When Blair Pendley was going through the overseas screening process for the move to Bahrain with her Marine Corps husband and four children, "the doctors were not at all concerned about my pregnancy being an issue," she said.

But the Tricare overseas contractor had a different opinion.

Tricare considers her pregnancy to be "high risk" because she is older than 35, she said. That means Tricare will not pay for her to receive pre-natal care and for the delivery of her baby by civilian doctors in Bahrain.

And that means Pendley, whose due date is Oct. 3, will not be able to move with her husband, who is scheduled to report to Bahrain by July 15. She and their four children – ages 8, 6, 4 and 2 – will stay behind at Camp Lejeune, North Carolina, at least until after the baby is born.

The Tricare Overseas Program contractor, International SOS Government Services, has determined there aren't adequate services in the local community to care for women with what's considered to be a high-risk pregnancy -- or to care for their babies, in the event of an emergency. So not only are moms-to-be like Pendley not able to go to Bahrain, those in the military community who become pregnant while living there, and are determined to be high-risk cases, are being advised to leave the country.

Their pregnancies won't be covered under the Tricare Overseas Program, under Tricare Prime or Tricare Prime Remote if they seek care in the civilian community. The clinic on base refers pregnant women for care in the local community.


Tricare officials did not provide a specific date when this policy took effect in Bahrain, but it is recent, according to spouses in contact with Military Times.

"This issue has been causing a lot of controversy, and everyone is asking questions about it – in the expectant moms groups, on base and even within the units," said one pregnant spouse in Bahrain, who spoke on the condition of anonymity. "I think that the majority of the chaos comes from the fact that we have not been presented with any official documentation about the new policy change." 

WHAT IS 'HIGH RISK'?

The spouse is in the low-risk category currently, she said, but her primary care manager has told her that anything other than a low-risk pregnancy will not be paid for by the Tricare Overseas Program if she decides to stay in Bahrain. 

The referral office on base has told her that Tricare will determine each pregnancy's risk level on a case-by-case basis, she said. A Defense Health Agency spokesman echoed that evaluation plan.

"Medical practitioners generally agree that using a concrete, absolute list of conditions to define 'high-risk' oversimplifies a complex process and can lead to medically unsound conclusions and decisions," Kevin Dwyer said, listing several "maternal and fetal factors," and issues such as physician and facility capability, that could contribute to the risk level.

It also means a low-risk pregnancy could become a high-risk one for any number of reasons, not all of which have to do with the health of the mother or fetus.

"I feel that this leaves the rest of us in the dark throughout our pregnancy, wondering if any little complication may result in us having to deliver our babies away from our husbands," the spouse said.


Members of the community were recently told that they could consider switching to Tricare Standard. Under that plan, Military families would pay upfront for all costs, then find out later how much Tricare would reimburse, she said.

Pregnant patients, and other patients, who are Tricare Overseas Program beneficiaries enrolled in Prime or Prime Remote generally have no out-of-pocket costs for covered health care services from their military hospital or military clinic primary care manager, or when they have the appropriate referral and prior authorization for other care from network or participating providers. But in Bahrain -- and some other overseas locations -- that's not the case if the pregnancies are considered high risk. Women with that risk level are advised to travel to a military medical facility in another country or in the U.S.

One military wife who has lived in Bahrain said she believes the policy is a good one.

"While the hospitals in Bahrain are quite nice, care is not the U.S. stand and maternity care is definitely not what you'd want if you had any risk factors," she said. "I know this seems like an inconvenience for many spouses, but truly I would not have wanted to receive maternity care there."

The change is not a new Tricare policy, Dwyer said -- just a reflection of the contractor's assessment of the level of nearby civilian care.

OPTIONS FOR MOMS-TO-BE

Tricare works with the respective service components to determine the best location for the beneficiary to receive medical care, Dwyer said. Depending on the situation, a pregnant patient may be offered several options, such as "stork nesting" at a military hospital or clinic overseas or in the U.S., or returning to the U.S. to a location with family support.

The service member's unit or the service component pays for the medical travel and lodging if the pregnant beneficiary is advised not to stay in that location, he said. 

This policy is not unique to Bahrain. Similar practices exist in other overseas locations determined to have either inadequate prenatal, obstetrical and/or neonatal care, Dwyer said. Among those are New Delhi; Jakarta, Indonesia; Qatar; Kosovo; Madagascar; Georgia; Chad; La Paz, Bolivia; El Salvador; and Suriname -- the list is not all-inclusive, Dwyer said, and changes as local health care conditions change.

If an expectant mother's pregnancy becomes high-risk in the latter stages -- when commercial airlines may deny or restrict travel -- a civilian air ambulance may be requested, Dwyer said. If the high-risk mom-to-be is on active duty, Tricare advises the respective service component about what's best medically for the mother, he said, and the component would decide the next step -- medical leave or an early permanent change-of-station move, for example.

Pendley said she and her husband, a Marine attorney, set up their PCS move for late June and had planned to leave at the end of June, but now she and her four children will stay behind. His orders will be changed to a one-year unaccompanied tour.

Once the baby is born and she and the baby are screened, she said she hopes his orders will be changed to a two-year accompanied tour so that she and the children can join him in Bahrain.

"It upsets me that they're not willing to look at this on a case-by-case basis," she said.

Situations such as Pendley's are what motivated the pregnant spouse already in Bahrain to speak out on the issue.

"I really just want to bring to people's attention what may happen were they to consider accompanying their spouse out to Bahrain with the idea of expanding their family while out here," she said. "There just needs to be some clarification about this new policy so that women don't have to have any unexpected stressors throughout their pregnancy."  


Karen Jowers covers military families, quality of life and consumer issues for Military Times. She can be reached at kjowers@militarytimes.com.