Five years later: Can women in Los Angeles County, California, get adequate pill supplies?

OBJECTIVES: This study sought to determine if pharmacies in Los Angeles County had implemented 2017 legislation requiring insurance companies based in California to fully reimburse for 13 cycles of oral contraceptives dispensed at once. STUDY DESIGN: We conducted a secret shopper telephone survey of Los Angeles County pharmacies nearly 5 years after the legislation went into effect. We chose the categorical state family program (Family PACT) to represent all programs covered by the legislation. Representative numbers of pharmacies were randomly selected in each of Los Angeles County's eight service planning areas in proportion to the number of women living in each area. We asked pharmacies if they would fill a prescription for a year's supply of contraception all at once for a patient enrolled in Family PACT. RESULTS: We contacted a total of 582 pharmacies and excluded the 150 unresponsive pharmacies. Of the 432 pharmacies contacted, only 3.2% said they would dispense a 1-year supply of pills at once to a patient enrolled in this representative program. Nearly 50% explicitly said they would not dispense 13 cycles at one time regardless of the prescription. CONCLUSIONS: Only 3.2% of surveyed pharmacies in Los Angeles County said they would comply with current legislation, which requires dispensing 1-year supply of pills at once. IMPLICATIONS: Collaboration among physicians, pharmacies, and patients along with enhanced insurance company oversight will be needed to improve dispensing practices to achieve the lower unintended pregnancy rates associated with providing adequate contraceptive supplies.

Contraceptive Beliefs and Practices of American Muslim Women.

Objective: To assess contraceptive beliefs and practices among American Muslim women residing in Southern California. Materials and Methods: English speaking Muslim women were approached in Southern California mosques and online and asked to participate in a survey about birth control. Primary outcome measures included the belief that Islam permitted use of contraceptives to prevent pregnancy, to treat menstrual disorders, and to suppress menstrual flow that would prevent attendance at religious rituals; personal contraceptive use was also assessed. Subgroup analysis investigated potential impacts of demographic variables. Results: The interview response rate was 88%. Among the convenience sample of 276 women, 64.4% were younger than 35 years of age, most were well educated, and had an above average income. Eighty percent of respondents believed that Islam allowed the use of contraception to prevent pregnancy, and 85.1% believed that it allowed for the treatment of menstrual disorders. Overall, 93.4% believed that Islam allowed the use of all reversible contraceptive methods, but 35% believed that Islam did not permit permanent contraceptive methods. Belief was related to higher income or educational level, headscarf use, and being Muslim from birth. Of the reproductive age sexually experienced participants, 96.5% reported ever using any contraceptive method. The most commonly ever-used methods included oral contraceptive pills (72.5%), male condoms (68.9%), coitus interruptus (39.9%), and intrauterine devices (21.2%). Conclusion: The vast majority of American Muslim women surveyed believe that their religion permits use of reversible contraceptive methods. They have used contraceptive methods at rates similar to other women in the United States.

Availability of long-acting reversible contraceptives in Los Angeles County clinics through a Medicaid state plan amendment program.

OBJECTIVE: To assess the availability of long acting reversible contraceptive (LARC) methods in Los Angeles County through providers participating in a California State Medicaid State Plan Amendment Program called Family Planning, Access, Care and Treatment (Family PACT). STUDY DESIGN: This was a cross-sectional telephone survey utilizing "secret shopper" methodology. From 855 Family PACT providers in Los Angeles County in 2015, a representative sample of 400 providers was selected for study. Young female researchers posing as potential patients called each sampled clinic to ask a scripted series of questions about LARC availability for Family PACT patients in that practice. RESULTS: All but one eligible practice (99.7%) responded to our questions. Among the 336 responding practices, 284 said they accepted Family PACT. Of those accepting Family PACT, staff answering the telephone call at 61% said they did not provide any LARC method onsite, 2% provided all currently available LARC methods, and 6% provided same-day placement of any LARC. CONCLUSION: The majority of Family PACT practices surveyed said that they did not provide any LARC onsite, and very few provided same-day LARC placement despite easy patient enrollment procedures, relatively reasonable reimbursement and concerted efforts to increase LARC use. Substantial barriers to greater uptake may rest at the provider level with either actual unavailability of LARC or staff perception of unavailability. IMPLICATIONS: Only a minority of Family PACT practices said that LARC methods were available onsite, which imposes substantial restriction to access for women who are entitled to have access without cost. Other states developing programs should be aware of this challenge.

LNG-IUS 12: a 19.5 levonorgestrel-releasing intrauterine system for prevention of pregnancy for up to five years.

INTRODUCTION: Globally, intrauterine devices (IUDs) are the second most commonly used form of reversible contraception because of their high efficacy, safety, convenience and cost effectiveness. The levonorgestrel releasing intrauterine system with daily average release of 20 mcg (LNG-IUS 20) is the popular choice because of its favorable bleeding patterns and many noncontraceptive benefits. A three year (LNG-IUS 8) became available three years ago. More recently, the LNG-IUS 12 was added. This new IUD shares a smaller frame, narrow inserter and lower rate of amenorrhea with the LNG-IUS 8, but it offers the five years of contraceptive protection of the LNG-IUS 20. Areas covered: This article provides information on the contraceptive efficacy, safety and tolerability of this new IUS based on approximately 60,000 cycles of use. Where available, the impacts of subject age, parity and body mass index (BMI) on study outcomes are reported. Expert opinion: This new LNG-IUS 12 with mid-dose hormone levels, smaller frame and longer effective life fills a niche that may better meet the needs of women who might appreciate the narrow insertion tube and/or the lower rates of amenorrhea. Cost will ultimately help determine success.

Assessment of urgent and ongoing contraceptive needs in an OB/GYN urgent care setting.

BACKGROUND: The potential that ongoing contraception and emergency contraception (EC) offer to reduce unplanned pregnancy and abortion is diminished by many barriers. Even when women seek care, their acute needs for those interventions may not be assessed. STUDY DESIGN: This is a retrospective chart review of charts of women potentially at risk for unplanned pregnancy who were provided care in an OB-GYN urgent care clinic in a tertiary care, training hospital. Information was collected about the patient's age group, her presenting complaint, the specialty of the resident who saw her and whether or not her needs for EC and ongoing contraception were assessed and/or met. RESULTS: Charts of 1006 visits were assessed; the visits of 666 potentially at-risk women were included. Slightly more than one third (37.5%) of women were asked about contraception. Only 11% of women were asked about recent unprotected intercourse; 20% of women with recent unprotected intercourse were given EC. CONCLUSIONS: Even in centers dedicated to women's reproductive health, the acute need for fertility control and EC is not adequately assessed. Many opportunities to reduce unintended pregnancy are missed.

Combined hormonal contraceptive trials: variable data collection and bleeding assessment methodologies influence study outcomes and physician perception.

Initially approved for use in the United States nearly 50 years ago, oral hormonal contraceptives containing both estrogen and progestin have undergone steady improvements in safety and convenience. Concurrent with improvements in safety associated with decreasing doses of both steroids, there has been an increased incidence of unscheduled bleeding and spotting. There exist no standards regarding data collection techniques and methods, and reporting and analysis of bleeding and spotting events during combined hormonal contraceptive (CHC) trials. For the regulatory review of hormonal contraceptives, data regarding the incidence of bleeding and spotting events are not included in either of the traditional categories of efficacy and safety. Standardization of methods for collecting and analyzing data about cycle control in all clinical trials of CHCs is long overdue. Until such standards are developed and implemented, clinicians need to familiarize themselves with the techniques used in each study in order to provide correct information to their patients about the frequency of bleeding and spotting associated with different formulations and delivery systems.

Extended-cycle oral contraception: a new option for routine use.

Extended use of oral contraceptive (OC) pills can successfully suppress endometrial activity and prevent menstruation for several months. Given that missed menses in women not using hormonal contraception may be of medical concern, understanding how hormonal contraceptives eliminate these concerns is important for both patient and healthcare provider acceptance. OC withdrawal bleeding is an artificial, iatrogenic event, which results from the deliberate, periodic interruption of hormonal support of the endometrium. Historically, it was important to provide periodic bleeding to reassure OC efficacy, but today it is recognized that these bleeding episodes are medically unnecessary and cause patient discomfort and out-of-pocket expenses. Decades of experience with prolonged use of OCs have been accumulated for women with specific menstrual-related problems such as endometriosis, dysmenorrhea, and menstrual migraine headaches. Today there is a US FDA-approved product to routinely reduce the number of withdrawal periods. Clinical trials show that there is an initial increase in unscheduled bleeding and spotting days with extended-cycle OC use, but an absolute decrease in total days of bleeding and spotting from the first cycle of use. Over time, unscheduled bleeding and spotting decreases to rates found with the use of conventional-cycle regimens. Every woman who is interested in using OC pills should be offered the opportunity to choose how to use them, to determine if and when she will have withdrawal bleeding.

Ambulatory diagnosis and medical management of ectopic pregnancy in a public teaching hospital serving indigent women.

OBJECTIVE: The study was undertaken to evaluate the outcomes of indigent women with possible ectopic pregnancy who were cared for in a public teaching hospital outpatient clinic by multiple residents. STUDY DESIGN: Retrospective review of patients seen in the Obstetric-Gynecologic Urgent Care Center at Harbor-UCLA Medical Center from September 1, 2000, through August 30, 2001, was performed. RESULTS: Of the 243 women being evaluated for possible ectopic pregnancy, 4 required surgical intervention during their diagnostic workup and 58 were lost to follow-up. Of the 31 women given methotrexate therapy, 25 successfully completed therapy, 2 required surgery, and 4 were lost to follow-up. Substantial investment was needed to contact patients who missed appointments. CONCLUSION: It is feasible to manage women with possible ectopic pregnancies on an ambulatory basis in a public teaching hospital, but close oversight is needed and both staff and patients must commit to significant follow-up. Local protocols can be modified to reduce the numbers of visits required.