Jennifer Salcedo

Pharmacy access to ulipristal acetate in Hawaii: is a prescription enough?

OBJECTIVE To determine pharmacy availability of ulipristal acetate (UPA) and compare to availability of levonorgestrel-containing emergency contraceptive pills (LNG-ECPs). METHODS We conducted an observational population-based study utilizing a telephone-based secret shopper methodology. Researchers called all 198 unique retail pharmacies in Hawaii on December 2013-June 2014, representing themselves as patients and physicians. RESULTS Only 2.6% of pharmacies had UPA immediately available, though 22.8% reported ability to order UPA. In contrast, 82.4% reported immediate availability of LNG-ECPs. No significant difference in availability was reported to patients and physicians. CONCLUSIONS Availability of UPA is limited and significantly lower compared to LNG-ECPs. The study period did overlap with a change in distributor for UPA, likely capturing some disruption of the supply chain. IMPLICATIONS Systems-based interventions are needed to address barriers to obtaining UPA.

Use of medications to decrease bleeding during surgical abortion: a survey of abortion providers' practices in the United States

OBJECTIVE Our objective was to document current practices of abortion providers on the use of medications to decrease bleeding during surgical abortion. STUDY DESIGN We emailed surveys to 336 abortion providers through a professional listserv to elicit information on their use of medications to prevent and treat bleeding during first- and second-trimester surgical abortion. RESULTS One hundred sixty-eight (50%) providers responded to our survey. The majority were obstetrician-gynecologists (83%) working in an academic practice (66%). Most completed a fellowship in family planning (87%) and currently perform abortions up to 22 or 24weeks of gestation (63%). Seventy-two percent routinely used prophylactic medications for bleeding. Providers who routinely used medications to prevent bleeding most commonly chose vasopressin (83%). Providers preferred methylergonovine as a treatment for excessive bleeding in the second trimester, followed by misoprostol. CONCLUSION We found that most providers routinely use medications to prevent bleeding and use several different regimens to treat bleeding during abortion. IMPLICATIONS We found that surgical abortion providers use a range of medications to prevent and treat hemorrhage at the time of surgical abortion. Scant evidence is available to guide abortion providers on the use of medications to decrease hemorrhage during surgical abortion. To provide evidence-based recommendations for the prevention and treatment of clinically significant bleeding, researchers should target the most commonly used interventions.

Pharmacy Access to Ulipristal Acetate in Major Cities throughout the United States

OBJECTIVE Ulipristal acetate (UPA) is a prescription emergency contraceptive pill (ECP). Despite the potential for UPA to reduce the risk of unintended pregnancies, a recent study in Hawaii demonstrated less than 3% of pharmacies stocked UPA and less than 23% reported the ability to order it. The primary outcome of our study was to assess the availability of UPA in a sample of large cities nationwide. STUDY DESIGN We conducted a telephone-based secret shopper study of 533 retail pharmacies sampled proportionally from 10 large cities in five geographic regions across the US. Callers represented themselves as uninsured 18-year-old women attempting to fill prescriptions for UPA between February and May 2016. Using a semi-structured questionnaire, callers inquired regarding availability and use of UPA. RESULTS Less than 10% (33/344; 95% CI: 6.5-12.7%) of pharmacies indicated the ability to immediately fill a UPA prescription, while 72% (224/311; 95% CI: 65.0-77.0%) of pharmacies without immediate availability reported the ability to order UPA, with the median predicted wait time of 24 h (IQR: 21.5 to 26.0 h). CONCLUSION Despite evidence for increased efficacy of UPA over levonorgestrel (LNG) ECPs, the availability of UPA in a sample of US major cities is extremely limited. Given that ECPs should be taken as soon as possible after unprotected sex, the long wait times when ordering UPA present an access barrier. Efforts to improve the availability of UPA are important to optimize the potential of ECPs to decrease unintended pregnancy following unprotected sex. IMPLICATIONS Interventions are needed to address barriers to obtaining UPA from retail pharmacies nationwide.

Emergency Contraception: Do Your Patients Have a Plan B?

Emergency contraception is used after unprotected sex, inadequately protected sex, or sexual assault to reduce the risk of pregnancy. Of emergency contraceptive methods available in the United States, the copper intrauterine device has the highest efficacy, followed by ulipristal acetate, levonorgestrel-containing emergency contraceptive pills, and the Yuzpe method. However, access to the most effective methods is limited. Although advanced prescription of emergency contraceptive pills and counseling on emergency contraception to all reproductive-aged women is recommended, women should be advised to contact their health care providers after taking emergency contraceptive pills to discuss possible copper intrauterine device placement and other follow-up.

Neuraxial blockade for external cephalic version: Cost analysis

Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates.

Contraception for Adolescents: Focusing on Long-Acting Reversible Contraceptives (LARC) to Improve Reproductive Health Outcomes

Adolescent pregnancy rates in the USA have reached an all-time low from their peak in the 1980s and 1990s. However, the USA maintains the highest rate of teenage pregnancy among developed nations. Adolescents experience higher typical use failure rates for user-dependent contraceptives compared to their adult counterparts. Long-acting reversible contraception (LARC), intrauterine devices (IUDs), and implants have failure rates that are both very low and independent of user age. In settings where the most effective methods are prioritized and access barriers are removed, the majority of adolescents initiate LARC. Use of LARC by adolescents significantly reduces rates of overall and repeat teen pregnancy. All methods of contraception are safe for use in teens, including IUDs and depot medroxyprogesterone acetate (DMPA). Dual use of LARC and barrier methods to reduce risk of sexually transmitted infection is the optimal contraceptive strategy for most adolescents. Adolescent access to evidence-based and confidential contraceptive services, provided in a manner that respects autonomy, is a vital public health goal.

Contraceptive Options for Women with Thrombophilia and Thromboembolic Disease

Thromboembolic diseases, including venous thromboembolism (VTE), are one of the leading causes of maternal mortality in the USA. However, for women at high risk of VTE due to thrombophilia or other risk factors, there is a large unmet need for appropriate contraceptive care. While combined hormonal contraception elevates VTE risk above that of nonusers, the highest risk periods are often during pregnancy and postpartum. Consequently, health care providers caring for women with VTE, or at high risk for VTE, should make every effort to address their contraceptive needs in an individualized and evidence-based fashion. This chapter explores current evidence on the safety of contraceptive use among women at high risk for thromboembolic disease and provides a framework for managing common contraceptive issues as they arise. Despite current research gaps, it is clear that most women under care for a current or a past VTE can safely use several effective contraceptive methods, including long-acting reversible contraception (LARC). Given the low typical-use failure rates of LARC methods, presenting such methods as first-line contraceptive agents should be routine in this population, as it should be for all women. Diligent attention to the contraceptive and preconception planning needs of women in this high-risk population will promote significant strides toward reducing unintended and mistimed pregnancy and its associated morbidity and mortality.