MADIGAN ARMY MEDICAL CENTER -Reproductive health care is a readiness issue. It is a personal issue and a family issue. Deciding how and when to have or add to a family is a concern that touches the active duty service member and their family members. Madigan Army Medical Center on Joint Base Lewis-McChord, in alignment with Department of Defense initiatives, is working to expand access to reproductive care and contraception options.

In a memorandum dated Oct. 22, 2022, Department of Defense Secretary Lloyd Austin addressed this issue saying, "Our greatest strength is our people. There is no higher priority than taking care of our people, and ensuring their health and well-being."

Austin's memo was entitled, "Ensuring Access to Reproductive Health Care" and was a direct response to the U.S. Supreme Court striking down the 1973 Roe v. Wade decision which legalized abortion nationwide.

"The recent Supreme Court ruling in Dobbs v. Jackson Women's Health Organization has impacted access to reproductive health care with readiness, recruiting, and retention implications for the Force. Since the Supreme Court's decision, we have heard concerns from many of our service members and their families about the complexity and the uncertainty that they now face in accessing reproductive health care, including abortion services. We also recognize that recent developments may create legal and financial risk for our health care providers as they carry out their lawful federal duties. I am committed to the Department taking all appropriate action, within its authority and consistent with applicable federal law, as soon as possible to ensure that our service members and their families can access reproductive health care and our health care providers can operate effectively," stated Austin.

With these concerns in mind, Austin directed all military treatment facilities to improve access to reproductive health care.

Madigan has established walk-in contraceptive services, is expanding products it has available and has just held a contraceptive conference for clinicians currently providing such care and those wishing to start.

Walk-in Contraceptive Clinics

While Madigan and its clinics have supported a wide variety of contraceptive care for years, it has recently established walk-in options for patients seeking same-day services.

Focused on ensuring that all possible options are readily available to active duty service members, the clinic at the Okubo Soldier-Centered Medical Home on North Fort is open to active duty only. It is open on odd Wednesdays - the first, third and fifth (if applicable) - each month, from 8 to 11:30 a.m.

The main OB/GYN clinic serves active duty service members as well as eligible family members, on a space-available basis, on even Wednesdays - the second and fourth - each month, from noon to 3:30 p.m.

Both clinics are closed on federal holidays and training days. Patients must check in at the start of clinic hours, have a pregnancy test (if applicable) and take part in group education and counseling before having an individual appointment for contraception.

Patients should plan on being at the clinic for a minimum of two hours to complete this full process, but can expect to walk out having received an internal contraceptive or a prescription to pick up a medication one at the pharmacy.

For more information to include addresses and phone numbers for the clinics please visit: https://madigan.tricare.mil/Health-Services/Womens-Health-Pregnancy/Walk-in-Contraceptive-Services. To see what Madigan has for men's health, have a look here: https://www.dvidshub.net/video/848130/madigan-urology-services-overview-2022.

Apps for info on the go

In addition, two newer applications are available for mobile devices that are designed to aid in selecting options that are appropriate for the individual.

The Decide + Be Ready App is an evidence-based mobile application that was developed through a collaboration between the Uniformed Services University of Health Sciences, Web & Mobile Technology Program Management Office and the University of California San Francisco to educate and assist in the selection of a contraceptive option that most readily meets their individual needs.

This app can be downloaded in all the major app stores.

The Deployment Readiness Education for service women app also includes information for service members on contraception options; in addition, it advises on women's health care guidance and other subjects important during deployment.

In response to the Navy Bureau of Medicine identifying gaps in knowledge of deploying service women, the Solution Delivery Division Web & Mobile Technology Program Management Office collaborated with the Navy Bureau of Medicine Office of Women's Health to produce this app.

The DRES app can be accessed at mobile.health.mil/dres/.

Testifying before the House Armed Services Committee in July 2022, Gil Cisneros, the undersecretary of defense for personnel and readiness, affirmed that reproductive health care will not be diminished by recent changes to national policy, but emboldened.

"Service members can receive the same reproductive health care after Dobbs as they did before the ruling," said Cisneros. "Consistent with long-existing federal law, 'covered abortions' - those cases that involve rape, incest or where the life of the mother would be endangered - will continue to be authorized to use federal funds and facilities. There is no interruption to this care."

This health care includes regular health exams and cancer screenings, contraceptive care, pregnancy and delivery services, care for menopause and the tracking and treatment of the range of ailments that can befall a person and their reproductive system. Options for addressing challenges to fertility are also available.

To review reproductive health care under TRICARE, visit: https://www.tricare.mil/CoveredServices/IsItCovered/BirthControl.

Austin's memo outlined aspects of delivering care that would receive attention, especially focused on educating patients on their options. The walk-in clinics also bolster delivery of care. One product that will see changes to improve its availability is the intrauterine device, or IUD.

"We are currently updating our policies so that service members and their families will be able to receive those IUDs through the TRICARE health care system without having to pay a copay, which is currently the thing right now," Cisneros said. "We're changing our policy, updating it, so that the copay will be eliminated with that."

Time, travel and awareness

For care and services a patient needs that are not provided at their local MTF, policies for time away, if active duty, and reimbursement for travel expenses are being expanded to provide fuller coverage for these events.

As mentioned, expanding the knowledge base of what is available is a major focus of Austin and the DoD's efforts in addressing access to contraceptive care.

To that end, Madigan's reproductive health professionals staged a full-day conference with a dozen presentations on subjects including the latest in contraceptive care, insertion and removal of devices, unscheduled bleeding on contraceptives and the impacts of obesity on different contraceptive options.

"We didn't know exactly what to expect," said Lt. Col. (Dr.) Kelly Langan, the director for the Obstetrics and Gynecology Residency Program, in regards to attendance.

Langan noted that since the mandate came down from higher headquarters to expand these services, there has been interest from throughout the medical center and its outlying clinics for more information and educational resources.

To fulfill that need, the Department of OB/GYN brought together subject matter experts from not only the OB/GYN clinic but Family Medicine, Preventive Medicine and the Reproductive Endocrinology and Infertility clinics to get well into the weeds of subjects that impact reproduction and contraception.

Mary Paul Backman, an advanced registered nurse practitioner, gave an overview of the latest in contraceptive care that covered the different forms of birth control, their pros and cons, their availability at the Madigan Pharmacy, whether there is a copay and what their cost is at an outside pharmacy.

She led off her presentation by telling the crowd that a little knowledge in contraceptive history goes a long way in avoiding some of the mistakes of the past. She offered the example of early birth control pills producing strokes because the estrogen level was too high. That resulted in a wariness to use prescription birth control that still lingers for some patients.

Backman also repeatedly asked the audience how much a certain form of contraception costs, reiterating that the cost can be a real barrier to use for many patients. She encouraged the attendees to consider this when prescribing.

That consideration was echoed in the common, and repeatedly stated, notion amongst the clinicians that contraception must be shared decision-making. A provider should not decide what a patient needs and merely prescribe. It needs to be a conversation that includes potential efficacy, ease and likelihood of use and possible barriers and problems.

A full presentation was dedicated to the number one reason women stop using a contraceptive - unscheduled bleeding.

Lt. Col. (Dr.) Ashley Hall, a physician in OB/GYN, reviewed every major contraceptive method available for Madigan patients and what the data show on bleeding when using them. She and the crowd walked through the reasons this could happen, what should be done to address it and how a provider can work with their patient to make sure the contraception chosen is right for them.

"We see a large range of experience with contraception; we more often see the patients who are coming back because they're having problems with it. And so, we develop this negativity bias. And it's true, a lot choose to discontinue it, but a lot more are happy with it. So, we shouldn't discourage women from any particular method. But we do need to be honest about the side effects that they can experience," she said.

One method that is right for many people but is underutilized is vasectomy, according to Dr. Keith Peterson, a physician in Family Medicine who performs the procedure.

He reported data that show that vasectomy is three times less common than tubal ligation even though it requires less recovery time and fewer days off work than the female form of permanent sterilization.

Peterson said the most common side effect of the procedure is bruising, which he noted was seen in roughly two percent of cases. Otherwise, the common questions of whether it will affect any aspect of a man's sexual activity are all answered by Peterson with a no.

"Men should participate in long-term contraception," he concluded.

Much more information was shared during the conference and the attendees engaged with not only questions for the presenters but answers from other attendees. With so many experts in the room, clinicians found the answers they needed.