Updates to the US Food and Drug Administration Regulations for Mifepristone: Implications for Clinical Practice and Access to Abortion.

This article provides information on recent changes in the US Food and Drug Administration (FDA) labeling and safety regulations for mifepristone (Mifeprex). The revised label now permits midwives, advanced practice nurses, and physician assistants to order and prescribe mifepristone, eliminating the requirement for physician supervision. The updated label also extends eligibility for use from 49 to 70 days' gestation and decreases the number of required visits from 3 to 2. The recommended dose of mifepristone has been reduced, and the dosage, timing, and route of administration for misoprostol have also been changed to reflect current research. These changes have implications for clinical practice and may lead to expanded access for women in the United States.

Rethinking the Well Woman Visit: A Scoping Review to Identify Eight Priority Areas for Well Woman Care in the Era of the Affordable Care Act.

PURPOSE: The annual pap smear for cervical cancer screening, once a mainstay of the well woman visit (WWV), is no longer recommended for most low-risk women. This change has led many women and their health care providers to wonder if they should abandon this annual preventive health visit altogether. Changing guidelines coinciding with expanded WWV coverage for millions of American women under the Patient Protection and Affordable Care Act have created confusion for health care consumers and care givers alike. Is there evidence to support continued routine preventive health visits for women and, if so, what would ideally constitute the WWV of today? METHODS: A scoping review of the literature was undertaken to appraise the current state of evidence regarding a wide range of possible elements to identify priority areas for the WWV. FINDINGS: A population health perspective taking into consideration the reproductive health needs of women as well as the preventable and modifiable leading causes of death and disability was used to identify eight domains for the WWV of today: 1) reproductive life planning and sexual health, 2) cardiovascular disease and stroke, 3) prevention, screening, and early detection of cancers, 4) unintended injury, 5) anxiety, depression, substance abuse, and suicidal intent, 6) intimate partner violence, assault, and homicide, 7) lower respiratory disease, and 8) arthritis and other musculoskeletal problems. CONCLUSIONS: The WWV remains a very important opportunity for prevention, health education, screening, and early detection and should not be abandoned.

Regulation of Certified Nurse-Midwife Scope of Practice: Change in the Professional Practice Index, 2000 to 2015.

INTRODUCTION: Certified nurse-midwives (CNMs) across the United States are educated in the same core competencies, yet scope of practice varies with state regulation. The Health Resources and Services Administration (HRSA) funded studies published in 1994 and 2004 on the professional practice environment of CNMs, nurse practitioners, and physician assistants, and developed the Certified Nurse-Midwife Professional Practice Index (CNMPPI), a 100-point scoring system of state regulation focusing on 3 domains: legal status, reimbursement, and prescriptive authority. The purpose of this study was to examine changes to CNM regulation between 2000 and 2015 by updating scores to the CNMPPI. METHODS: Individual state CNMPPI scores from 2000 were updated for every year through 2015 by reviewing data published in the American College of Nurse-Midwives (ACNM) quarterly publication Quickening, the annual advanced practice registered nurse legislative updates in the journal Nurse Practitioner, and the ACNM State Legislative and Regulatory Guidance. RESULTS: Mean state scores increased 18%, from 69.7 in 2000 to 79.8 in 2015, and variation between state scores fell. Increases were seen in all 3 domains, with the greatest increase in the domain of prescriptive authority and the smallest in the legal domain. Individual state CNMPPI scores tend to be correlated with scores of adjacent states. DISCUSSION: The CNMPPI can be used to document changes in practice authority of CNMs. The increase in state CNMPPI scores and decrease in variance across states can be interpreted as indicating growth of professional authority and increasing consensus regarding the CNM role. The scoring system needs to be updated to reflect the current health systems environment and to include certified midwives and other midwives meeting the International Confederation of Midwives definition of a midwife. Applications of the CNMPPI to future research are discussed.

Long-acting reversible contraceptives for teenagers: primary care recommendations.

Long-acting reversible contraceptive (LARC) methods are underutilized in the adolescent population despite their superior efficacy over non-LARC methods. The purpose of this article is to discuss the barriers that lead to underutilization of these methods and present an evidence-based approach for the use of LARC methods among adolescents in the primary care setting.

Clinical issues in post-abortion care.

This article provides an overview of the clinical issues in post-abortion care, including types of abortion procedures, expected post-abortion course, possible complications, and the components of the post-abortion visit. By providing follow-up care to their patients, NPs can increase continuity of care and promote successful contraceptive use.

Applying ethical practice competencies to the prevention and management of unintended pregnancy.

Using a case study that incorporates patient, nurse practitioner, and student perspectives, we address ethical principles of respect for autonomy, beneficence, and fairness; professionals' right of conscience; and a social justice model for the discussion of prevention and management of unintended pregnancy. Through an ongoing process of self-reflection and values clarification, nurses can prepare for the challenge of applying ethical principles to the reproductive health care of women.

Great expectations: points of congruencies and discrepancies between incoming accelerated second-degree nursing students and faculty.

This study analyzes the expectations that incoming students and faculty bring to accelerated pre-licensure education programs for second-degree students. Although research supports the congruence of expectations between students and faculty as essential to learning, anecdotal evidence and single case reports suggest there may be important discrepancies in expectations of second-degree students and their faculty. Data are intended to support curriculum review, refinement, and innovation in these programs.

Implanon: a review of the literature with recommendations for clinical management.

Implanon is a new implantable, progestin-only contraceptive which was approved in the United States in July 2006. Implanon is comprised of a single ethylene vinylacetate copolymer rod that is 4 cm long and 2 mm in diameter. It is inserted subdermally in the groove between the biceps and triceps of the nondominant arm. A literature review was conducted and side effects are discussed. Implanon offers promise as a high-efficacy, long-term contraceptive and can enhance the contraceptive options offered by the women's health care providers. Clinical trial data indicate that the device is both safe and effective.

Professional right of conscience.

In recent years there have been numerous media reports of professionals attempting to expand the right of conscience and deny health care services requested by consumers. While the media has focused the most attention on pharmacists' right to refuse access to contraception, this trend is an expansion of the right originally established to protect professionals from being required to perform abortions or to provide direct assistance with abortions. State legislatures have addressed this issue, in some cases by overtly protecting consumers' rights and in other cases by broadening professional right of conscience. In this article, the literature on provider right of conscience is reviewed, and approaches advised by professional organizations are discussed.

Update on medication abortion.

This article provides an overview of medication abortion in the United States 6 years after the approval of mifepristone (RU486; Mifeprex; Danco Laboratories, LLC, New York, NY) by the US Food and Drug Administration (FDA). The adoption of mifepristone is considered in the context of epidemiologic data on abortion, abortion access, and the safety of abortion. The risks of medication and aspiration abortion are discussed in the context of abortion-related mortality, recent experience with obstetric and gynecologic infection with Clostridium sordellii, and the limits of scientific knowledge on the incidence of this infection in women. Innovative protocols studied since FDA approval of mifepristone are presented, and implications for clinical practice are discussed.

Current issues in emergency contraception: an overview for providers.

Emergency contraception has the potential to greatly reduce the number of unintended pregnancies occurring each year in the United States. Emergency contraception is a safe and effective intervention to which all women should have easy access in the event of an act of unprotected intercourse. Methods of emergency contraception include combined hormone oral contraceptive pills, progestin-only oral contraceptive pills, a dedicated progestin-only emergency contraceptive product, and insertion of a copper intrauterine device. Barriers exist to the increased use of emergency contraception, including the prescription-only status of all of the methods and lack of accurate knowledge on the part of health care providers and consumers. This article provides an overview of the clinical management of emergency contraception.

Complementary therapies as adjuncts in the treatment of postpartum depression.

Postpartum depression affects an estimated 13% of women who have recently given birth. This article discusses several alternative or complementary therapies that may serve as adjuncts in the treatment of postpartum depression. The intent is to help practitioners better understand the treatments that are available that their clients may be using. Complementary modalities discussed include herbal medicine, dietary supplements, massage, aromatherapy, and acupuncture. Evidence supporting the use of these modalities is reviewed where available, and a list of resources is given in the appendix.

Role of human papilloma virus testing in cervical cancer prevention.

A clear causal relationship has been established between human papilloma virus (HPV) infection and the development of cervical cancer. Genital HPV infection is currently the most common sexually transmitted disease worldwide. The recent 2001 American Society for Colposcopy and Cervical Pathology Consensus Guidelines have included HPV testing for management of women with cervical cytological abnormalities. Clinicians now face the challenge of deciding when to use HPV testing in follow-up of abnormal Pap tests. This article includes updates on HPV, cervical cancer screening, and HPV testing technology. Recommendations for integration of HPV testing into clinical practice are provided.

Homeopathy and women's health care.

A 1997 survey revealed that 40% of Americans use some type of complementary therapy or medicine and that many use such therapies in conjunction with treatments prescribed to them by conventional medical practitioners. One alternative modality that is growing in popularity is homeopathy. Although use of this modality is growing, many health care providers know very little about it. This article provides an introduction to homeopathy, including its historical origins and theoretical principles. Also included is a review of two meta-analyses that examined the efficacy of homeopathy in clinical trials. The homeopathic approach to prolonged pregnancy is presented as an example of a potential application to women's health. Information on education and certification in homeopathy is provided, along with resources on homeopathy available to women's health care providers. Implications for nursing practice are discussed.

Clinical uses of mifepristone: an update for women's health practitioners.

In September 2000, the U.S. Food and Drug Administration (FDA) approved the use of mifepristone for the provision of medical abortion. Although mifepristone was developed and marketed because of its potential to effect early first-trimester medical abortion, it has additional applications to health care, including the treatment of gynecologic conditions, cancer, and Cushing's disease. The controversial nature of abortion has dominated the publicity about mifepristone. The evidence for the safety and efficacy of mifepristone in medical abortion has been overshadowed, and many clinicians are unaware of the other potential uses of the drug. This article provides a discussion of background information on the pharmacology, development of, and research on mifepristone and an update on current and potential uses in health care today. Information on the FDA-approved regimen and alternative protocols for management of mifepristone in its use in abortion care are presented.

The role of exercise in the prevention and treatment of wasting in acquired immune deficiency syndrome.

Involuntary weight loss with lean tissue depletion is a serious and AIDS-defining complication of HIV infection. This article explores definitions of AIDS wasting syndrome (AWS), its etiology, methods of assessing body composition, and pharmacological treatments. Recent research literature on the role of exercise in the prevention and treatment of AWS is reviewed. Included are studies of the safety of exercise, the effects of exercise on the immune system, and the effects of exercise on weight gain and body composition as well as studies of exercise in combination with medications and other interventions. Implications for clinical practice are discussed.