September 3, 2025
VIA ELECTRONIC SUBMISSION
Secretary Douglas A. Collins
Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420
RE: Reproductive Health Services (RIN 2900-AS31)

Dear Secretary Collins,
National Organization for Women-New York City (NOW-NYC) submits this comment
in opposition to the proposed rule published in the Federal Register on August 4, 2025, entitled
“Reproductive Health Services.” 1 NOW-NYC is dedicated to defending the rights of women
and advancing gender equality. NOW-NYC’s membership includes veterans and service
members who would be impacted by the promulgation of the proposed rule. NOW-NYC
unequivocally opposes the efforts of the Department of Veterans Affairs (VA) to reinstate the
ban on abortion counseling and services at VA sites and repeal the 2022 exceptions to the
abortion exclusion for Civilian Health and Medical Program of the Department of Veterans
Affairs (CHAMPVA) beneficiaries.

Dobbs v. Jackson Women’s Health Organization 2 overturned the federal constitutional right to
an abortion as established in Roe v. Wade 3 and Planned Parenthood of Southeastern Pennsylvania v. Casey. 4
The Supreme Court’s decision in Dobbs turned existing problems of suboptimal pregnancy health
care and insufficient abortion access for veterans into a crisis, as veterans in states with new bans
and limits are now unable to access the non-VA care they may have used in the past.
VA recognized that Dobbs led to patchwork coverage of lifesaving reproductive health care
across the country, placing pregnant veterans’ lives and reproductive health at risk based solely on
where they lived. In response, in 2022, VA expanded coverage of abortion counseling and
abortions in cases of rape, incest, or where the health or life of the pregnant person was
endangered for veterans and CHAMPVA beneficiaries. This expansion ensured life-saving access
to abortion throughout the United States for veterans and CHAMPVA beneficiaries. The
proposed rule would turn back the clock, banning abortion care in instances of rape, incest, and
health emergencies.

This proposed recission would put CHAMPVA beneficiaries and women veterans at
grave risk. While VA maintains that lifesaving abortions would still be allowed, the proposed rule
would force healthcare providers to wait until the last minute to provide lifesaving care. This
forced deterioration is irreconcilable with VA’s commitment to protecting the lives of pregnant

1 Reproductive Health Services, 90 Fed. Reg. 36415 (Aug. 4, 2025).
2 597 U.S. 215 (2022).
3 410 U.S. 113 (1973).
4 505 U.S. 833 (1992).

people. 5 This elimination of services is especially dangerous, given that veterans experience
outsized levels of pregnancy complications, complications that may require abortion care to
protect the life and health of the pregnant veteran. 6 Women veterans disproportionately exhibit a
host of risk factors, many stemming from the stressors of previous service, that precipitate harmful
and dangerous pregnancies.
Moreover, when an agency rescinds a rule with significant reliance interests, it is required
to provide a heightened justification for the recission. 7 VA has provided no such adequate
justification, meaning that promulgation of the proposed rule would be arbitrary and capricious,
in violation of the Administrative Procedure Act (APA).

I. THE PROPOSED RULE WOULD ESCALATE THE EMERGENCY WOMEN VETERANS FACE
IN THE WAKE OF DOBBS.
Dobbs has created a public-health emergency. Women veterans 8 were already uniquely
predisposed to pregnancy complications that make their pregnancies dangerous or deadly to
carry to term, but these existing risks now amount to an acute crisis: without access to VA-
provided abortion care, many of these veterans who require this procedure for the sake of their
health or life will have nowhere to turn. Dobbs caused pregnant veterans across the country to
lose access to abortion care from non-VA providers. 9 As of July 7, 2025, most abortions are
banned in at least sixteen states 10 —including Texas, which is home to the most women veterans
of any state. 11 Taken together, more than half a million women veterans—835,269 to be
exact, comprising 40% of all women veterans—live in these abortion-ban states. 12 Travel to
states where abortion is legal is often impracticable 13 and results in an unsustainable influx of
patients. 14 Moreover, many of these states where abortion is legal still impose onerous restrictions
5 Reproductive Health Services, 90 Fed. Reg. 36415 (Aug. 4, 2025).
6 See infra Section I.A.
7 Food & Drug Admin. v. Wages & White Lion Invs., L.L.C., 145 S. Ct. 898, 917-19 (2025).
8 This comment uses “woman” and “women,” though many transgender and nonbinary veterans who are not women
have the capacity to get pregnant and are also affected by this proposed rule. “Woman” is used to align with the
language of the proposed rule and reflect the language of the research from which this comment draws. Nonetheless,
this comment is equally applicable to pregnant veterans who are not women.
9 See Sarah McCammon, Two Months After The Dobbs Ruling, New Abortion Bans Are Taking Hold, NPR (Aug. 23, 2022,
2:42 PM ET), https://www.npr.org/2022/08/23/1118846811/two-months-after-the-dobbs-ruling-new-abortion-
bans-are- taking-hold (explaining the wide scope of post-Dobbs abortion bans and the rapidity with which they are
taking effect).
10 See Tracking Abortion Laws Across the Country, N.Y. TIMES (Jul. 7, 2025, 5:31 PM ET),
https://www.nytimes.com/interactive/2024/us/abortion-laws-roe-v-wade.html (identifying twelve states as total ban
states and four states as six-week ban states which is before most pregnant people know they are pregnant).
11 Women Veterans Report 2024, Texas Veterans Commission-Women Veterans Program, 9, https://tvc.texas.gov/wp-
content/uploads/2024/11/Womens-Veteran-Report-2024.pdf.
12 In the sixteen states, there are respectively 43,668 (Alabama), 22,466 (Arkansas), 166,290 (Florida), 100,472
(Georgia), 12,130 (Idaho), 35,958 (Indiana), 16,858 (Iowa), 26,584 (Kentucky), 31,364 (Louisiana), 24,879
(Mississippi), 39,924 (Missouri), 32,668 (Oklahoma), 52,170 (South Carolina), 7,418(South Dakota), 47,695
(Tennessee), 203,997 (Texas), and 10,656 (West Virginia) women veterans. Veteran Population – National Center for
Veterans Analysis and Statistics, https://perma.cc/AR5F-URNB.
13 “People living in [abortion-ban states] will have to travel an average of 276 miles each way to access the procedure
in parts of the country where abortion remains legal . . . . That’s, on average, six times farther than before.” Mathieu
Benhamou, Kelsey Butler & Chloe Whiteaker, Americans in 26 States Will Have to Travel 552 Miles for Abortions,
BLOOMBERG (June 24, 2022, 8:15 PM ET), https://www.bloomberg.com/graphics/2022-supreme-court-abortion-
travel.
14 See Margot Sanger-Katz, Claire Cain Miller & Josh Katz, Interstate Abortion Travel Is Already Straining Parts of the

3
that would limit women veterans’ access to abortion care. 15
“The Department of Veterans Affairs operates 171 medical centers nationwide, one-fifth
of which are located in states that have made abortion illegal or have sharply curtailed access to
the procedure.” 16 In states with abortion restrictions, VA employees acting in the scope of
federal employment may still provide abortions. 17 This ability to provide care, regardless of
underlying state restrictions, is precisely why the 2022 rule was lifesaving. Should VA promulgate
the proposed rule, a significant percentage of women veterans will be consigned to carrying
dangerous and life-threatening pregnancies to term. This runs directly counter to VA’s proper
role as “the United States’ provider of needed medical services to those who served, delivered on
behalf of a grateful nation.” 18

A. Veterans Are Especially Vulnerable to Pregnancy Complications
As VA has recognized, “VA serves a population that is particularly vulnerable to adverse
pregnancy outcomes,” and “[v]eterans of reproductive age, in particular, have high rates of
chronic medical and mental health conditions that may increase the risks associated with
pregnancy.” 19 Pregnancy is physically taxing; even otherwise healthy women regularly experience
adverse health outcomes. 20 However, various factors, including the stressors of service and other
life events that disproportionately affect those who serve, make pregnancy even riskier for
women veterans. These risk factors include post-traumatic stress disorder (PTSD), other mental
health conditions, hypertension, chronic kidney disease, epilepsy, and adverse childhood events. 21
Veterans need abortion access in a post-Dobbs world to ensure they are not conscripted
into carrying health- or life-threatening pregnancies to term. Because women veterans experience
these conditions and traumatic experiences at higher rates than their civilian peers, they exhibit
substantially higher rates of pregnancy complications. Abortions may be the only option to
preserve the health or lives of the women experiencing these pregnancy complications. 22
System, N.Y. TIMES (July 23, 2022), https://www.nytimes.com/2022/07/23/upshot/abortion-interstate-travel-
appointments.html (finding that, “[i]n cities near states with bans[,] . . . wait times were already starting to get longer”
just a month after Dobbs, such that 22% of clinics “were booking appointments more than three weeks out” and 13%
“were unreachable or were so full that they were not taking new appointments”).
15 See Tracking Abortion Laws Across the Country, supra note 10 (reporting that, for example, public funds cannot be used
to cover the cost of procedures in Colorado, Delaware, Kansas, Nebraska, Nevada, New Hampshire, Rhode Island,
Pennsylvania, Virginia, and D.C. and identifying North Carolina, Nebraska, and Utah as states with significantly
stricter abortion bans than pre-Dobbs).
16 Patricia Kime, VA to Provide Abortions, Counseling for Cases of Rape, Incest and Medical Complications from Pregnancy,
MILITARY.COM (Sept. 2, 2022), https://www.military.com/daily-news/2022/09/02/va-provide-abortions-counseling-
cases-of-rape-incest-and-medical-complications-pregnancy.html. 
17 Abortion Services, U.S. DEP’T VETERANS AFFS, https://www.womenshealth.va.gov/topics/abortion-services.asp.
18 Reproductive Health Services, 90 Fed. Reg. 36415, 36416 (Aug. 4, 2025).
19 87 Fed. Reg. 55287, 55295 (Sept. 9, 2022).
20 See, e.g., Kayode O. Osungbade & Olusimbo K. Ige, Public Health Perspectives of Preeclampsia in Developing Countries:
Implication for Health System Strengthening, 2011 J. PREGNANCY 1, 2 (“Worldwide, the incidence of preeclampsia ranges
between 2% and 10% on pregnancies); Off. on Women’s Health, Body Changes and Discomforts, U.S. DEP’T HEALTH &
HUM. SERVS., https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/body-changes-and-discomforts
(describing the various body changes and discomforts that tend to accompany pregnancy, including but not limited
to constipation, dizziness, fatigue, sleep problems, heartburn, hemorrhoids, and numb or tingling hands).
21 See infra Sections I.A.1-.5.
22 See Facts Are Important: Abortion Is Healthcare, AM. COLLEGE OF OBSTETRICS & GYNECOLOGY,

4
1. POST-TRAUMATIC STRESS DISORDER
PTSD disproportionately affects women veterans and drives much of their
predisposition for pregnancy complications. Although PTSD plagues a large proportion of
veterans, 23 women veterans experience PTSD at higher rates than do men veterans, as well as
both women civilians and men civilians. 24 Approximately 20% of women veterans who were
deployed to Iraq and Afghanistan suffer from PTSD, as do 27% of Vietnam War women
veterans. 25 This includes pregnant women veterans: one study found that 20% of pregnant
women veterans have PTSD or another anxiety disorder. 26
Women veterans are exposed to trauma at a higher rate than the general population. This
includes trauma related to that from combat which is equal to their men veteran comrades. 27 An
alarming number of women veterans have also experienced military sexual trauma (MST)—by
the VA’s own count, about 1 in 3. 28 Women comprise only approximately 20% of service
members, yet 63% of MST survivors. 29 A majority of women veterans who have suffered MST
have PTSD (60%), although PTSD also affects a substantial portion of those who have not
(43%). 30 Rates of MST have only increased in recent years, 31 leaving a growing population of
women veterans vulnerable to PTSD and associated pregnancy complications. Additionally,
https://www.acog.org/advocacy/facts-are-important/abortion-is-healthcare.
23 See PTSD: National Center for PTSD, How Common Is PTSD in Veterans?, U.S. DEP’T VETERANS AFFS.,
https://www.ptsd.va.gov/understand/common/common_veterans.asp (estimating that between 11-20% of Iraq and
Afghanistan veterans, 12% of Gulf War veterans, and 30% of Vietnam War veterans have or have had PTSD).
24 See Keren Lehavot, Post-traumatic Stress Disorder by Gender and Veteran Status, 54 AM. J. PREVENTATIVE MED. E1 (2018)
(finding that women veterans reported the highest rates of lifetime and past-year PTSD compared to all the other
subgroups).
25 PTSD: National Center for PTSD, Traumatic Stress in Women Veterans, U.S. DEP’T VETERANS AFFS.,
https://www.ptsd.va.gov/professional/treat/type/trauma_female_veterans.asp (citing Randall B. Williamson, VA
Health Care: Preliminary Findings on VA's Provision of Health Care Services to Women Veterans, U.S. GOV.
ACCOUNTABILITY OFF. (July 16, 2009), http://www.gao.gov/new.items/d09899t.pdf, and R.A. KULKA ET AL.,
TRAUMA AND THE VIETNAM WAR GENERATION: REPORT OF FINDINGS FROM THE NATIONAL VIETNAM VETERANS
READJUSTMENT STUDY (1990)).
26 Kristina M. Cordasco et al., Care Coordination for Pregnant Veterans: VA’s Maternity Care Coordinator Telephone Care
Program, 8 TRANSLATIONAL BEHAV. MED. 419, 424 (2018).
27 Off. Health Equity, Women Veterans and Pregnancy Complications, U.S. DEP’T VETERANS AFFS.,
https://www.va.gov/HEALTHEQUITY/Women_Veterans_and_Pregnancy_Complications.asp; see also Heidi M.
Zinzow et al., Trauma Among Female Veterans: A Critical Review, 8 TRAUMA VIOLENCE ABUSE 384 (2007) (finding that
female veterans experiences higher rates of trauma exposure than the general population and that female veterans may
be exposed to combat as often as man veterans).
28 Women Veterans Health Care, Military Sexual Trauma, U.S. DEP’T VETERANS AFFS,
https://www.womenshealth.va.gov/topics/military-sexual-trauma.asp; see also Military Sexual Trauma, U.S. DEP’T
VETERANS AFFS, https://www.mentalhealth.va.gov/docs/mst_general_factsheet.pdf (“[A]bout 1 in 3 women and 1
in 50 men respond ‘yes,’ that they experienced MST, when screened by their VA provider. [R]ates of MST are
higher among women, because there are so many more men than women in the military”).
29 See, e.g., Dave Phillips, ‘This Is Unacceptable.’ Military Reports a Surge of Sexual Assaults in the Ranks, N.Y. TIMES (May 2,
2019), https://www.nytimes.com/2019/05/02/us/military-sexual-assault.html (citing U.S. DEP’T OF DEFENSE,
DEPARTMENT OF DEFENSE ANNUAL REPORT ON SEXUAL ASSAULT IN THE MILITARY (2018),
https://int.nyt.com/data/documenthelper/800-dod-annual-report-on-sexual
as/d659d6d0126ad2b19c18/optimized/full.pdf#page=1 [hereinafter 2018 DEP’T DEFENSE REPORT]).
30 See Deborah Yager et al., DSM-IV Diagnosed Posttraumatic Stress Disorder in Women Veterans With and Without Military
Sexual Trauma, 21 J. GEN. INTEN. MED. S65 (2006) (finding that 60% of women veterans with MST had PTSD and
43% of women with other traumas had PTSD, such that MST strongly predicted the development of PTSD).
31 See Phillips, supra note 29 (reporting “an increase of 38 percent” in instances of “unwanted sexual contact” from
2016 to 2018 (citing 2018 DEP’T DEFENSE REPORT)).

5

unwanted pregnancies, especially those which are the result of rape or incest, will likely only
exacerbate symptoms associated with PTSD or mental health issues, increasing the risk to the
health and life of the women veteran. These traumas disproportionately experienced by women
veterans may give rise to the PTSD-associated pregnancy complications that are treatable
through abortion.
Women veterans with PTSD exhibit an increased prevalence of gestational diabetes, and
preeclampsia. One study reported that the risks of gestational diabetes and preeclampsia “were
significantly increased by 30-40%” in women veterans with PTSD. 32 Similarly, active PTSD is
associated with “35% increased odds of spontaneous preterm delivery” for women veterans. 33
Women veterans with PTSD, depression, and a history of MST have been shown to be more
likely to develop chronic illnesses, such as hypertension, and heart attacks 34 —all of which are risk
factors for pregnancy complications. 35 PTSD is also a predictor for maternal death: in one study
examining women veterans who experienced maternal morbidity events during pregnancy, 29%
had PTSD. 36
A recent study also identified “moral injury,” or distress related to transgression of deeply
held moral beliefs, as a risk factor for gestational diabetes and preeclampsia for women
veterans. 37 Moral injury may arise from the same experiences that lead to PTSD, such as “combat
and military sexual trauma.” 38
The same study also found that PTSD symptoms were predictors of additional risks,
such as postpartum depression, anxiety, and perception of a difficult pregnancy. 39 Taken
together, “one in two women veterans (50 percent) who became pregnant during the
study period experienced a negative pregnancy outcome,” including postpartum depression
32 Jonathan G. Shaw et al., Post-traumatic Stress Disorder and Antepartum Complications: A Novel Risk Factor for Gestational
Diabetes and Preeclampsia, 31 PAEDIATRIC & PERINATAL EPIDEMIOLOGY 185, 190 (2017) (evaluating nearly 16,000
VHA-covered deliveries); see also Trisan Horrom, Gestational Diabetes and Preeclampsia Rates Higher In Women With
PTSD, U.S. DEP’T VETERANS AFFS. (Apr. 26, 2017), https://www.research.va.gov/currents/0417-pregnancy.cfm
(discussing the 2017 Shaw et al. study); Women Veterans and Pregnancy Complications, supra note 27 (discussing the
implications of the 2017 Shaw et al. study).
33 Jonathan G. Shaw et al., Posttraumatic Stress Disorder and Risk of Spontaneous Preterm Birth, 124 OBSTETRICS &
GYNECOLOGY 1111, 1116 (2014) (observing over 16,000 VHA-covered deliveries); see also Women Veterans and Pregnancy
Complications, supra note 27 (discussing the implications of the study). This is consistent with other studies linking
PTSD to higher rates of preterm birth. See, e.g., Kimberly Ann Yonkers at al., Pregnant Women With Posttraumatic Stress
Disorder and Risk of Preterm Birth, 71 JAMA PSYCHIATRY 897 (2014) (finding that women with PTSD are four times more
likely to experience preterm birth).
34 Janet K. Han, Cardiovascular Care in Women Veterans, 139 CIRCULATION 1102, 1105 (2019) (citing S.M. Frayne et al.,
Medical Profile of Women Veterans Administration Outpatients Who Report a History Of Sexual Assault Occurring While In The
Military, 8 J. WOMEN’S HEALTH GENDER-BASED MED. 835 (1999), and S.M. Frayne et al., Burden of Medical Illness in
Women With Depression and Posttraumatic Stress Disorder, 164 ARCH. INTERNAL MED.1306 (2004)).
35 See, e.g., infra note 40.
36 Joan L. Combellick et al., Severe Maternal Morbidity Among a Cohort of Post-9/11 Women Veterans, 29 J. WOMEN’S
HEALTH 577, 581 (2020).
37 Yael I. Nillni et al., The Impact of Posttraumatic Stress Disorder and Moral Injury on Women Veterans’ Perinatal Outcomes
Following Separation From Military Service, 33 J. TRAUMATIC STRESS 248 (2020); see also Off. Rsch. & Dev., PTSD, Moral
Injury Tied to Pregnancy Complications, U.S. DEP’T VETERANS AFFS (Apr. 14, 2020),
https://www.research.va.gov/currents/0420-PTSD-and-moral-injury-linked-to-pregnancy-complications.cfm
(describing the findings of the Nillni et al. study).
38 See PTSD, Moral Injury Tied to Pregnancy Complications, supra note 37.
39 Id.

6

or anxiety (30%), miscarriage (25%), obstetrical medical condition (e.g., preeclampsia, gestational
diabetes) (22%), emergency C-section (9%), NICU care for the infant (8%), preterm birth (6%),
stillbirth (2%), and ectopic or tubal pregnancy (2%). 40
Pregnancy itself can exacerbate these conditions. For instance, one study found that
pregnant veterans were twice as likely to be diagnosed with depression, anxiety, PTSD, bipolar
disorder, or schizophrenia as non-pregnant veterans. 41 The aggravation of these conditions
contributes to the increased risk of high-risk pregnancies that can threaten the pregnant veteran’s
life.

2. HYPERTENSION
Women veterans frequently suffer from hypertension, which is correlated strongly with
adverse pregnancy outcomes. Hypertension, or high blood pressure, “is the most common
condition for [women veterans].” 42 Black women veterans exhibit a particularly high prevalence of
hypertension, experiencing the condition 2.3 times as often as white women veterans. 43
Moreover, research has shown that veterans who have experienced MST are at higher risk for
hypertension, 44 further amplifying its risk in women veterans.
Hypertension has serious implications for pregnancy. “Hypertension is one of the
leading causes of increased pregnancy complications in reproductive-aged women. Hypertensive
pregnancies have increased risks of fetal growth restriction, placental abruption, preterm birth,
cesarean delivery, and preeclampsia, which is a dangerous complication accompanied by
proteinuria and may result in serious adverse consequences for the mother and fetus.
Preeclampsia is also associated with persistent postpartum cardiovascular impairment.” 45
Hypertension is also associated with an increased risk of cardiovascular disease,
“including fatal conditions such as stroke, myocardial infarction, abdominal aortic aneurysm, and
heart failure.” 46 Cardiovascular disease is in turn a predictor of further pregnancy complications. 47

3. CHRONIC KIDNEY DISEASE
Veterans are disproportionately afflicted with chronic kidney disease (CKD), which is
40 Women Vets Report Adverse Pregnancy Outcomes, Postpartum Mental Health Problems After Leaving Service, B.U. SCH. MED.
(Apr. 15, 2020), https://www.bumc.bu.edu/busm/2020/04/15/women-vets-report-adverse-pregnancy-outcomes-
postpartum-mental-health-problems-after-leaving-service (discussing Nillni et al., supra note 37). Other studies have
noted that PTSD may increase the risk of cardiovascular disease, which itself poses large threats to healthy and safe
pregnancies. See Melanie Arenson & Beth Cohen, Posttraumatic Stress Disorder and Cardiovascular Disease, 28 PTSD RSCH.
Q. 1 (20187).
41 Kristin M. Mattocks et al., Pregnancy and Mental Health Among Women Veterans Returning from Iraq and Afghanistan, 19 J.
WOMEN’S HEALTH 2159 (2010).
42 Seth Byland, Thesis, Self Reported Cardiovascular Health and Health Behaviors in Women Veterans 5 (2022), available at
https://scholarcommons.sc.edu/cgi/viewcontent.cgi?article=7643&context=etd.
43 See Han, supra note 34, at 1103 (also reporting that women veterans have worse hypertension control).
44 Am. Heart Ass’n, High Blood Pressure Risk Higher Among Veterans Who Experienced Sexual Trauma While Serving,
MEDICAL XPRESS (Sept. 27, 2021), https://medicalxpress.com/news/2021-09-high-blood-pressure-higher-
veterans.html (reporting on research presented at the American Heart Association’s Hypertension Scientific Sessions
in 2021).
45 Dan-dan Wu et al., Increased Adverse Pregnancy Outcomes Associated With Stage 1 Hypertension in a Low-Risk Cohort:
Evidence From 47 874 Cases, 75 HYPERTENSION 772, 772 (2020).
46 Id.
47 Id.; see also Han, supra note 34 (describing the increased risks pregnant women face when suffering from
cardiovascular disease). 

7

linked to a variety of pregnancy complications. “As a group, veterans have higher rates of
chronic kidney disease (CKD) than the general U.S. population. While kidney disease affects 1 in
7 Americans, it affects about 1 in 6 veterans, including more than 40,000 VA-enrolled veterans
with kidney failure (end-stage renal disease or ESRD) who rely on dialysis or a kidney transplant
to survive.” 48 Approximately 10-15% of VA patients suffer from CKD stages 3-5, a prevalence
concentrated among women veterans, Black veterans, Native Hawaiian/Pacific Islander
veterans, and those with hypertension. 49
CKD is associated with increased risk for a host of pregnancy complications. “Even mild
CKD is associated with a higher risk of adverse maternal and fetal outcomes, including
worsening of maternal kidney function, proteinuria, and hypertension, as well as preterm birth
and fetal growth restriction.” 50 “Women with chronic kidney disease are less able to make the
renal adaptations needed for a healthy pregnancy. Their inability to boost renal hormones often
leads to normochromic normocytic anemia, reduced expansion of plasma volume, and vitamin
D deficiency.” 51
Like other risk factors, CKD is associated with preeclampsia. Approximately 20% of
women who develop early preeclampsia have previously unrecognized CKD. 52 If preeclampsia
develops, a woman’s renal function will deteriorate further. Women with only moderate renal
impairment still have a 40% risk of a decline in renal function throughout pregnancy, and 65% of
women with severe renal impairment have “a decline in renal function during the third trimester,
which persisted in most women and deteriorated to end stage renal failure.” 53
CKD is also associated with other risk factors that together even further aggravate the
chances of pregnancy complications, since “[m]aternal hypertension, proteinuria, and recurrent
urinary tract infection often coexist in women with chronic kidney disease.” 54

4. EPILEPSY
Women veterans exhibit high rates of epilepsy, a condition linked to a multitude of
pregnancy complications. More than 87,000 veterans in the VA health care system have been
diagnosed with epilepsy, “16% of whom have comorbid traumatic brain injury (TBI), and nearly
25% also have post- traumatic stress disorder (PTSD).” 55 Notably, “psychiatric comorbidities,
catamenial epilepsy, and [lower] bone health . . . are unique to women veterans with epilepsy.” 56
Epilepsy is linked to pregnancy complications, as is the medication taken to control
seizures. Between 15% and 30% of women living with epilepsy will experience “an increase in
48 Veterans and Kidney Disease, AM. KIDNEY FUND, https://www.kidneyfund.org/get-assistance/veterans-and-
kidney- disease.
49 Chronic Kidney Disease (CKD) Surveillance System, CTRS. FOR DISEASE CONTROL & PREVENTION,
https://nccd.cdc.gov/ckd/; see also Off. Health Equity, Kidney Disease in Veterans, U.S. DEP’T VETERANS AFFS.,
https://www.va.gov/HEALTHEQUITY/Kidney_Disease_In_Veterans.asp.
50 Michelle A. Hladunewich et al., Pregnancy in Women With Nondialysis Chronic Kidney Disease, UPTODATE (Aug. 2022),
https://www.uptodate.com/contents/pregnancy-in-women-with-nondialysis-chronic-kidney-disease.
51 David Williams & John Davidson, Chronic Kidney Disease in Pregnancy, 336 BMJ 211, 211 (2008).
52 Id.
53 Id. at 212.
54 Id.
55 VA Epilepsy Ctrs. Excellence et al., Providing Quality Epilepsy Care for Veterans, 33 FED. PRAC. 26, 26 (2016).
56 Id. at 31.

8

seizure frequency, most often during the first or third trimester,” and “generalized seizures
(especially tonic- clonic ones) carry [higher] risk to both mother and baby. These risks include
trauma from falls or burns, increased risk of premature labor, miscarriages, and lowering of the
fetal heart rate.” 57 Epilepsy also increases the risk of trauma to the mother (e.g., a fall) that has
additional effects on the fetus (e.g., placental abruption). 58 These risks are increased significantly if
the woman elects not to take her medication, 59 given that epilepsy medication itself is linked to
increased chances of birth defects. 60 Accordingly, women veterans with epilepsy are in a bind,
even for wanted pregnancies: forgo medication and incur one set of increased risks, or take
medication and incur another.
5. OTHER RISK FACTORS
Moreover, some women veterans may have been exposed to potential occupational and
environmental hazards that are associated with adverse birth outcomes. For instance, one study
of women Navy veterans showed that exposures to heavy metals, pesticides, petroleum
products, and other chemicals were associated with adverse live-birth outcomes. 61 This study is
consistent with others showing that exposure to toxins may have adverse effects on female
reproductive health, pregnancy outcomes, and offspring development. 62
B. Women Veterans’ Heightened Mental and Physical Health Risk Factors
Lead to Increased Pregnancy Complications
The above-detailed factors place women veterans at disproportionately high risk for
myriad pregnancy complications, including preeclampsia and eclampsia, and other common
comorbidities, such as gestational diabetes, preterm birth, maternal death, intrauterine growth
restriction, postpartum depression, suicidality, cardiovascular disease, and postpartum
hemorrhage (among others). Some evidence suggests that “pregnancy-related deaths among
Veterans using VA healthcare are nearly double the national rate.” 63
Most crucially, preeclampsia is a leading cause of maternal death. Women veterans are at
a 32% higher risk of preeclampsia, eclampsia, and hypertension than their civilian peers. 64
Preeclampsia is responsible for over 70,000 maternal deaths every year. 65 It also places affected
57 Risks During Pregnancy Due to Epilepsy, EPILEPSY FOUND., https://www.epilepsy.com/lifestyle/family-
planning/pregnancy-risks.
58 See Mayo Clinic Staff, Epilepsy and Pregnancy: What You Need to Know, MAYO CLINIC,
https://www.mayoclinic.org/healthy- lifestyle/pregnancy-week-by-week/in-depth/pregnancy/art-20048417.
59 Id.
60 Id. (reporting that epilepsy medication taken during pregnancy can lead to increased risks of “cleft palate, neural
tube defects, skeletal problems, and heart and urinary track problems” in the fetus, a risk which “increase[s] with
higher doses and if you take more than one anti-seizure medication”).
61 Laurel Hourani & Susan Hilton, Occupational and Environmental Exposure Correlates of Adverse Live-Birth Outcomes Among
1032 US Navy Women, 42 J. OCCUPATIONAL & ENV. MED. 1156 (2000).
62 See, e.g., Sunil Kumar, Anupama Sharma & Chaoba Kshetrimayum, Environmental & Occupational Exposure & Female
Reproductive Dysfunction, 150 INDIAN J. MED. RSCH. 532 (2019) (concluding that certain chemical exposures during
pregnancy may have a profound impact on the health of the mother and of the child).
63 Health Servs. Rsch. & Dev., CDA 20-224 – HSR&D Study, U.S. DEP’T VETERANS AFFS.,
https://www.hsrd.research.va.gov/research/cda_abstracts.cfm?Project_ID=2141708956 (noting that “[p]reliminary
data from pilot work suggest that the rate of pregnancy-associated deaths among Veterans using VA maternity care
benefits is nearly double the national rate”).
64 Jodie Katon et al., Gestational Diabetes and Hypertensive Disorders of Pregnancy Among Women Veterans Deployed in Service of
Operations in Afghanistan and Iraq, 23 J. WOMEN’S HEALTH 792 (2014).
65 Sarosh Rana et al., Preeclampsia: Pathophysiology, Challenges and Perspectives, 124 CIRCULATION RSCH. 1094, 1094 (2019)

9

women at “increased risk for damage to the kidneys, liver, brain, and other organ and blood
systems,” and, in some cases, “organ failure or stroke.” 66 “In severe cases, preeclampsia can
develop into eclampsia, which includes seizures. Seizures in eclampsia may cause a woman to lose
consciousness and twitch uncontrollably. If the fetus is not delivered, these conditions can cause
the death of the mother and/or the fetus.” 67
Women veterans also experience a 40% higher risk of gestational diabetes. 68 Gestational
diabetes is similarly “associated with maternal mortality and morbidity, meaning there is a higher
risk for women dying in pregnancy and of serious complications during pregnancy and delivery.
These include: needing to go to the Intensive Care Unit during pregnancy or birth, significant
blood loss during birth and having a C-section.” 69 Approximately half of women who
develop gestational diabetes then develop Type 2 diabetes later in life, and gestational diabetes
also increases the chance that a woman will develop cardiovascular disease. 70
These effects are even more pronounced for marginalized groups, including and
especially women veterans of color. A higher population of women veterans are Black (30%) and
live in rural areas (25%) compared to the general population, 71 and these demographics are
drastically overrepresented in the subgroup of women veterans who die during or shortly after
giving birth. 72 For instance, Black, Asian, and other pregnant persons of color are at particular
risk of gestational diabetes when affected by PTSD. 73
Importantly, these risk factors are also overrepresented in the subset of the women
veteran population that relies on VA for reproductive health care coverage, as opposed to
Medicaid or private insurance. 74 “For instance, women veterans who use VA maternity care
(additionally reporting that it is responsible for 500,000 fetal deaths every year); see also Labib Ghulmiyyah & Baha
Sibai, Maternal Mortality from Preeclampsia/Eclampsia, 36 SEMINARS IN PERINATOLOGY 56, 56 (2012) (reporting that
preeclampsia/eclampsia is one of the three leading causes of maternal morbidity and mortality).
66 What Are the Risks of Preeclampsia & Eclampsia to the Mother?, NAT’L INST. HEALTH,
https://www.nichd.nih.gov/health/topics/preeclampsia/conditioninfo/risk-mother.
67 Id.
68 Katon et al., supra note 64.
69 Marla Paul, ‘Alarming’ Rise in Gestational Diabetes in U.S., NW. MED. (Aug. 23, 2021),

‘Alarming’ Rise in Gestational Diabetes in U.S.

70 Marlene Cimons, Gestational Diabetes During Pregnancy Is Rising. Experts Are Alarmed., WASH. POST (Apr. 8, 2022, 12:05
PM ET), https://www.washingtonpost.com/health/2022/04/08/gestational-diabetes-worrisome-increase-pregnancy
(citing research from the Centers for Disease Control & Prevention and the American Heart Association).
71 See Women’s Health Evaluation Initiative, VA Palo Alto Health Care Sys. & Women’s Health Servs., U.S. DEP’T
VETERANS AFFS., Sourcebook: Women Veterans in the Veterans Health Administration, Volume 4: Longitudinal Trends in
Sociodemographics, Utilization, Health Profile, and Geographic Distribution, U.S. DEP’T VETERANS AFFS. 25, 30 (Feb. 2018),
https://www.womenshealth.va.gov/docs/WHS_Sourcebook_Vol-IV_508c.pdf [hereinafter 2018 SOURCEBOOK].
Compare Nicholas Jones et al., 2020 Census Illuminates Racial and Ethnic Composition of the Country, CENSUS.GOV (Aug. 12,
2021), https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-
population-much-more-multiracial.html (finding that the Black population accounts for 12.4% of all people living in
the United States); Elizabeth A. Dobis et al., Rural America at a Glance, U.S. DEP’T AGRICULTURE 2 (2021),
https://www.ers.usda.gov/webdocs/publications/102576/eib-230.pdf?v=5018.2 (finding that 14% of the U.S.
population lives in rural areas).
72 See Combellick et al., supra note 36, at 581 (finding that 44% of women veterans who experienced maternal
morbidity events were Black and 29% lived in rural areas).
73 See Gayathri Delanerolle, A Systematic Review and Meta-Analysis of Gestational Diabetes Mellitus and Mental Health Among
BAME Populations, 14 ECLINICALMEDICINE (2021), available at https://pubmed.ncbi.nlm.nih.gov/34308317.
74 Jonathan G. Shaw et al., Selection of Higher Risk Pregnancies into Veterans Health Administration Programs: Discoveries from

10

benefits are about three and a half times more likely to have active post-traumatic stress
disorder, five and half times more likely to have current symptoms of depression, and
four times more likely to have a service-connected disability rated at 50 percent or
above compared to pregnant women veterans who elect not to use the VA maternity
benefit. These characteristics make this population high risk for pregnancy complications.” 75
As VA recognized in 2022, these risk factors and their implications mean that women
veterans require abortion access “to save their lives and preserve their health.” 76
C. Ensuring Parity with Respect to VA’s Gender-Specific Health Care
Along with endangering lives, if VA were to reintroduce the restrictions on abortion-
related care it would be abandoning congressional intent in providing equal access to health care
for all veterans. Recognizing the deficiencies between care offered to women and men veterans,
Congress passed the Deborah Sampson Act 77 in 2021 to support VA’s previous commitments to
expanding women’s health services. 94 To revert to the policy as it was prior to 2022 would be a
step backward in the VA’s progress towards its goal to provide quality women’s health care.
Reversing VA’s important measures to address these risks and disparities faced by
pregnant veterans would be to the detriment of veteran women’s reproductive healthcare. Women
veterans comprise the fastest-growing share of the veteran population 78 —and an increasingly
large share of Veterans Health Administration (VHA) patients. 79 Reintroducing restrictions on
abortion-related care will endanger the lives of these veterans across the country, regardless of
VA’s assertions to the contrary. 80 And even for those lucky veterans who would manage to
survive dangerous and life-threatening pregnancies and births, such births are often incredibly
traumatic and fertility-threatening. 81 Restrictions on abortion-related care that would force
women veterans into such traumatic situations does not align with a commitment to women’s
reproductive health care.
Additionally, VA owes women veterans care that is at least comparable to that offered to
them while on active duty, and this reversion would directly conflict what is offered by
TRICARE. Even under TRICARE, abortions are covered when the pregnancy is the result of

Linked Department of Veterans Affairs and California Birth Data, 53 HEALTH SERV. RSCH. 5260, 5269-70 (2018) (“VA-
covered mothers were significantly more likely to suffer preeclampsia (4.5 percent) than their Medicaid-covered (3.2
percent) or Private/other covered (peers) 13.1 percent of newborns delivered under VA coverage received NICU-
level care vs. 9.3 percent under Private/other coverage”).
75 Women Veterans: The Journey Ahead, DAV 11 (2018), https://www.dav.org/wp-content/uploads/2018_Women-
Veterans-Report-Sequel.pdf; see also id. at 19 (“VA patients frequently have diagnoses that create challenges during
pregnancy. These include anxiety (21 percent), depression (28 percent), post-traumatic stress disorder (19 percent),
musculoskeletal problems (17 percent), neurological issues (10 percent) and endocrine dysfunction (10 percent).”).
76 87 Fed. Reg. 55287, 55295 (Sept. 9, 2022).
77 Tester’s Historic Deborah Sampson Act Signed Into Law, S. COMM. ON VETERANS’ AFFS., (Jan. 5, 2021),
https://www.veterans.senate.gov/2021/1/testers-historic-deborah-sampson-act-signed-into-law.
78 2018 SOURCEBOOK, supra note 71, at 13 (finding that the number of women in the 18-44 age group increased 2.3x
from 2000 to 2015).
79 Id. at 1 (finding that the proportion of women VHA patients increased by nearly 60% from 2000 to 2015).
80 See Reproductive Health Services, 90 Fed. Reg. 36415, 36416 (Aug. 4, 2025).
81 Rodolfo S. Camargo, Rodolfo C. Pacagnella, José G. Cecatti, Marcos A. Parpinelli, João P. Souza & Maria H.
Sousa, Subsequent Reproductive Outcome in Women who have Experienced a Potentially Life-Threatening Condition or a Maternal
Near-miss during Pregnancy, 66 Clinics 1367 (São Paulo) (2011), https://doi.org/10.1590/S1807-59322011000800010.

11

rape or incest and when the life of the mother is at risk. 82 Considering veterans often face
exacerbated health issues because of their service, VA has a responsibility to provide health care
that meets or exceeds the quality and scope provided to current service members.
II. VA HAS THE AUTHORITY TO PROVIDE ABORTION SERVICES.
VA contends that the 2022 expansion of abortion care was “legally questionable.” 83
However, the Secretary of the Department of Veterans Affairs has the legal authority to
implement a rule providing abortion services to pregnant veterans under the Veterans’ Health
Care Eligibility Reform Act of 1996 and his general rulemaking authority. 84 Moreover, no federal
law restricts VA’s authority to provide these services.
The Veterans’ Health Care Eligibility Reform Act of 1996 establishes VA’s statutory
authority to provide abortion care, providing that “the Secretary may, to the extent resources
and facilities are available . . . furnish hospital care, medical services, and nursing home care
which the Secretary determines to be needed.” 85 As VA recognized in 2022, yet fails to refute in
this proposal, the 1996 law gave the Secretary new wide-ranging authority to provide veterans
medical services overall, superseding the 1992 Act’s more restrictive authority. It replaced prior
service-by-service Congressional authorizations. It also supplanted the limited grant of authority
under Section 106 of the Veterans Health Care Act of 1992 (“HEALTH CARE SERVICES
FOR WOMEN”) which purported to authorize “general reproductive healthcare,” 86 but actually
excluded “under this section infertility services, abortions, [and] pregnancy care.” 87
Courts have historically deferred to VA’s reasoned discretion to determine what medical
services are “needed” under the 1996 statute. Hence, in East Paralyzed Veterans Ass’n, Inc. v.
Secretary of Veterans Affairs, the Federal Circuit found that “[e]xcept where the [statute] requires
specific services or care for [a] designated medical condition, the Secretary has broad
discretion to determine the precise hospital or medical services to be supplied.” 88
The Ninth Circuit in Veterans for Common Sense v. Shinseki put it simply: “Congress was
quite serious about limiting our jurisdiction over anything dealing with the provision of veterans’
benefits.” 89 The Secretary’s interpretation of what medical services are “needed” under the 1996
statute is legally valid so long as that interpretation is reasonable. A decision to provide lifesaving
abortion care is clearly reasonable, particularly because after Dobbs it became nearly impossible
for many women veterans to otherwise access a vital medical procedure.
Moreover, VA has previously used its authority under the 1996 statute to update its
82 TRICARE, Abortions, https://perma.cc/6VFM-5JK2.
83 Reproductive Health Services, 90 Fed. Reg. 36415, 36416 (Aug. 4, 2025).
84 38 U.S.C. § 501.
85 Veterans’ Health Care Eligibility Reform Act of 1996, 38 U.S.C. § 1710(a)(3) (emphasis added).
86 VA possesses similar authority to provide abortion services to certain spouses, children, survivors, and caregivers
of veterans under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA).
Denson v. United States, 574 F.3d 1318, 1347 (11th Cir. 2009). CHAMPVA authorizes VA to provide CHAMPVA
beneficiaries with those medical services which the Secretary has determined to are entitled to “medically necessary
and appropriate for the treatment of a condition and that” VA has not “specifically excluded.” 38 C.F.R. § 17.270(b)
(2022).
87 Veterans Health Care Act of 1992, Pub. L. 102–585, 106 Stat. 4943 § 106(a)(3).
88 257 F.3d 1352, 1362 (Fed. Cir. 2001).
89 678 F.3d 1013, 1023 (9th Cir. 2012).

12

interpretation of which reproductive services are “needed” without regard to the Section 106 of
the 1992 Act. In 1999, recognizing that the limitation of reproductive health care services in
Section 106 of the 1992 Act had been limited to Section 106 alone and that VA now had the
authority under the 1996 Act to provide services it deemed were “needed,” VA promulgated a
rule that expanded the range of “needed” reproductive services provided to women to include
infertility and pregnancy services. 90 As VA explained:

The Secretary has authority to provide healthcare as determined to be
medically needed. In our view, medically needed constitutes care that is
determined by appropriate healthcare professionals to be needed to
promote, preserve, or restore the health of the individual and to be in
accord with generally accepted standards of medical practice. The care
included in the proposed ‘medical benefits package’ is intended to meet
these criteria. . . . [U]nder these criteria, we have determined that
reproductive sterilization, surgery to reverse voluntary sterilization,
infertility services (other than in vitro fertilization), and surgical
implantation of penile prostheses should not be excluded. Appropriate
changes are made to the medical benefits package to reflect these
determinations. 91

Thus, Section 106 of the 1992 Act does not cabin VA’s authority under the 1996 law, or any
other statute, to provide infertility, abortion, or pregnancy services “as needed.” VA’s
interpretation of its authority was correct in 1999 and remained correct in 2022.
A public-health emergency ensued post-Dobbs and remains throughout America today. It
was objectively reasonable for VA in 2022 to respond to this emergency by recognizing that
pregnant veterans need to be able to access abortion services, and no statute impedes VA from
providing abortion services to pregnant veterans. Insofar as VA is rescinding its rule because of its
erroneous view of the law, this is arbitrary and capricious. 92
III. VA’S PROPOSED RECISSION VIOLATES THE APA.
Recission of final agency rules demands the same hard look review as rule promulgation
under State Farm. As such, agency actions are arbitrary and capricious if they fail to “examine the
relevant data and articulate a satisfactory explanation for its action” or if the agency “relied on
factors which Congress has not intended it to consider, entirely failed to consider an important
aspect of the problem, [or] offered an explanation for its decision that runs counter to the
evidence before the agency.” 93 While there is typically no heightened standard for evaluation of
agency rule recissions, sometimes an agency must provide more “detailed justification . . . when,
for example, its new policy rests upon factual findings that contradict those which underlay its
90 Enrollment—Provision of Hospital and Outpatient Care to Veterans, 64 Fed. Reg. 54207, 54210 (Oct. 6, 1999)
(codified at 38 C.F.R. § 17.38).
91 Id.
92 SEC v. Chenery Corp., 318 U.S. 80, 94 (1943) (“an order may not stand if the agency has misconceived the law”);
Nat’l Ass’n of Regul. Util. Comm’rs v. ICC, 41 F.3d 721, 727-28 (D.C. Cir. 1994) (“the agency purported to find in the
statute a legal constraint . . . that is simply not there . . . on that basis of incorrect statutory interpretation alone, we
would be obliged to reject the . . . reasoning”); Baltimore & O.R.R. Co. v. ICC, 826 F.2d 1125, 1129 (D.C. Cir. 1987)
(stating that an agency may not “assert a nonexistent congressional prohibition as a means to avoid responsibility for
its own policy choice”).
93 Motor Vehicle Mfrs. Ass’n of U.S., Inc. v State Farm Mut. Auto. Ins. Co., 463 U.S. 29, 43 (1983).

13

prior policy; or when its prior policy has engendered serious reliance interests that must be taken
into account.” 94
Here is such a case and the agency falls short of the decision making required by the
APA. The agency has presented starkly different facts than those it presented just a year ago,
namely in its description of the necessity of the abortion access landscape and the necessity of
such coverage by VA. The agency has also ignored the extensive research presented by NOW-
NYC that substantiates VA’s current abortion policy or a more generous version. Moreover, the
agency has failed to adequately address reliance interests on the policy. VA claims there is no
reliance since fewer veterans utilized the policy than expected but abortion incidence under the
policy is not the same as reliance on the policy. If anything, VA acknowledges there is some
reliance 95 and brushes past engaging with it, clearly in violation of the APA. 96 Moreover, even if
projections on usage were off, this does not speak to the magnitude of reliance by those who
used the exception. Additionally, VA does not consider the reliance on counseling and lifestyle
decisions that depended upon access to abortion care at VA health facilities. In any case, VA is
required in these circumstances to justify its abrupt change in direction and to a degree that is
higher than what is typically required of the agency.
Lastly, VA’s proposed rule would unduly burden women’s access to health care and
violate female veterans’ substantive due process rights, in violation of Section 1557 of the
Affordable Care Act and the Fifth Amendment of the U.S. Constitution.

* * *

The current VA rule granting access to basic abortion services protects women veterans
from conscription into harmful and dangerous pregnancies, for which they are uniquely at risk.
These services are all the more necessary in the wake of the emergency Dobbs created for women
veterans’ access to reproductive health and safety. The VA’s proposed recission would aggravate
this emergency, violating the APA and threatening the lives of the women veterans the VA is
supposed to care for.