss, with specific rules and qualifications. Back To Top

On Uniforms

Women’s bodies undergo substantial changes throughout a pregnancy to support the growing baby. Commanders are required to ensure that soldiers are issued their authorized uniforms and that soldiers’ uniforms are properly fitted (see AR 700-84 paragraph 1-4.g). While the rules and processes differ depending on the type of uniform and whether the pregnant soldier is an officer or enlisted, leaders must ensure that women are afforded access to the required maternity uniforms needed to do their jobs.

All pregnant soldiers are authorized to draw Maternity Utility Uniforms (MUU) from their installation Central Issue Facility (CIF) with a copy of their pregnancy profile. Some installations also require a signed memorandum from their commander. The drawn uniforms must be documented as Organizational Clothing and Equipment (OCIE) on the individual soldier’s clothing record. Active duty expectant mothers are authorized three sets (tops and trousers) of uniforms and Reserve and National Guard soldiers are authorized two sets. These uniforms can be issued at any point in pregnancy, and as a soldier gets farther along in their pregnancy, they can swap to receive a bigger size if at any point the size issued no longer fits properly. Unless the soldier already has maternity uniforms on their clothing record, commanders should never deny authorization to draw maternity uniforms. Lastly, soldiers who are pregnant or trying to become pregnant are authorized to wear the Army Combat Uniform (ACU) without permethrin.

Enlisted soldiers who require the Army Service Uniform-Maternity or Army Green Service Uniform (ASU-M/AGSU-M) for their official duties may be issued the ASU-M with a Personal Clothing Request signed by their commander. The clothing request is documented in DA Form 3078 with all required components of the ASU-M and  “Issued as supplemental items as authorized by CTA 50-900 (Clothing and Individual Equipment)” in the remarks. The soldier will take the clothing request and copy of their pregnancy profile to the local Military Clothing Sales to acquire the issued clothing items. Following pregnancy, the uniform issue is active for three years. The Army will not issue a new ASU-M within that time. If the soldier has another pregnancy more than three years later, she is authorized an additional supplemental issue and can obtain it by repeating the above steps. The ASU-M does not need to be returned. 

Commissioned officers are not authorized to draw the ASU-M and must acquire their own uniforms. Among this group, several noted that many installations have lending closets or thrift stores which often have gently used ASU-M’s for free or at severely discounted prices.

Photo by Valerie Conrad Photography

Although current policy does not specify this, common sense dictates that in most cases soldiers that are within the postpartum body composition deferment period should not be required to wear the ASU/AGSU or be forced to purchase larger sizes. Soldiers appearing before promotion (or similar) boards should be authorized to have a hanger inspection. At no time should a soldier be denied the opportunity to appear before the board because she does not yet fit into her ASU while still within the deferment period. Additionally, board members should be briefed that this will not negatively affect their assessment of the soldier to ensure equal opportunity and non-discrimination as per DoD policy. Lastly, soldiers and leaders need to be aware that even if a woman is meeting body composition standards, their pre-pregnancy uniform still may not fit due to anatomical changes from the pregnancy, or physical impacts of breastfeeding. Back To Top

On Family Care Plans

AR 600-20, 5-3, covers command responsibilities for establishing family care plans. Family care plans are an essential tool to ensure family members are properly cared for when a soldier is deployed or otherwise not available due to military requirements. Commanders must ensure single-parent soldiers, dual-military couples with dependents, or soldiers otherwise responsible for caring for dependents under the age of 18 have completed workable family care plans. These are not legal status documents, nor are they intended to cover unique requirements for childcare outside normal hours (e.g. extra hours or events starting before on-post child care centers open in the morning). Pointedly, these plans were never intended to cover unique circumstances like a global pandemic; during which secondary caregivers would be unable to travel or support dependents. As with so much of caring for pregnant and postpartum soldiers, “common sense, good judgment, and cooperation must prevail.” The Sergeant Major of the Army recently said:

“Soldiers having issues with their family care plans need to communicate with their chain of command. Leaders need to listen, be flexible and do what’s best for the Army, their soldiers and their families. That’s what our nation expects and what our people deserve. In these challenging times, we must know our people better than ever, be flexible to balance their needs with the needs of the Army, and continue to put people first in everything we do.”

Commanders should address the requirement for family care plans with pregnant soldiers in the initial pregnancy counseling (ideally around 6-10 weeks into the soldier’s pregnancy), but conduct a separate family care plan counseling session (documented on DA Form 5304) with the pregnant soldier no later than 90 days prior to the soldier’s due date. Since the family care plan must be completed within 60 days of counseling and on file with the command no later than 60 days prior to the due date, commanders should aim to hold their family care plan counseling sessions no later than the soldier’s 20-week mark. As this is when many pregnancy restrictions kick in, this session also serves as a formal opportunity to ensure the soldier is receiving the care she requires.

The family care plan is documented on DA Form 5305 and outlines the person(s) who shall provide care for a soldier’s dependent family members in the absence of the soldier due to military duty (training exercises, temporary duty, deployments, etc.). The plan shall address the legal, medical, logistical, educational, monetary, and religious arrangements for care of the soldier’s dependent family members. The plan must include all reasonably foreseeable situations and be sufficiently detailed and systematic to provide for a smooth, rapid transfer of responsibilities to the caregiver in the absence of the soldier. On-post CDC’s will also require a copy of the family care plan.

All soldiers on active duty shall submit the final family care plan through the chain of command no later than 60 days prior to the date of the birth of the child (extensions may be authorized). Failure to produce the family care plan may result in disciplinary or administrative action that may result in separation from the Army. 

Commanders (and first line leadership) should familiarize themselves with family care plan requirements as early as possible so that they are prepared to advise and assist soldiers who are becoming military parents for the first time, whether through pregnancy, adoption, or marriage.  While the family care plan has specific requirements, this may be the first time that a soldier is considering being separated from their future child. Back To Top 

On the Pregnancy and Postpartum Physical Training (P3T) Program 

The P3T Program is a comprehensive physical fitness training and education program designed to assist pregnant and postpartum soldiers by ensuring their safety, health, and fitness to meet the unique physical fitness requirements for postpartum recovery and mission-readiness while supporting a higher standard of care. The P3T program creates comprehensive support systems for pregnant soldiers that are integral to their holistic health, quality of life and well-being, readiness, and long-term retention. Leader support of this program is critical – whether it be installation Program Managers, command teams, or appointed Exercise Leaders and Instructor Trainers who serve in leadership roles.

Photo by Brian Forsmo

The goal of exercise during pregnancy is to maintain the highest levels of holistic health, overall readiness, and fitness consistent with the maximum safety for the soldier and baby. Soldiers are expected to meet strenuous physical fitness standards when they return to their jobs after their disenrollment from P3T. The program aims to help pregnant and postpartum soldiers maintain fitness throughout their pregnancies and to help them meet the standards of the Army Body Composition Program (ABCP) and Army Combat Fitness Test (ACFT), as well as meet the functional physical requirements of their Military Occupational Speciality (MOS). Exercise during pregnancy may decrease the risk of gestational diabetes, preeclampsia, C-section, and preterm birth or lower birth weight for the baby, and can also be a factor in preventing postpartum depression. Aerobic and strength-conditioning exercises should be encouraged as an important component of optimal health before, during, and after pregnancy for women with uncomplicated pregnancies. The changes in the body during and after pregnancy drives the frequency, intensity, duration, and types of drills and exercises performed. Soldiers (with assistance and guidance from their certified Exercise Leaders and Instructor Trainers) adjust the dose and range of movement based on their specific needs, level of conditioning, and trimester. Soldiers who maintain fitness, with some adaptations based on physiological changes to support and preserve core and pelvic health throughout their pregnancies, optimize benefits toward a healthy pregnancy and healthy weight gain. This fitness also reduces physical discomforts and stress during pregnancy, and promotes healthy postpartum weight loss and a smoother return to full physical readiness.

Per AR 350-1 and FM 7-22, P3T enrollment is mandatory for all pregnant soldiers. U.S. Army Medical Command (MEDCOM) provides P3T education and training materials through the Army Public Health Center (APHC) website. Local commanders are responsible for execution according to the implementation standards set forth in Army policy and the APHC P3T Manuals (the Technical Guide 255 series). P3T distance learning and instructor courses are both available through the Army Training and Requirements Resource (ATRRS). US Army Reserve, National Guard, and other soldiers not able to directly participate in organized P3T due to remote status must work with their supervisors to employ the fundamentals of P3T and digitally-available products to maintain their fitness throughout pregnancy and aid in postpartum recovery, but no other P3T special services are offered.

There are ongoing efforts to optimize the P3T program for the ACFT, improve accessibility for Reserve and Guard soldiers, and ensure that it is fully integrated with Holistic Health and Fitness (H2F) doctrine and systems. Female medical readiness is an emerging priority in the federal healthcare system with an increase in female service members, integration of women into combat roles, implementation of rigorous functional physical fitness test requirements, and the development of multi-disciplinary human performance optimization programming. Aligning P3T with existing initiatives and policies and latest research in promotion of women’s health, fitness, and readiness strengthens our female service members and families as a key component of the Army’s total force.

Additionally, the Army is working to develop a P3T app to increase accessibility of information and training guidance for soldiers and leaders, especially those in the Reserve and National Guard or on more remote duty installations. The provision of safe postpartum fitness programming and adequate timelines for recovery is imperative for female soldiers since the ability to meet return to duty requirements in a timely manner has significant ramifications for career progression and retention. Improved access to quality, evidence-based resources are necessary for female soldiers to promote injury prevention, general wellness, overall health, and fitness throughout pregnancy, with a progressive return to holistic health and readiness postpartum.

All postpartum soldiers should be taught signs and symptoms of pelvic floor and abdominal tissue dysfunction to monitor during exercise and run progressions — such as pelvic pressure, pain, and urinary or fecal incontinence. Pelvic health conditions are common following pregnancy and delivery and can severely impact readiness and quality of life. These signs indicate the need for further or ongoing assessment and management prior to continuing and progressing training. Further resources are recommended below; an understanding of the breadth of pregnancy and postpartum physiological changes, considerations impacting recovery timelines, and risk factors are fundamental topics for any P3T training programming and educational curriculum.

One of the fundamental aspects of physical training is to build camaraderie while developing mission-oriented fitness and healthy lifestyles- and P3T is no different. When conducting training as a unit or group, it maintains cohesion, reinforces performance, and sustains readiness and retention. This camaraderie and peer support is a significant benefit of the P3T program. Multiple units typically consolidate P3T education classes at the installation or brigade-level to establish support and educational networks on topics of pregnancy, labor and delivery, newborn babies, and parenting issues. Weekly education sessions are taught during P3T during pregnancy, and monthly during postpartum to improve soldier preparedness for pregnancy and parenthood (see FM 7-22 for core curriculum topics). Utilizing resources such as the chaplain, MFLC, FAP, counseling through Military One Source, behavioral health, or Army Community Service (ACS) offerings is critical in providing proper holistic support and education for partners as well, discussed throughout this article. A critical intent of educational sessions should be enhancing soldier and family knowledge of regulations, resources and support systems available within and beyond the military community to assist them during these transformative and often stressful chapters of their lives.

Commanders have a responsibility to oversee P3T training just like any other physical training. Pregnant soldiers should not be directed to “fall out with the profiles” or “go walk the track.” Each installation’s P3T program is administered with slight differences, and commanders should become familiar with the one their soldiers will attend. The recently updated FM 7-22, Holistic Health and Fitness, is a guide commanders should read (at a minimum) to expand their P3T knowledge. Commanders must support P3T with trained and dedicated personnel and are highly encouraged to visit P3T sessions as a leadership responsibility, showing dedication to championing readiness in all facets of all soldier’s lives, and as an opportunity to spot-check the effectiveness of the program.

Pregnant and postpartum soldiers often ask for recommendations on further information, resources, and personal training programs to empower them beyond the training manuals and resources that exist within the P3T Program. For soldiers and leaders searching for more information, see the “additional resources” section at the end of the article.

One area of particular emphasis is the postpartum return to running and vigorous, high impact activities. Published in 2019, postpartum return to running guidelines for medical, health, and fitness professionals managing this population are the most pragmatic, evidence and conditions-based approach to determine safe eligibility for impact training in postpartum women. These are routinely referenced as the “gold standard” and are utilized internationally by military pelvic health and rehabilitation professionals, and for elite female athletes. These guidelines recommend a progressive, graded return to running at three months postpartum, following a foundation of strength-building and low-impact conditioning exercises, balance, coordination, and impact control. This approach applies key load and impact testing to assess and rebuild readiness to progress to running and jumping in a safe, sustainable, and effective manner that minimizes risk for pelvic floor dysfunction and musculoskeletal injuries. Quality guidance is imperative for soldiers and leaders to implement strength and conditioning training for pregnant and postpartum athletes, while managing challenges and common symptoms to support long-term core and pelvic health. This is critical for optimal athletic function, readiness, and performance. Back To Top

On Army Body Composition Program (ABCP), Army Physical Fitness Test (APFT), and Army Combat Fitness Test (ACFT)

Pregnant soldiers are exempt from some regulatory requirements specific to body composition and fitness to accommodate the unique nature of pregnancy and postpartum recovery. This is not a ‘lowering of standards’ or a drain on readiness, but an acknowledgement that pregnant women have different considerations and requirements as their bodies grow and nourish a baby.

Women will gain weight during pregnancy as part of a healthy pregnancy and are therefore exempt from ABCP standards for the duration of their pregnancy and up to 365 days after the pregnancy ends, which increased from 180 days with a recent Army announcement. Additionally, soldiers who are between 181 to 365 days postpartum as of 26 March 2021, and were previously flagged and entered into the ABCP after their pregnancy ended, will have their flag removed and they will be removed from the ABCP program.

If a soldier is enrolled in the ABCP prior to pregnancy, she will remain flagged. Once the soldier’s deferment is over, she can participate in a record weigh-in and, when required, a body fat assessment. Soldiers entered or re-entered in the ABCP after pregnancy will be considered first-time entries into the program (AR 600-9, paragraph 3–14 will not apply). If a soldier is enrolled in ABCP and a medical provider determines that the soldier became pregnant prior to being entered into the ABCP, the flag will be removed using code “KZ.”

Photo courtesy of Willow Tree Photography

Similarly, soldiers are exempt from standard APFT and ACFT record testing upon medical confirmation of pregnancy. All postpartum (any pregnancy that lasts 20 weeks and beyond) soldiers are exempt from the record APFT for 180 days and record ACFT for 1 year following completion of pregnancy. Soldiers must be medically cleared prior to taking an APFT and ACFT. Refer to AR 600-9, FM 7-22, DA PAM 40-502, HQDA EXORD 164-20 (FRAGO 1) and the soldier’s postpartum profile for additional information. Although the postpartum profiles are normally only 42 days (this corresponds to the maternity convalescent leave period), the deferments for body composition and fitness testing extend beyond the end of the profile. Soldiers still within the fitness testing deferment period should also be exempt from unit specific fitness standards.

FM 7-22 states  that leaders should “give postpartum Soldiers the chance to practice ACFT events and measure their body composition as part of their needs analysis and program development.” This group has heard of this being used to give postpartum soldiers full diagnostic ACFTs as regulation does not explicitly exempt soldiers from taking diagnostics, but we strongly recommend only doing so in close consultation with the soldier and her provider. This should be based on her level of comfort and readiness to prevent increased risk of injury during a time in which the soldier is still progressively healing. The soldier may be experiencing ongoing postpartum complications and symptoms, and not yet be ready to take a full diagnostic due to issues discussed below such as pelvic health. Even when taking diagnostics (which cannot lead to punitive action), soldiers will likely place pressure on themselves or feel pressure from those around them to push through certain pain and discomforts in the moment that should not be ignored during the critical healing periods postpartum. We recommend leaders allow the soldier the opportunity to take it on her own to familiarize with each event and do so safely with supervision and support from a leader they trust such as a P3T representative or another leader. 

Commanders are required to conduct profile reviews. We recommend this to be done in conjunction with the soldier’s leadership and a medical representative, to discuss how the leaders can best support their soldiers’ specific profiles to assist the soldier in their injuries or limitations and preparation for the PT test as well as other physical demands. This meets the intent of familiarization, while respecting where the soldier is at in her recovery process and motivating her to continue to improve without increasing the risk of injury or exacerbation of dysfunctions the soldier may still be rehabilitating postpartum. Ideally, the P3T program will have a comprehensive screening and disenrollment process, as well as apply principles of progressive overload through the postpartum period to familiarize and build confidence and capacity leading up to the release to unit-level PT. 

Administratively, all current valid passing, and failing, APFT scores remain valid until further notice. If the soldier failed their last APFT and was flagged, the flag remains in effect. In instances where a soldier was unable to take an APFT within the 12 months (pregnancy, surgery, or injury profile) but passed their last record APFT, the soldier’s last record APFT remains valid until further notice. Refer to HQDA EXORD 164-20 (FRAGO 1). If a soldier takes an APFT (and we assume ACFT will follow suit) and fails, but is later found to have been pregnant during the test, the flag is to be removed immediately using flag code “KZ.” Back To Top

On Pregnancy and Professional Military Education (PME) 

Photo courtesy of Autumn Trinity Photography

When possible, pregnancy should not be used as a justification to prevent soldiers from attending PME. AR 350-1 paragraph 3-13, which requires a passing APFT and adherence to ABCP standards for graduation, can be interpreted as justification for denying attendance to a pregnant or postpartum soldier. Soldiers should check with each individual institution on application of this policy. PME course managers should thoroughly assess physical demands of the course and make every effort to accommodate pregnant and postpartum soldiers when it will not significantly detract from their ability to complete the course. Denying attendance to soldiers without reasonable justification can have detrimental impacts on their career progression and should not be the default. Soldiers may be authorized to attend PME with a temporary profile similar to the exemption in AR 350-1, paragraph 3-14a. Under current COVID-19 provisions, a current passing APFT score and body composition is valid for PME (enlisted and officer), functional courses, operational course credit consideration, or distant learning/ education requirements in accordance with HQDA EXORD 164-20 “APFT and ACFT During the COVID-19 Outbreak” (FRAGO 1). Back To Top

On Specialized Care and Support Options

As needed throughout pregnancy and postpartum, mothers are encouraged to request through their Primary Care Manager (PCM) or Obstetrician/Gynecologist (OB/GYN) a consultation with a Pelvic Floor Physical Therapist (to evaluate and proactively address any core or pelvic health symptoms), mental health specialists, lactation consultants, chiropractor, etc. Each soldier is their best advocate, and honesty is encouraged with their care team and support system to ensure they have access to the specialists they need. Leaders should encourage and support referrals to specialists as needed and not treat appointments as an inconvenience or burden. This is especially important when things don’t go well- such as traumatic births, injuries during birth, unfavorable health conditions of the child, or discovery of conditions that would cause the child to become part of the Exceptional Family Member Program (EFMP).

Just as our current medical model automatically refers sports/tactical injuries to physical therapy where graded protocols are the standard of care to support such healing efforts, the same thoughtful considerations should be applied for postpartum healing and return to readiness. Often, soldiers are either not aware of these options, or barriers to care exist such as a lack of local specialized care providers. Postpartum soldiers especially benefit from proactive, collaborative, and comprehensive approaches to care to optimize long-term health, readiness, performance, and well-being.

Soft tissues, muscles, and bone structures undergo nine months of progressive loading through pregnancy, as well as the physical stress of delivery, which result in various muscular strains to the abdominal wall and pelvic floor muscles identical to that of other sport/tactical related musculoskeletal injuries. 

When it comes to core and pelvic health, many Army women can benefit from greater accessibility to pelvic health specialists, and the opportunity to receive a referral for a Pelvic floor physical therapy exam between 6-12 weeks postpartum. This exam provides an individualized assessment and guided pelvic floor rehabilitation, to alleviate further injuries and to assist in bridging the gap between medical clearance and athletic clearance. Most women are navigating a complex array of symptoms and conditions in the postpartum period (regardless of delivery method) as they recover and return to higher intensity and higher impact fitness demands such as the ACFT, running, strength-training, rucking, etc. These symptoms and conditions can include (but are not limited to) urinary incontinence, diastasis recti, and pelvic organ prolapse. These often go untreated due to a lack of awareness that many of the symptoms of dysfunction – though commonly experienced by mothers – are not “normal” conditions that have to be dealt with alone.

Photo courtesy of Candy Fields Photography

If postpartum soldiers are experiencing symptoms of pelvic dysfunction (pelvic pressure, pelvic pain, urinary incontinence, or fecal incontinence) either in activities of daily living, duty, or when exercising, they should request a referral to a Pelvic Floor Physical Therapist (PFPT) through their PCM. These are often uncomfortable, highly sensitive and personal challenges soldiers may be dealing with but may not feel comfortable bringing to their leadership’s attention or even their PCM, who may not be as familiar with these issues. Normalizing dialogue surrounding the common health-related challenges of the postpartum period, checking in regularly with postpartum soldiers to ask if they are receiving the support they need, and assisting with connecting them to resources can go a long way.

Unfortunately, pelvic health specialists are not available on every installation. If no PFPTs are available within the MTF, the soldier’s provider should facilitate a referral to a civilian-based specialist who accepts TRICARE. Performing an internet search for ‘local pelvic rehabilitation’ will lead one to several databases to help find local resources.” The soldier can call local clinics directly to ensure they accept TRICARE, then call the patient advocate line or PCM to approve the referral.

Lastly, this group recommends postpartum soldiers seek assistance from the Army Wellness Center (AWC) on their installation for a variety of helpful resources and coaching services to support holistic health and fitness. BodPod analysis over time, as well as baseline metabolic rate testing may be especially valuable, especially the latter if they elect to breastfeed. It is not uncommon for breastfeeding mothers to burn 400-800 additional calories per day, and restricting food intake suddenly postpartum may have the unintended effect of inhibiting weight loss and affecting milk supply. The AWC can offer a variety of tests and tools to support building and sustaining healthy lifestyles, including the body composition analysis, nutrition, sleep habits, stress management via biofeedback, fitness testing, and tailored plans among many others to further assist with recovery, return to duty, and performance optimization. Appointments for AWC visits can book up quickly so soldiers are encouraged to make appointments in advance to ensure they have access relatively soon post-birth. Back To Top

Enabling Postpartum Recovery and Care

Every birth event is unique. For some it can be easy; for others, a near-death traumatic event. In all circumstances, the body will take time to recover from the pregnancy and birth event and there may be long-lasting health impacts that need to be considered. If there is a history of past sexual trauma or the birth itself is significantly traumatic, there may also be an increased risk for postpartum depression, anxiety, and/or resurfacing of post-traumatic disorder symptoms. 

Leaders are encouraged to address the unique physical, mental, and emotional needs of each woman and approach their recovery with patience and empathy. This process begins with convalescent leave, postpartum profiles, and time for family bonding. Eventually your soldier will return to work, and recover to meet Army standards for weight and fitness. She may continue to require individualized support for physical recovery, lactation, and mental health. Soldiers within the physical fitness recovery period who are exempt from fitness testing should not be required to meet unit specific fitness standards such as ruck marches and longer runs. Proper support during this time could make the difference between a negative experience and serious injuries or development of a lifelong passion for the Army profession. Back To Top

On Postpartum Profiles

After a birth event, the hospital or medical provider will issue a postpartum profile (different from the pregnancy profile) in accordance with DA PAM 40-502 chapter 4-12. The post-partum profile starts on the day of discharge from the hospital, or the completion of the pregnancy if the soldier is not hospitalized. This profile period is for 45 days, roughly aligned with the six weeks of maternity convalescent leave discussed below. The postpartum profile allows PT at the soldier’s own pace. Additionally, soldiers are encouraged to use the at-home component of Army P3T while on convalescent leave to begin restorative, rehabilitative movement and strength-building postpartum. Reserve and National Guard soldiers are excused from duty for six weeks following release from the hospital.

After receiving clearance from a profiling provider, postpartum soldiers take part in the postpartum component of Army P3T. Postpartum soldiers return to unit physical training at 180 days after hospital discharge unless medically assessed and diagnosed with a condition they must continue rehabilitating and recovering prior to transition to unit PT. Soldiers must receive clearance from a health care provider prior to returning to regular unit PT if it is before 180 days following pregnancy completion. The above guidance is only modified if, upon evaluation of a physician, it has been determined the postpartum soldier requires a more restrictive or longer profile because of complicated or unusual medical problems. Back To Top

On Leave

The Army Military Parental Leave Program (covered in AR 600-8-10) has three types of non-chargeable leave that are authorized: maternity convalescent leave, primary caregiver leave, and secondary caregiver leave. The purpose of these leave periods are to promote bonding as a family and enable recovery. Soldiers should not be asked to return to the unit for administrative requirements; only the commander has the authority to recall a soldier from leave. Common reasons some commands attempt to call soldiers in off leave include annual training requirements, evaluations, and personnel or medical readiness deficiencies. Commands have a responsibility to forecast these requirements and work with the soldier to proactively address them before the birth. For practical reasons, maternity convalescent leave and caregiver leave must be broken up on the leave form or put on two separate leave forms to mitigate confusion. 

Maternity convalescent leave (as prescribed by AR 600-8-10) is a 6-week convalescent period for a military member immediately following pregnancy and childbirth. Maternity convalescent leave is non-chargeable and cannot be denied by the commander. It will begin on the first full day after the date of discharge or release from a hospital (or similar facility) following childbirth. If the soldier is not hospitalized, it will start upon the completion of the birth event. MTF Commanders, or their designee, can authorize additional convalescent leave on top of maternity convalescent leave in cases where appropriate. A supervisor will sign the mother out on leave; the soldier does NOT need to physically report to the unit to sign out after a birth event. Leaders should discuss the reporting procedures for birth events with their pregnant soldiers and outline the timeline for maternity convalescent and other leave as part of their regular counseling. 

The two types of caregiver leave require soldiers to designate themselves as either a primary or secondary caregiver. This process should be done as soon as practicable but at least 60 days prior to the expected due date or date of adoption. Either parent can be designated primary or secondary caregiver, but soldiers may not be designated as both. For dual active duty couples, one covered soldier will be primary and the other secondary for each birth event. They may not transfer any benefits to the other. If a soldier wishes to be designated a caregiver for a child born outside of marriage, parentage must be prescribed by enrolling the child in the Defense Enrollment Eligibility Reporting Systems (DEERS).

Photo by Ashley Murray

Caregiver leave is a non-chargeable leave period that must be taken within one year. Primary caregivers are authorized 42 days of leave and secondary caregivers are authorized 21. Caregiver leave may be taken in conjunction with maternity convalescent leave or started within one year of the birth event. They must be taken in only one increment and soldiers can choose to take less than the authorized time. They may not be authorized if the child is given up for adoption or parental rights are surrendered. If not used within the 1-year window after birth event the leave is forfeited. In the unfortunate circumstance that the child dies, the soldier is no longer eligible for caregiver leave, but may be transitioned to emergency or convalescent leave status. If the soldier is either deployed or about to deploy within three months, the soldier may elect to delay taking their caregiver leave until after completion of the deployment. The period of deferral for deployment does not count towards the one-year period after a birth event. Commanders may elect to authorize caregiver leave during a deployment although this is not required and may be restricted due to mission requirements. Caregiver leave is not authorized for soldiers whose spouses serve as a surrogate. See AR 600-10-8 paragraph 5-5 for details on the process for applying and approving caregiver leave.

Soldiers are authorized to take ordinary leave in addition to their military parental leave program benefits. Soldiers may elect to take leave prior to the birth event and transition to maternity convalescent or caregiver leave after the birth event. If a soldier elects to use ordinary leave after the birth event, leaves must be taken in the order of: maternity convalescent, caregiver, then ordinary leave.

Unfortunately, there are times where the mother is discharged from the hospital, but the infant remains hospitalized. These can be physically and emotionally trying times for parents and they must be able to support their child as a caregiver and medical advocate.  A mother in this situation should discuss “boarding status” with their providers, which allows the mother to remain in the hospital with the infant for a short period of time. The first O5 in the chain of command may authorize up to 10 days of administrative leave of absence as a non-medical attendant for either parent. For the birth parent, this leave of absence would be taken after her convalescent leave ends (which is for physical healing from the birth event) but before primary or secondary caregiver leave is taken. For the non-birth parent, this would be taken prior to secondary caregiver leave. Requests for extensions beyond 10 days must be authorized by HRC. See AR 600-8-10 para 5-12 for more details.

In the case of Reserve and National Guard soldiers not on active duty, the term “maternity leave” refers to a period of excusal from the IDT period(s) or active duty. Re-scheduling of excused absences will be in accordance with AR 140–1 or NGR 350–1, as appropriate.  Maternity leave for Reserve and National Guard soldiers will normally not exceed 6 weeks from the date of release from the hospital. If the attending physician determines it necessary to extend this period, they will provide a statement to that effect. The soldier will send her written request, with the physician’s statement, to her unit commander for approval. Maternity leave ends on the date the unit commander determines the soldier is medically fit to return to duty, however, they must adhere to the recommendation of the soldier’s physician. When a soldier’s pregnancy is terminated by means other than delivery, the unit commander will decide the period of excusal. The unit commander will consider the physician’s recommendation when making this decision. Back To Top 

On DEERS Registration of a Dependent and Other Administrative Actions

Upon birth, the hospital will provide a temporary certificate of live birth and a to-do list upon delivery that includes how to apply for a permanent birth certificate and social security number. Soldiers should register their new baby in DEERS and update their Servicemembers’ Group Life Insurance (SGLV) and DD93 with their S1 as soon as possible, but not later than 30 days after birth. Excessive delays in registering the newborn may result in complications for billing medical services with TRICARE so this is best done sooner rather than later. Soldiers do not need the permanent social security card to register in DEERS as long as they provide a copy within 90 days. If dual military, register the child under both parents as sponsor and secondary. A birth parent is not required to establish proof of parentage. In the event a child is born outside of a marriage, the member’s parentage of the child must be established pursuant to the criteria prescribed by DEERS. Children of dual-military couples, single parents, or who will not be residing in the sponsor’s household are eligible to receive a Uniformed Services Identification Card immediately. Others are eligible for an ID card upon turning ten years of age. Back To Top 

On Child Care

In the initial pregnancy counseling, childcare and childcare options should be discussed. This discussion is worth revisiting right before or right after the soldier returns to work. Leaders should understand the type of care their soldier is using, as well as the limitations of that care. These discussions should include work hour expectations, and planning factors for events outside of provider hours, and what to do when a child is sick.

As soon as a soldier becomes pregnant, we recommend they initiate the request process for childcare if they are considering military child care (even if they are exploring alternative options as well). Visit MilitaryChildcare.com to get on the waiting list for a CDC on post. This is a non-committal request, but it is helpful to apply and initiate this request as soon as possible due to the traditionally long waitlists. 

The primary options for childcare include: the CDC, Family Child Care (FCC) Providers, which are Child Youth Services (CYS) certified, family run centers, often in a family home; off post child care centers; non CYS family providers; and au pairs or nannies. Each family is different, and some families might need a combination of one or more of these options, like the CDC and an off post family run center, depending on their own situation. This needs to be discussed openly and honestly between the soldier and leader. 

On post care at the CDC or with an FCC provider is subsidised by rank/income structures, and spaces are awarded by a priority grouping determined on marital status, income, and job types (Military, GS, off post job, etc.). Younger, single parents are usually in the highest priority category, along with dual military couples. Check with your local CYS for more details. 

These facilities and providers are usually open to provide care Monday – Friday, from 0600-1800. Some rare facilities have extended hours from 0500-2000. Spots in these facilities are often limited, and it is not uncommon for a family to register at first discovery of pregnancy and still not have a spot for the child when the primary caregiver and secondary caregiver need to go back to work. Waiting lists of 12-18 months or more are not uncommon at certain posts. 

Photo taken by Latricia Pridgen

Off post providers can be subsidized through the Army Fee Assistance program, through the Child Care Aware of America (CCAoA) Website at childcareaware.org, not to be confused with the website where soldiers register for on base care. Army Child Care Fee Assistance was created to provide authorized active duty and Reserve Component personnel assistance in locating, selecting, and offsetting the cost of civilian child care when on-base child care is not available or a viable option for the service member and their family. The programs available through CCAoA provide subsidies for eligible military dependents enrolled in quality commercial child care programs throughout the United States. CCAoA authorizes subsidy amounts based on Total Family Income (TFI) for eligible Army families, and supplies monthly payments directly to the prospective child care provider. Eligible providers for the fee assistance program must have a state child care license, a state inspection report dated within the last 12 months, a complete provider fee assistance application, and must meet additional high quality accreditation standards. The centers do not have to apply for the certification, but many do. 

The process for approval for the fee assistance program can take 4-12 weeks. 

Off post centers might have different hours, often 0600-1800, but this can vary widely. Some posts have daycare centers that are open even earlier, or even overnight and weekends. These centers may or may not be certified for the fee assistance program. Ensure your soldiers know what their chosen center’s hours are, and if it meets program criteria for the fee assistance program. Off post family-run centers are often not eligible for the fee assistance program, and their hours will vary. 

Having a nanny or au pair join a family is also a choice for some families such as dual military families, or those with unusual work schedule requirements- like nurses or doctors on irregular 12 hour shifts- and others. However, this may be a cost prohibitive or otherwise impractical option. 

Leaders should carefully consider the need to start work before the CDC opens, or to work their soldiers late. If an early call or late evening is going to occur, giving advance notice of more than 24 hours is preferred. Most soldiers are able to make occasional exceptions for their daily child care plans in order to accomplish the mission, but it should be the exception and not the norm.

Unfortunately, children get sick, and those with certain illnesses may not return to their care center for a certain amount of time. Providers may or may not write the soldier a “sick slip” and it is not ideal to have a sick, miserable child in an office environment. Leaders should use common sense judgement, and often the best action might be to send the soldier home to be with their child. Additionally, we recommend that dual military married couples alternate days at home with a sick child so this responsibility is equally shared and it does not disproportionately affect one soldier, or that the parents be authorized to telework during this period if possible. Healthy babies typically require six routine appointments in their first 18 months, and unforeseen illnesses will require more. It is important to remember these appointments are typically only available during duty hours. Dealing with childcare and sick kids can be stressful for new parents. Leaders should treat their soldiers with care, compassion, common sense, and good judgement. Back To Top

On Deployments, Exercises, and TDY Exemptions

In accordance with AR 614-30, a military mother of a newborn is not eligible for Temporary Duty (TDY) or assignment away from their permanent duty station, to include a dependent-restricted tour, for 6 months after childbirth, unless the soldier waives deferment or the commander further extends the soldier’s deferment (referred to as a Postpartum Operational Deferment). These soldiers’s deployability code will be “PD”. If a soldier who is adopting a child and is a single parent or one member of a military couple is denied concurrent travel or selected for dependent-restricted tour (including TDY or assignment away from permanent duty station), they are not eligible for 6 months from the date the child is placed in the home as part of the adoption process, unless the soldier waives deferment or the commander further extends the soldier’s deferment.

The FY 2020 National Defense Authorization Act (NDAA) and ALARACT 022/2021 extended the Postpartum Operational Deferment to 12 months. This Postpartum deferment period requires the soldier to be coded in eMILPO with the corresponding parenthood code (“PD”). Soldiers may be deployed in the first 12 months after giving birth ONLY with the approval of the healthcare provider with a medical waiver and either (1) at the election of the soldier or (2) as directed by the Secretary of Defense in the interest of national security. Soldiers who elect to voluntarily deploy prior to the end of the 12-month deferment must first be cleared by their medical provider. AR 600-20 states that soldiers who are breastfeeding or expressing milk remain eligible for field training, mobility exercises, and deployment (after completing their postpartum deployment deferment period). Among this group, we have seen varying interpretations of this deferment period as it applies to field training and other mobility exercises for breastfeeding mothers. Given this ambiguity and room for disparate interpretation, this group recommends leaders consider the intent of the National Defense Authorization Act (NDAA) below to maximize bonding between the birth parent and the infant during the first year of life, to the extent possible.

The intent of the Fiscal Year 2020 NDAA is to keep the mother and baby together for the first year of life and ensure that she is fully healed prior to deploying. Similarly, it is recommended that commanders use this same thought process when deciding whether or not to send mothers away for training events. Separating the birth parent from the infant in the first year of life increases the risk of postpartum depression and anxiety in the mother, and can also increase the risk of Sudden Infant Death Syndrome (SIDS). For command teams making this decision, it is important to also remember that every family situation is unique. This group recommends leaders consider all factors, such as the soldier’s Family Care Plan, whether they are breastfeeding, their milk supply considerations along with their child’s needs, and the capacity for the team to support lactation and logistics of storing and transporting the milk based on the anticipated field conditions. These should be weighed against the soldier’s role on the team and potential impact of absence to the unit, the length of field exercise/deployment, as well as the mother’s perspective and concerns prior to making a decision. It is never easy leaving our children, especially when they are so young, but compassionate support and empowerment from the team makes a tremendous difference. Back To Top

On Temporary Promotions for Soldiers Prevented from Completing Mandatory Professional Military Education due to Pregnancy or Postpartum

Temporary promotions (reference MILPER Message Number 20-394) are authorized for soldiers who are prevented from completing mandatory PME courses to qualify themselves for promotion to the ranks of Sergeant through Sergeant Major when they are unable to attend PME for while serving on a temporary profile due to pregnancy or postpartum. Soldiers and leaders should work with their unit S1 and follow HRC administrative guidance.

Recently, guidance was issued to clarify temporary promotions and postpartum profiles (Army G-1, 08 FEB 21). Typically, soldiers will receive a 45 day postpartum profile after delivery. This profile is sufficient evidence to support a temporary promotion even if it is expired because it identifies the date of delivery which is what the temporary promotion is based on. Commanders should not tell soldiers they are not eligible for a temporary promotion if they are within one year of the delivery date. Soldiers have 60 days to get the DA 4187 signed by the first general officer in their chain of command and to HRC in order to accept the promotion. The month that HRC receives and processes the DA 4187 will determine the effective promotion date for the soldier. Back To Top 

Supporting Lactating Soldiers

As articulated in AR 600-20, 5-5, extensive medical research has documented that breastfeeding has significant health, nutritional, immunologic, developmental, emotional, social, and economic benefits for both mother and child. The World Health Organization (WHO), United Nations Children’s Fund (UNICEF), American Academy of Pediatrics (AAP), and the National Institutes of Health (NIH) recommend exclusive breastfeeding for the first six months, and continued breastfeeding for two years or more. Given the benefits of breastfeeding, commanders are responsible for notifying all soldiers of this breastfeeding and lactation support policy during initial pregnancy counseling. Commanders will counsel all pregnant soldiers as required by AR 600-8-24 or AR 635-200.

Photo courtesy of Emma Waters Photography

In addition to infant health, breastfeeding increases postpartum readiness by reducing the risk of postpartum hemorrhage, type 2 diabetes, and breast, uterine, and ovarian cancer. Studies have also found an association between early cessation of breastfeeding and postnatal depression and/or anxiety for the mother. It is critical for all leaders and teammates to be proactive and become informed in supporting a mother’s choice and commitment to breastfeed her child, and this support begins when the soldier is pregnant during the commander’s counseling and follow-on conversations with leaders and teammates. Mothers returning to work should be treated as valued team members who will continue to make a positive impact in the unit. Mothers who work in dynamic operational environments face unique challenges to maintain a breastfeeding relationship with their child, but the team’s understanding, support, and open communication with mothers who desire to breastfeed will make a significant difference. Back To Top

On Regulations that Support Breastfeeding Soldiers

Federal Law 41 CFR 102-74.426 states that a woman may breastfeed her child at any location in a federal building or on federal property that the soldier and child is otherwise authorized to be. There are no federal or state laws that require a breastfeeding mother to use any additional items to cover themselves or their child while breastfeeding. AR 670-1 states that soldiers who are actively breastfeeding their child are authorized to unzip, unbutton, or remove the coat and/or shirt as necessary to permit breastfeeding. In accordance with AR 670-1/DA PAM 670-1, soldiers who are nursing are authorized to wear a commercially available breastfeeding shirt during their nursing period that has a dual layer over the chest to allow the top layer to be lifted and the lower to be pulled down to enable breastfeeding. The Army recently approved the development of a lactation shirt that will eventually be issued with the maternity uniform. 

Returning to work after childbirth is a time of transition for the soldier and can increase stress and anxiety. Soldiers desiring to continue to breastfeed upon returning to work face additional challenges. Soldiers who want to breastfeed upon return to duty will notify their chain of command as soon as possible. This notification allows commanders to determine, through open dialogue, how to best support the soldier and ensure a workplace with appropriate space for expressing milk. Lactation support, including counseling and pumping equipment, is available through military treatment facilities and TRICARE. There are a variety of readily available resources to assist Army leaders in upholding these requirements and providing maximum support to breastfeeding mothers in your unit. When in doubt, contact a certified lactation consultant to assist you in establishing spaces or procedures to support breastfeeding mothers.  Mothers can also seek support from a number of online resources for breastfeeding for military moms, some of which provide pumping strategies tailored toward field environments and HAZMAT considerations. The Occupational Health Clinic can also assist with assessing any environmental hazards that may affect breastfeeding or safe lactation and milk storage.

Photo courtesy of Amanda Hughes Photography

By regulation AR 600-20, commanders will designate a private space, other than a restroom, with locking capabilities for a soldier to breastfeed or express milk. This space must include a place to sit, a flat surface (other than the floor) to place the pump on, an electrical outlet, and access to a safe water source within reasonable distance from the lactation space. Refrigeration, a microwave, mirror, clock, and command hooks, if available in the budget, are suggested as well. The goal is to create a relaxing environment that is convenient, easily accessible, and conducive to breastfeeding and/or pumping. Further recommendations for establishment of a lactation room can be found in the original Athena Thriving article. For those leaders struggling to find dedicated space in their unit footprints, commercially available lactation pods could offer a suitable alternative and some are even General Services Administration (GSA) contracted with available National Stock Numbers (NSN). Leaders need to keep in mind that the space must be private, sanitary, and comfortable. Cleaning closets or similar spaces should not be used, especially due to the storage of chemicals. The lactation space should also be in close proximity to the soldier’s work area to minimize travel time. It should maximize efficiency and minimize impact to the soldier and team, so sending a soldier to a lactation room across post is not an appropriate solution. When a unit makes or has a lactation room, it should be advertised consistently so that all current soldiers, newcomers, and visiting service members, DA civilians, or families,  are aware. Often the best lactation rooms are not well-known because the information is not shared, but this should be common knowledge across the unit so lactating mothers may have immediate access during their time of need. Best practices include sharing it via a flyer in common areas, ensuring staff duty desk is aware of the location and how it can be accessed for visitors, sharing it on the unit social media account, informing subordinate leaders, and sharing with unit P3T representatives so they can inform the mothers within the unit as well. We recommend P3T programs and/or garrison representatives maintain a continually updated “map” of lactation rooms around post (along with a point of contact) for reference, as this is not only helpful for soldiers within their own units, but also soldiers who conduct off-site meetings and work across the installation. This can equip them with the knowledge of existing rooms they can rely upon when needed.

When no dedicated space is available, a mixed use area can be used, with the lactating mother having priority use of the space when needed. Such spaces include shared offices and break rooms. However, this is not the recommended solution and should be the last resort. Lactating soldiers often feel pressure to delay their pumping to accommodate other users of the room, are asked or forced to end pumping sessions early due to other users, or or not ask for it when it’s truly needed because they do not want to inconvenience others. These concerns also apply to the practice of referring soldiers to a key-holder, which can cause embarrassment or reluctance to use the space. This group recommends a dedicated room only for lactation with a cipher lock with a pin known by the soldier(s) using the room so they can come and go as needed, and it is safe to store milk and personal supplies in the room. If pumping is not conducted on a consistent, predictable schedule, it can lead to pain and clogged milk ducts from engorgement, mastitis and other health concerns, and a loss in milk supply. These shared-space solutions may also result in frequent interruptions for mothers during lactation sessions causing her to feel rushed and even worried about someone entering the room mid-pumping session, an added stressor which can severely affect pumping output.

Commanders will ensure that soldiers have adequate time to express milk but must be aware that each soldier’s situation is unique. The time required to express breast milk varies and depends on several factors, including the age of the infant, amount of milk produced, quality of the pump, and distance the pumping location is from the workplace, as well as how conveniently located the water source is from the pump location. For example, new mothers commonly express milk every 2 to 3 hours for 15 to 30 minutes, but this timeframe may change as the child ages. When a child is six months old and begins eating solid foods, the number of breaks a soldier needs to breastfeed or express milk may decrease. Commanders will provide reasonable lactation breaks for soldiers for at least one year after the child’s birth in accordance with AR 600-20. However, this does NOT mean commanders should ONLY support the soldier for one year. Soldiers desiring to provide breast milk to their child(ren) beyond one year after the child’s birth should notify their chain of command as soon as possible to allow the command to determine how to best support the soldier. Support should be given to the soldier and her family for as long as she chooses to breastfeed, as the benefits of breastfeeding do not end at one year, as previously discussed. Lastly, for more information soldiers can find lactation support personnel at military treatment facilities, through TRICARE, or other commercially available resources. Back To Top  

On Lactation During Field Training, Mobility Exercises, and Deployment

Soldiers who are lactating remain eligible for field training, mobility exercises, and deployment after completing their postpartum deployment deferment period. Commanders and leaders must ensure they are having candid conversations with postpartum soldiers who are going to the field and above all, soldiers must know that they are supported. Soldiers especially need supportive, understanding leadership and open communication at all levels when lactating in field training environments, as being apart from their young child overnight or for extended periods of time, and being in low-resource environments can present a significant amount of stress, anxiety, health concerns, and milk supply concerns for the lactating soldier. 

Photo courtesy of Amber Bennett Photography

During field training and mobility exercises, commanders will provide private space for soldiers to express milk (AR 600-20). Soldiers participating in field training and mobility exercises should bring manual pumps as a back-up. If the soldier (or designated personnel) cannot transport expressed milk to the garrison, the soldier’s commander will permit her the same time and space to express and discard her breast milk with the intent to maintain physiological capability for lactation. Commanders should work with the supporting medical officer to determine whether milk storage and/or transportation will be feasible during the exercise, and are encouraged to support the soldier in doing so. Having to discard expressed milk can severely affect the soldier’s morale and milk supply. Every effort should be made by commanders at all levels to assist lactating soldiers with storing their milk in a field environment. When the soldier cannot transport the expressed milk to garrison, it can be stored in field food establishment refrigerators in accordance with a recent waiver to TB MED 530. Additionally, soldiers can conduct a quick internet search for best practices on pumping and storing milk during field training and mobility exercises, and see additional information and resources below.

Expressed milk that is stored in the field must be kept inside a covered, leak proof container that is identified as a container for the storage of breastmilk. The lactating soldier is responsible for supplying all equipment and containers needed to express and safely store the milk, and ensure they are labelled accordingly (at minimum: soldier name, date and time of expression, and contact information). After eight days of refrigeration, if the milk has not already been picked up by the soldier or the unit, the milk will be discarded. After 365 days of freezing, abandoned milk will be discarded. During a refrigerator/freezer failure, the milk will be handled according to the local policy for other food items during this situation, and the soldier should be alerted if this occurs.

If pumping is not conducted on a consistent, predictable schedule, and these breaks are not given freely to the soldier, it can lead to pain and clogged milk ducts from engorgement, mastitis infections and other health concerns, and a loss in milk supply for the baby. Furthermore, adequate hydration and caloric intake are critical for maintaining milk supply. Proper sanitation of pumping parts can be difficult, but this is necessary after each session. Milk storage and transportation can be logistically challenging in low-resource environments, but with engaged leadership and coordination, it is possible to protect expressed milk and minimize health risks. For example, one option for a logistics plan would be to place breast milk in a cooler, take the cooler to a refrigeration unit at the field kitchen, transport it to the rear with a logistics resupply, and then hand it off to the caregiver. Ideally, breastmilk should be used within 72 hours, which is a reasonable window for transportation. With proper refrigeration, breast milk can be refrigerated up to 8 days. Back To Top 

On Securing a Breastmilk Pump Free of Charge

TRICARE will cover the cost of a breastmilk pump and parts, to include storage bags. In order to acquire the pump, the soldier’s OB/GYN will write a prescription in the third trimester of pregnancy. Soldiers can go here to see commonly used breast pump providers who work with TRICARE. There is also an option to get reimbursed up to the annual max for TRICARE breast pumps, if the mother prefers to purchase a pump that is not available via these companies, some of which are more hands-free type pumps and may be the preferred option for soldiers who wish to have more flexibility and mobility when pumping. A lactation consultant during or after birth can assist with determining the correct flange size as well, as this affects pumping output. Lastly, replacement bags and pump parts are covered to a certain extent by TRICARE, so mothers are encouraged to work with these companies to place requests as needed. Back To Top

On Immunizations and Environmental Hazards While Breastfeeding

In accordance with DA PAM 40-502, chapters 4-9, pregnant soldiers are exempt from all immunizations except influenza and tetanus-diphtheria. These immunizations are vital during pregnancy as the mother will pass her antibodies to the fetus, thus protecting her baby after birth. Antibodies from these vaccines will transfer to the fetus, protecting the baby after birth. Tetanus is naturally occurring in the environment and has an 80-100% fatality rate among infants whose mothers were not immunized. Lactating Soldiers can also be exempt from immunizations when breastfeeding for the same reasons as pregnancy; soldiers should speak with their medical provider about any questions or concerns.

Soldiers who are lactating should work with their occupational health agencies, medical providers, and leaders to understand and minimize risk. Some contaminants pass into breast milk and others do not, based on the type, method, frequency of exposure, and other factors. Soldiers should discuss with their PCM all of the potential Hazardous Materials (HAZMAT) exposures and have a memo signed by their PCM to provide their commander to minimize risks of exposure to breastfeeding children. 

In cases where daily work environment involves HAZMAT exposure, soldiers should take precautions to minimize exposure by wearing protective gear, standing upwind of vapors and exhaust, keeping work clothes separate from street clothes, showering before leaving work, washing hands before eating or pumping, and ensuring the lactation space is in a different area of the workplace outside of the contamination range. soldiers should be informed of all the options, and request reassignment to a different duty while lactating if determined necessary. The CDC has published guidance for acceptable lead levels and others, to assist with occupational hazard assessments. Back To Top

On Shipping Breastmilk

There are a number of reasons why soldiers and their families may need to ship breast milk. Separation often occurs due to TDY, deployments, training exercises or schools, or other job requirements. Many military families also PCS while breastfeeding and may choose to ship milk. The Joint Travel Regulation (JTR) does not explicitly authorize shipment of breastmilk as a reimbursable expense so authorization is technically left at the discretion of the approving official in consideration of local policies, the expense, and available local budget. 

Some private companies that ship breast milk offer military discounts, where soldiers only pay for the cooler and shipping supplies. Lastly, there are several YouTube videos which demonstrate cost effective “do it yourself” techniques to ship breast milk using styrofoam containers and dry ice. Back To Top 

On Pregnancy and Postpartum Mental Health Considerations

Although pregnancy is traditionally considered a time of emotional well-being, it is common for women to experience a range of difficult emotions during and after pregnancy. Examples of these emotions include: worry, sadness, stress, and fear. For many women, these normal emotional experiences are remedied on their own. However, some women may experience severe and/ or prolonged emotional difficulties such as depression and anxiety.

Research has increasingly shown that pregnant women, as many as 10 to 15 percent of expectant mothers, begin to experience significant mood symptoms while pregnant. This is sometimes referred to as perinatal depression. Symptoms include: sadness, crying spells, diminished interest in being a mother, sense of guilt/ worthlessness, especially about not being a good mother, strong anxiety, tension, or fear about the child’s future, difficulty concentrating, focusing, and completing tasks, thoughts of death, irritability, and sleep problems (not related to discomfort associated with sleep positions). Treatment options for perinatal depression include behavioral health counseling and medication management. If left untreated, these symptoms can impact the health of the pregnant mother and baby, as well as worsen and continue into the postpartum period. 

Following childbirth, many women undergo a variety of fluctuations in mood. Anywhere between 50 to 85 percent of postpartum women experience postpartum blues, also referred to as “baby blues.” Women having baby blues might notice drastic mood swings, anxiety, sadness, irritability, weapiness, and difficulty concentrating. The onset of baby blues is shortly after delivery and typically lasts one to three weeks, often resolving on its own. The baby blues is not to be confused with postpartum depression, which is a severe and distinct behavioral health condition. 

Up to 1 in 7 women experience postpartum depression (PPD) which is characterized by a combination of clinical depressive symptoms but also includes: crying more than usual, intense irritability and anger, withdrawal from loved ones, feeling numb or disconnected from the baby, having thoughts of hurting oneself or the baby, and fear of not being a good mother. In very rare instances, women with PPD may also experience psychotic symptoms to include delusions (beliefs not based in reality) and hallucinations (seeing or hearing things that are not actually there). PPD symptoms, or other symptoms of postpartum anxiety or rage typically emerge 2 to 3 months after childbirth but can occur even later.  For a diagnosis of PPD, symptoms must be present for at least two weeks but often last longer and do not typically improve without treatment. Treatment for PPD is crucial because untreated postpartum depression not only impacts mothers, but can have detrimental and long term effects on child development. That said, active duty soldiers or dependents experiencing postpartum depression should seek behavioral health services through their embedded behavioral health provider or at their local military treatment facility.

As leaders, this information underscores the importance of understanding behavioral health issues DURING and AFTER pregnancy. From a humanity perspective, leaders need to understand the emotional challenges sometimes associated with pregnancy and childbirth (and the significant physiological, hormonal changes) to fully appreciate the additional hurdles that female soldiers undergo as they start and expand their families. For a practical perspective, leaders need to be knowledgeable of the unique behavioral health considerations for pregnant and postpartum soldiers in order to identify any negative changes in mood, behavior, or performance. This enables leadership to promptly refer soldiers to appropriate medical or behavioral health care in support of their wellbeing and that of their child.

While addressing the topic of mental health care for women in the military, it is important to highlight trauma informed care during pregnancy, delivery, and postpartum beyond regarding resources for survivors of sexual trauma. According to a 2013 study, a history of sexual trauma has a significant impact on the ability to sleep, increased risk of depression, and overall health for new mothers. Additionally, trauma can affect a mother’s ability to breastfeed although abuse survivors are often more likely to initiate breastfeeding than non-survivors of abuse. From a 2011 study, violence against women was a strong correlation with self reported postpartum depression. Given the strong correlations between trauma and behavioral health concerns, screening for sexual trauma and violence against women should start at the beginning of perinatal care and follow parents well after postpartum transition periods. Back To Top

Conclusion

Throughout this guide, we have primarily discussed the regulations, processes, guidelines, and considerations when it comes to leading pregnant and postpartum soldiers and their families. However, it is important not to forget the “art” of leadership — namely communication and empathy. Even the most zealous and enthusiastic leaders can forget that pregnancy and adoption are often complicated and emotional experiences for soon-to-be and new parents. Communication and empathy allow us to take care of our soldiers without overwhelming them. 

In concluding, we’d like for you to pause and think briefly about the human dimension of leadership and the impact it might have. 

Photo courtesy of Thirty Won Photography

Imagine if you will, two different scenarios. In the first, a young woman sits alone in her barracks room having recently discovered she is pregnant. She already has reservations about her “old school” chain of command; who only talk about “making numbers” for the upcoming National Training Center rotation and tend to treat women a “little differently” as it is. She doesn’t personally know any other mothers within her unit, so she doesn’t know if it is even possible to continue serving and progressing in her career while carrying and caring for a child. Nervous and terrified, she approaches her platoon sergeant about her recent discovery and is met with ignorance, sneers, frustration, rumors, and immediate questions about “who the father is” and “who she fraternized with.” Begrudgingly, and without knowing about other options, she makes her way to the S1 shop and begins filling out paperwork for a separation as her stomach turns, growing more anxious, disappointed, and disheartened as she thinks about feeling she has no choice but to leave the Army she loves.

Now- imagine a #PeopleFirst leader who understands the positive impacts of empathy and is well versed with the information in this guide. When the soldier- who trusts them- breaks the news, her sergeant pulls this guide out of their desk and simply says “okay, let’s get to work on making sure you’re taken care of. Are you tracking what options you have?” With a deep sigh of relief, the young soldier looks up and sees hope. Hope, support, someone who cares about her and the mission, and the feeling that she is truly part of the team; and begins once again to imagine herself enjoying a long and satisfying career in service to her country, while at the same time being a fantastic mother to her growing child.

The most powerful line in our Noncomissioned Officer Creed reads: “All soldiers are entitled to outstanding leadership; I will provide that leadership.” Not to SOME soldiers, but to ALL soldiers. 

What kind of leader are you? What kind of leader do you want to be? The future of our Army is more diverse; not less. It will be more inclusive; not less. We encourage you to understand these policies, understand these regulations and best practices, and apply them with empathetic leadership to build powerful, cohesive, innovative teams that can accomplish any mission. Our soldiers deserve nothing less- and our incredible women who balance difficult careers while raising children are absolutely no exception. Back To Top 

This is my squad! And it is better because of the amazing mothers and families who are in it.  

“The critical component (of the Army’s People First Strategy) is ensuring today’s leaders are committed to building cohesive teams based on dignity and respect. The Army’s future success hinges on our ability to acquire, develop, employ, and retain the best talent our country has to offer. We must continue in our efforts to enhance an Army culture that repels harmful behaviors and builds trust and respect.” -Mr. Christopher Lowman, senior official performing the duties of the Under Secretary of the Army

Photo courtesy of Megan Christine Photography

The views expressed are those of the authors and do not reflect the official policy or position of the Medical Command, US Army, Defense Health Agency, Department of Defense or the US Government. 

About the Authors, listed alphabetically:

Maj. Chris Barber is honored to serve as an Army Physician Assistant (PA) and PA educator. He is currently assigned to the Keller Army Community Hospital at West Point, where he serves as the Interservice Physician Assistant Program (IPAP) Clinical Coordinator. Additionally, Maj Barber has spent the past year working in COVID-19 response efforts. He has multiple combat, operational, and humanitarian deployments. He is the proud father of three daughters and three sons. He tweets @BuckeyeGrad1999

Lt Col. Kelly Bell is a Reserve soldier serving with the 103D ESC as the Nurse Advisor for their Cactus Covid Task Force.  She is a Certified Emergency Nurse and has served in various leadership and staff positions. She has two daughters and has pushed policy change from the grass-roots level for several years. She initiated the request to authorize the lactation undershirt (now approved for wear throughout the DoD) and submitted the white paper which led to the TB MED 530 Waiver. She is a volunteer with Mom2Mom Global/Breastfeeding in Combat Boots and helps administer their Facebook page along with the Army Mom Life and Army Leadership Parenting Information Forum Facebook groups. She tweets at @kmbell75.

Sgt. 1st Class Myeshia Boston is a Senior Human Resources Non Commissioned Officer (NCO) serving with the United States Army Special Operations Command. She is currently performing duties as a brigade Sexual Assault Response Coordinater (SARC). She has three children and balances being an effective leader and a nurturing mother. She helped spearhead the conversation leading to temporary promotions for pregnant and postpartum soldiers, as well as other working proposals. She is an administrator for the Army Mom Life group, and ACFT training for pregnant and postpartum Soldiers. She believes in advocating for necessary change through documented evidence and presenting logical solutions. She tweets at @MBoston89

Capt. Kelsey Boursinos is a signal officer currently attending Signal Captains Career Course (SCCC) at Fort Gordon, GA. Following SCCC, she will be working in the G6 as a plans officer within the 25th Infantry Division. She was enrolled in the Simultaneous Mentorship Program while in college, serving in the Ohio National Guard while pursuing her commission through The University of Cincinnati’s Reserve Officers’ Training Corps (ROTC) program. She is the wife of an active duty military intelligence officer and a mother to a sassy little girl. She is passionate about supporting her sisters in arms as they navigate motherhood while serving and she is an administrator for The Army Mom Life and Army leadership Parenting Information Forum Facebook pages. She tweets at @kboursinos.

Lt Col. Ian Fleischmann is a military intelligence officer currently assigned to Headquarters, Department of the Army, G-8 and preparing to take command of a military intelligence battalion. Since commissioning from the United States Military Academy (USMA) in 2004 he has served as an intelligence officer for infantry, cavalry, field artillery, and aviation units at the battalion through division level. He and his wife aspire daily to raise their three boys to be men of character. He tweets @TecumsehBurning.

1st Lt. Megan Gephart is the Public Affairs Officer (PAO) for the 25th Infantry Division Artillery and plans to officially transition to the public affairs field this year. Since commissioning from USMA in 2018 as a Military Intelligence officer, she has served as a research assistant for West Point’s Combating Terrorism Center and Graduate Scholarship Program, and an assistant S2 in a Light Infantry Battalion in the 25th Infantry Division. She is married to an active duty engineer officer, and a mother of a 2 year old son and another little one on the way. She serves as a P3T Program Manager and Instructor Trainer, a certified pregnancy & postpartum athleticism coach, and is passionate about supporting and advocating for her sisters in arms so they are empowered to meaningfully contribute and thrive in both the military profession and motherhood. She tweets at @ArmedtotheHeart.

Capt. Michelle Gonzalez, PhD, is a clinical psychologist currently serving as the behavioral health officer for the 1st Armored Brigade Combat Team (ABCT) of the 3rd Infantry Division. Capt. Gonzalez has a long standing research and clinical career focused on serving ethnic, racial, economic, and gender minority groups. Capt. Gonzalez has specialized clinical training in the treatment of sexual trauma with an emphasis in women’s mental health, having completed a Postdoctoral Fellowship at the Durham VA Medical Center. As a female army officer and research scientist, Capt. Gonzalez continues to “fight the good fight” in pursuit of gender equality and equal opportunity.

Capt. Dominique Davidson Dove, ESQ, is a former adjutant general officer who will be going to her next duty assignment as an active duty judge advocate. Since commissioning from Old Dominion University, Capt. Dove has been an Executive Officer, Company Commander, and a Batallion Victim Advocate. For several years, she spent numerous hours advocating for survivors of sexual assault and domestic violence. She also has extensive training in military sexual trauma and used her legal background to participate in various initiatives to improve regulations pertaining to women in the Army. Capt. Dove is married to a supportive husband and they share one 20- month-old daughter. She tweets at @ebonybella5.

Lt Col. Sara Harmon is a Medical Service Corps officer and a healthcare administrator for the Army. She is married to an Army Reservist and a mom to two fierce young women, and one rambunctious boy who loves tanks and playing Army. She has worked in Military Treatment Facilities large and small, including Walter Reed National Military Medical Center and Landstuhl Regional Medical Center. She is currently stationed at the Pentagon in the DoD and VA Collaboration Office. She tweets occasionally at @Karmalinda79.

Sgt. Nicole Pierce is a Behavioral Health NCO for the 17th Field Artillery Brigade. She is set to PCS this spring to Fort Sill, Oklahoma and will be assigned to Reynolds Army Health Clinic. She is married to an active duty Infantryman, who will be serving as a Drill Sergeant at Fort Sill and they have two little girls. She founded and administrates multiple Facebook groups for her sisters in arms including The Army Mom Life, Army Leadership Parenting Information Forum, ACFT Training for Pregnant and Postpartum Soldiers, and Sisters-In-Arms. She is passionate about helping her sisters in arms and making the Army more accepting when it comes to mothers serving. She tweets at @thatsassynco.

Spc. Sheyla Scholl is a Chemical, Biological, Radiological, Nuclear, and High-Yield Explosive (CBRNE) soldier in USAR MEDCOM and formerly Minnesotta Army National Guard (MNARNG). She is a spouse to an active duty airman at Joint Base San Antonio (JBSA) and a mom of two courageous little girls. A stage 4 blood cancer survivor, she has served as a reviewer on the Congressionally Directed Medical Research Program twice while championing healthcare and Military Sexual Trauma (MST) public policy at the state and federal level. As a survivor of MST, she struggled with navigating through trauma informed pregnancy and delivery, but particularly breastfeeding. Her new mission is to spread awareness about the impact that sexual abuse and post traumatic stress from complex medical conditions has on new parents.

Lt Col. Scott Stephens is an armor officer. In his 22 years of service, he has led armor and combined arms units from the platoon to battalion level through multiple combat and rotational deployments, as well as serving in a variety of broadening assignments. He is the proud husband of an Army veteran, and the loving father of one fierce young woman and two amazing young men. He tweets at @scottjstephens.

Maj. Hannah Williams is an active duty logistics officer currently serving as a brigade S4 in the 101st ABN DIV (AASLT). She has been a mentor and advocate for gender integration while working in several Infantry Brigade Combat Teams (IBCTs) and as an instructor at the United States Military Academy. She is married to an infantry officer, and is a proud mother to a young daughter and two stepsons. She tweets at @H_KWilliams

References, Regulations, and Recommended Readings:*

Army and DoD Regulations:

  • AR 40-501/502, DA PAM 40-502: Medical Readiness
  • AR 350-1: Army Training and Leader Development
  • AR 135-91: Service Obligations, Methods of Fulfillment, Participation Requirements, and Enforcement Procedures
  • AR 600-8-10: Leave and Passes
  • AR 600-8-24: Officer Transfers and Discharges
  • AR 600-9: The Army Body Composition Program
  • AR 600-20: Army Command Policy
  • AR 635-200: Active Duty Enlisted Administrative Separations
  • AR 670-1: Wear and Appearance of Army Uniforms and Insignia
  • DA PAM 670-1: Guide to the Wear and Appearance of Army Uniforms and Insignia
  • AR 700-84: Issue and Sale of Personal Clothing
  • DA PAM 40-502: Medical Readiness Procedures
  • DA PAM 670-1: Guide to Wear and Appearance of the Army Uniforms and Insignia
  • Army Directive 2019-05: Army Parental Leave Program
  • ALARACT 22/2021: Deferment From Deployment Authorized for Twelve Months After the Birth of a Child
  • HQDA EXORD 164-20 (FRAGO 1): APFT and ACFT during COVID 19 Outbreak
  • Field Manual 7-22: Holistic Health and Fitness
  • Department of the Army Memorandum: Authorization for Female Soldiers to wear an Optional 499 or Sand T-shirt during Postpartum nursing
  • Medical (TB MED) 530: Tri- Service Food Code
  • Waiver to Medical (TB MED) 530: Tri-Service Food Code, for Storage and Management of Breast Milk during Field Training and Mobility Exercises
  • DOD Instruction 1342.19 (30 NOV 2017) Family Care Plan
  • DOD Instruction (04 SEP 2020) 1350.02 DOD Military Equal Opportunity Program
  • Defense Health Agency procedural Instruction 6200.02, “Comprehensive Contraceptive Counseling and Access to the Full Range of Methods of Contraception,” 13 May 2019

 P3T Resources:

Centering Pregnancy:

Other Resources:

Additional Breastfeeding and Lactation Support Resources:

Additional Recommended Readings: 

*The appearance of non-federal entities in this compilation is for information purposes only. This list does not constitute endorsement by the U.S. Government, the Department of Defense, or the U.S. Army.

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Categories: Case Study, Leadership, Leading Change, SHARP/Discrimination