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What are the challenges facing women’s health care facilities today? According to those participating in Contraceptive Technology Update’s 1999 Contraception Survey, providers are moving to fast to educate themselves about the use of complementary and alternative medi cine and deal with the budget crunch brought on by the rise in use of the contraceptive injectable Depo-Provera (depot medroxyprogesterone acetate, or DMPA).
More than half of survey respondents responded "yes" to the question, "Is the use of alternative medicine by patients becoming a concern in their practice or facility?" That number has risen from the 28% level reported in 1998.
According to many survey respondents, the survey words "a concern" should be replaced by "accepted" because both patients and providers are expressing interest in alternative therapies.
"I would not classify it as a concern; patients and professionals are looking at alternative medicine," says Deborah Mathis, MSN, CRNP, women’s health coordinator at the University of Pennsylvania Student Health Center in Pittsburgh. "We have always discussed vitamin and mineral supplements to supplement other treatments, and we have had inservices and individual learning/ readings that co-workers share."
A number of facilities are encompassing alternative therapies in their practice, say survey respondents. About one-third of those who indicate use of such therapies say they are including herbal medicine, with 20% including massage therapy.
The Washington (DC) Free Clinic now offers acupuncture, reports Lois Wessel, FNP, director of primary care. There is a waiting list to see the acupuncturist, she notes.
"We are trying to educate ourselves and recommend those practices supported by either an extensively documented history of success or well-designed studies," says Patricia Carrick, FNP-C, clinic coordinator at Beaverhead Family Planning Clinic in Dillon, MT. "We try to maintain an open attitude and invite our patients to share their experiences so we can learn, too."
A 1997 national telephone survey of randomly selected households, mirroring a similar survey performed in 1991, showed that use of at least one of 16 alternative therapies increased from 33.8% in 1990 to 42.1% in 1997.1 The therapies showing the most increase in use included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. The probability of users visiting an alternative medicine practitioner increased from 36.3% to 46.3%, according to survey results.
"As [midwives], we look at alternative therapies, because we tend to draw [those] who want alternative therapy," says Debbie Freels, MSN, certified nurse midwife at University Physicians Clinic in Boonville, MO, and clinical instructor of nursing at University of Missouri at Colum bia. "The people I notice that for are mostly menopausal-aged women, but I have had a few pregnant women, too."
One finding from the 1997 telephone survey remains consistent with its earlier 1990 predecessor: More than 60% of patients who used alternative therapies did not disclose this information to their regular physicians.1
"We are trying to be very open-minded about it, because it is really important that they let us know exactly what they are taking," says Judy Lee, ARNP, women’s health nurse practitioner at Gateway District Health Department in Owings ville, KY. "I try to approach it [by asking] Are you using any herbal medications?’ then explain why I’m asking, because some of them become very defensive. It doesn’t make any difference, but I want to make sure that anything we prescribe isn’t going to cause an interaction problem."
Almost one-quarter of providers say clinic cost considerations come into play when start -ing patients on DMPA. As previously reported in CTU, many clinics are having to make hard choices as they find themselves caught between finite contraceptive budgets and escalating demands for the injections. (For details, see CTU, January 1998, p. 1.)
To meet the DMPA demand, Beaverhead Family Planning Clinic charges one flat fee for patients 19 years old and above and offers a sliding fee for younger patients, says Carrick.
Sometimes the restrictions set by certain managed care organizations also come into play, notes Ann Tyree, FNP-C, family nurse practitioner at Beach Physicians and Surgeons in Huntington Beach, CA.
"I have to write for authorization from the [health maintenance organization] for Depo, because they won’t give it unless I have good documentation that the patient can’t take oral contraceptives for some reason," Tyree explains. "The fact that it might be a better choice for this particular patient, or that the patient wants that method, does not matter."
1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997. Results of a follow-up national survey. JAMA 1998; 280:1,569-1,575.