Clinical Edge Journal Scan

The next study explored ways to identify patients who have HCC using PIVKA-II (prothrombin induced by vitamin K deficiency/antagonist – II), a promising marker that may be more sensitive/specific than AFP in identifying patients with liver cancer. Feng et al. used enzyme-linked immunosorbent assay (ELISA) to measure serum PIVKA-II levels in 168 patients with HCC, 150 patients with benign liver disease, and 153 healthy controls. Patients with HCC had significantly higher median PIVKA-II levels (181.50 mAu/mL), compared with atients with noncancerous liver disease (28.6 mAU/mL) or healthy controls 21.82 mAU/mL), with p<0.0001. In addition, PIVKA-II was more sensitive (83.9% vs 64.3%) and more specific (91.5% vs 84.7%) than AFP in identifying patients with HCC. When PIVKA-II and AFP were combined, sensitivity (81.95%) and specificity (89.3%) were increased more, suggesting that this combination of markers may be most useful in clinical practice to identify patients who have HCC.

Finally, in patients whose HCC was treated with orthotopic liver transplantation, acute organ rejection was found to be linked to HCC recurrence. Gul-Klein et al. identified 252 patients who underwent liver transplantation for HCC between 2001 and 2015, 91 of whom had confirmed acute rejection, and 47 of whom had recurrent HCC (the median time to HCC recurrence was 20 months). HCC recurrence was identified in 28.6% of patients with acute rejection, and in 13% of patients without acute rejection (p=0.002). Acute rejection within 20 months of liver transplantation was identified as a significant risk factor for HCC recurrence in multivariate analysis (hazard ratio of 2.91). The authors suggested that more intensive monitoring for HCC recurrence may be appropriate for patients who have evidence of acute rejection.

The next study explored ways to identify patients who have HCC using PIVKA-II (prothrombin induced by vitamin K deficiency/antagonist – II), a promising marker that may be more sensitive/specific than AFP in identifying patients with liver cancer. Feng et al. used enzyme-linked immunosorbent assay (ELISA) to measure serum PIVKA-II levels in 168 patients with HCC, 150 patients with benign liver disease, and 153 healthy controls. Patients with HCC had significantly higher median PIVKA-II levels (181.50 mAu/mL), compared with atients with noncancerous liver disease (28.6 mAU/mL) or healthy controls 21.82 mAU/mL), with p<0.0001. In addition, PIVKA-II was more sensitive (83.9% vs 64.3%) and more specific (91.5% vs 84.7%) than AFP in identifying patients with HCC. When PIVKA-II and AFP were combined, sensitivity (81.95%) and specificity (89.3%) were increased more, suggesting that this combination of markers may be most useful in clinical practice to identify patients who have HCC.

Finally, in patients whose HCC was treated with orthotopic liver transplantation, acute organ rejection was found to be linked to HCC recurrence. Gul-Klein et al. identified 252 patients who underwent liver transplantation for HCC between 2001 and 2015, 91 of whom had confirmed acute rejection, and 47 of whom had recurrent HCC (the median time to HCC recurrence was 20 months). HCC recurrence was identified in 28.6% of patients with acute rejection, and in 13% of patients without acute rejection (p=0.002). Acute rejection within 20 months of liver transplantation was identified as a significant risk factor for HCC recurrence in multivariate analysis (hazard ratio of 2.91). The authors suggested that more intensive monitoring for HCC recurrence may be appropriate for patients who have evidence of acute rejection.

The next study explored ways to identify patients who have HCC using PIVKA-II (prothrombin induced by vitamin K deficiency/antagonist – II), a promising marker that may be more sensitive/specific than AFP in identifying patients with liver cancer. Feng et al. used enzyme-linked immunosorbent assay (ELISA) to measure serum PIVKA-II levels in 168 patients with HCC, 150 patients with benign liver disease, and 153 healthy controls. Patients with HCC had significantly higher median PIVKA-II levels (181.50 mAu/mL), compared with atients with noncancerous liver disease (28.6 mAU/mL) or healthy controls 21.82 mAU/mL), with p<0.0001. In addition, PIVKA-II was more sensitive (83.9% vs 64.3%) and more specific (91.5% vs 84.7%) than AFP in identifying patients with HCC. When PIVKA-II and AFP were combined, sensitivity (81.95%) and specificity (89.3%) were increased more, suggesting that this combination of markers may be most useful in clinical practice to identify patients who have HCC.

Finally, in patients whose HCC was treated with orthotopic liver transplantation, acute organ rejection was found to be linked to HCC recurrence. Gul-Klein et al. identified 252 patients who underwent liver transplantation for HCC between 2001 and 2015, 91 of whom had confirmed acute rejection, and 47 of whom had recurrent HCC (the median time to HCC recurrence was 20 months). HCC recurrence was identified in 28.6% of patients with acute rejection, and in 13% of patients without acute rejection (p=0.002). Acute rejection within 20 months of liver transplantation was identified as a significant risk factor for HCC recurrence in multivariate analysis (hazard ratio of 2.91). The authors suggested that more intensive monitoring for HCC recurrence may be appropriate for patients who have evidence of acute rejection.

Key clinical point: Women in rural areas were less likely to receive counseling about emergency contraception than urban women, but counseling rates were low for both groups (2% and 3%, respectively). 

Major finding: Between 2006 and 2017, 10% of rural women and 19% of urban women who had ever had sex reported ever using emergency contraception pills, and ever-use of emergency contraception pills more than doubled in both groups between 2006-2008 and 2015-2017.

Study details: The data come from 28,448 teens and women aged 15-44 years who participated in the National Survey of Family Growth between 2006 and 2017.

Disclosures: The study received no outside funding; one coauthor was supported by the Maine Economic Improvement Fund. The other researchers had no financial conflicts to disclose.

Source: Milkowski CM et al. Contracep X. 2021 Feb 8. doi: 10.1016/j.conx.2021.100061. 

Key clinical point: Women in rural areas were less likely to receive counseling about emergency contraception than urban women, but counseling rates were low for both groups (2% and 3%, respectively). 

Major finding: Between 2006 and 2017, 10% of rural women and 19% of urban women who had ever had sex reported ever using emergency contraception pills, and ever-use of emergency contraception pills more than doubled in both groups between 2006-2008 and 2015-2017.

Study details: The data come from 28,448 teens and women aged 15-44 years who participated in the National Survey of Family Growth between 2006 and 2017.

Disclosures: The study received no outside funding; one coauthor was supported by the Maine Economic Improvement Fund. The other researchers had no financial conflicts to disclose.

Source: Milkowski CM et al. Contracep X. 2021 Feb 8. doi: 10.1016/j.conx.2021.100061. 

Key clinical point: Women in rural areas were less likely to receive counseling about emergency contraception than urban women, but counseling rates were low for both groups (2% and 3%, respectively). 

Major finding: Between 2006 and 2017, 10% of rural women and 19% of urban women who had ever had sex reported ever using emergency contraception pills, and ever-use of emergency contraception pills more than doubled in both groups between 2006-2008 and 2015-2017.

Study details: The data come from 28,448 teens and women aged 15-44 years who participated in the National Survey of Family Growth between 2006 and 2017.

Disclosures: The study received no outside funding; one coauthor was supported by the Maine Economic Improvement Fund. The other researchers had no financial conflicts to disclose.

Source: Milkowski CM et al. Contracep X. 2021 Feb 8. doi: 10.1016/j.conx.2021.100061. 

Key clinical point: Successful implementation of immediate postpartum LARC was associated with clinical implementation champions, often supported by an interdisciplinary team, and favorable payer reimbursement policies.

Major finding: On average, maternity hospitals used 18 suggested strategies to implement immediate postpartum long-active reversible contraception (LARC) services.

Study details: The data come from a case study of 11 maternity hospitals and included semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators.

Disclosures: Lead author Dr. Moniz was supported by the Agency for Healthcare Research and Quality (AHRQ); coauthors were supported by the National Institutes of Health (NIH) National Institute of Diabetes and Digestive and Kidney Diseases.

Source: Moniz MH et al. Implement Sci Commun. 2021 Apr 12. doi: 10.1186/s43058-021-00136-7.

Key clinical point: Successful implementation of immediate postpartum LARC was associated with clinical implementation champions, often supported by an interdisciplinary team, and favorable payer reimbursement policies.

Major finding: On average, maternity hospitals used 18 suggested strategies to implement immediate postpartum long-active reversible contraception (LARC) services.

Study details: The data come from a case study of 11 maternity hospitals and included semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators.

Disclosures: Lead author Dr. Moniz was supported by the Agency for Healthcare Research and Quality (AHRQ); coauthors were supported by the National Institutes of Health (NIH) National Institute of Diabetes and Digestive and Kidney Diseases.

Source: Moniz MH et al. Implement Sci Commun. 2021 Apr 12. doi: 10.1186/s43058-021-00136-7.

Key clinical point: Successful implementation of immediate postpartum LARC was associated with clinical implementation champions, often supported by an interdisciplinary team, and favorable payer reimbursement policies.

Major finding: On average, maternity hospitals used 18 suggested strategies to implement immediate postpartum long-active reversible contraception (LARC) services.

Study details: The data come from a case study of 11 maternity hospitals and included semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators.

Disclosures: Lead author Dr. Moniz was supported by the Agency for Healthcare Research and Quality (AHRQ); coauthors were supported by the National Institutes of Health (NIH) National Institute of Diabetes and Digestive and Kidney Diseases.

Source: Moniz MH et al. Implement Sci Commun. 2021 Apr 12. doi: 10.1186/s43058-021-00136-7.

Key clinical point: African American males aged 14-15 years were more likely than 18- to 19- year-old males to use a condom the last time they had sex.

Major finding: Increased condom use was associated with personal factors including high positive attachment to the boyfriend/girlfriend as was a greater number of sexual partners, younger age at first sexual encounter, and knowledge that the individual had a sexually-transmitted infection in the past year.

Study details: The data come from the Mobile Youth Survey, a community-based survey of adolescents in Mobile, Alabama, between 1998 and 2011; the study population included 3,718 individuals.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Chambliss JT et al. Am J Mens Health. 2021 Apr 15. doi: 10.1177/15579883211009039.

Key clinical point: African American males aged 14-15 years were more likely than 18- to 19- year-old males to use a condom the last time they had sex.

Major finding: Increased condom use was associated with personal factors including high positive attachment to the boyfriend/girlfriend as was a greater number of sexual partners, younger age at first sexual encounter, and knowledge that the individual had a sexually-transmitted infection in the past year.

Study details: The data come from the Mobile Youth Survey, a community-based survey of adolescents in Mobile, Alabama, between 1998 and 2011; the study population included 3,718 individuals.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Chambliss JT et al. Am J Mens Health. 2021 Apr 15. doi: 10.1177/15579883211009039.

Key clinical point: African American males aged 14-15 years were more likely than 18- to 19- year-old males to use a condom the last time they had sex.

Major finding: Increased condom use was associated with personal factors including high positive attachment to the boyfriend/girlfriend as was a greater number of sexual partners, younger age at first sexual encounter, and knowledge that the individual had a sexually-transmitted infection in the past year.

Study details: The data come from the Mobile Youth Survey, a community-based survey of adolescents in Mobile, Alabama, between 1998 and 2011; the study population included 3,718 individuals.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Chambliss JT et al. Am J Mens Health. 2021 Apr 15. doi: 10.1177/15579883211009039.

Key clinical point: Immediate postpartum insertion of copper intrauterine devices is effective and acceptable for women living in low- and middle-income countries.

Major finding: The six-month continuation rate for immediate postpartum copper IUDs was 87% in low- and middle-income countries; pooled estimated rates of adverse outcomes at six months were 6% for expulsion, 5% for removal, and 0.2% for infection.

Study details: The data come from a meta-analysis of 11 studies of the use and continuation of postpartum long-acting reversible contraception in low- and middle-income countries, including 2 randomized, controlled trials and 9 prospective cohort studies.

Disclosures: The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Doris Duke Charitable Foundation. The researchers had no financial conflicts to disclose.

Source: Marchin A et al. J Womens Health Dev. 2021 Mar 18. doi: 10.26502/fjwhd.2644-28840059. 

Key clinical point: Immediate postpartum insertion of copper intrauterine devices is effective and acceptable for women living in low- and middle-income countries.

Major finding: The six-month continuation rate for immediate postpartum copper IUDs was 87% in low- and middle-income countries; pooled estimated rates of adverse outcomes at six months were 6% for expulsion, 5% for removal, and 0.2% for infection.

Study details: The data come from a meta-analysis of 11 studies of the use and continuation of postpartum long-acting reversible contraception in low- and middle-income countries, including 2 randomized, controlled trials and 9 prospective cohort studies.

Disclosures: The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Doris Duke Charitable Foundation. The researchers had no financial conflicts to disclose.

Source: Marchin A et al. J Womens Health Dev. 2021 Mar 18. doi: 10.26502/fjwhd.2644-28840059. 

Key clinical point: Immediate postpartum insertion of copper intrauterine devices is effective and acceptable for women living in low- and middle-income countries.

Major finding: The six-month continuation rate for immediate postpartum copper IUDs was 87% in low- and middle-income countries; pooled estimated rates of adverse outcomes at six months were 6% for expulsion, 5% for removal, and 0.2% for infection.

Study details: The data come from a meta-analysis of 11 studies of the use and continuation of postpartum long-acting reversible contraception in low- and middle-income countries, including 2 randomized, controlled trials and 9 prospective cohort studies.

Disclosures: The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Doris Duke Charitable Foundation. The researchers had no financial conflicts to disclose.

Source: Marchin A et al. J Womens Health Dev. 2021 Mar 18. doi: 10.26502/fjwhd.2644-28840059. 

Key clinical point: Women taking oral contraceptives showed lower volume in the hypothalamic and pituitary gland compared to normally cycling women based on magnetic resonance imaging (MRI) data.

Major finding: Hypothalamic and pituitary volumes were significantly lower in women using oral contraceptives compared to naturally cycling women (B = -81.2 for both; P = 0.002 and P = -0.04, respectively).

Study details: The data come from a prospective study of 50 healthy women aged 18 and older, including 21 oral contraceptive users, and 29 naturally cycling women.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Chen KX et al. PLos One. 2021 Apr 21.  doi: 10.1371/journal.pone.0249482. eCollection 2021.

Key clinical point: Women taking oral contraceptives showed lower volume in the hypothalamic and pituitary gland compared to normally cycling women based on magnetic resonance imaging (MRI) data.

Major finding: Hypothalamic and pituitary volumes were significantly lower in women using oral contraceptives compared to naturally cycling women (B = -81.2 for both; P = 0.002 and P = -0.04, respectively).

Study details: The data come from a prospective study of 50 healthy women aged 18 and older, including 21 oral contraceptive users, and 29 naturally cycling women.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Chen KX et al. PLos One. 2021 Apr 21.  doi: 10.1371/journal.pone.0249482. eCollection 2021.

Key clinical point: Women taking oral contraceptives showed lower volume in the hypothalamic and pituitary gland compared to normally cycling women based on magnetic resonance imaging (MRI) data.

Major finding: Hypothalamic and pituitary volumes were significantly lower in women using oral contraceptives compared to naturally cycling women (B = -81.2 for both; P = 0.002 and P = -0.04, respectively).

Study details: The data come from a prospective study of 50 healthy women aged 18 and older, including 21 oral contraceptive users, and 29 naturally cycling women.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Chen KX et al. PLos One. 2021 Apr 21.  doi: 10.1371/journal.pone.0249482. eCollection 2021.

Key clinical point: Women’s attitudes towards contraceptives affect their willingness to accept a novel HIV prevention product in the form of a vaginal ring; pre-emptive counseling to address women’s concerns may encourage acceptance.

Major finding: Women surveyed about their experience using a monthly dapivirine vaginal ring reported side effects related to menses, and expressed some concern about the long-term impact of the ring and contraception use on fertility.

Study details: The data come from a subset of 214 women of childbearing age enrolled in the ASPIRE trial at 15 sites in Malawi, South Africa, Uganda, and Zambia who received a monthly dapivirine vaginal ring designed for HIV prevention.

Disclosures: The study was supported by the e National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health. The vaginal rings were supplied by the International Partnership for Microbicides (IPM). The researchers had no financial conflicts to disclose.

Source: Leslie J et al. BMC Womens Health. 2021 Apr 23. doi: 10.1186/s12905-021-01321-5.

Key clinical point: Women’s attitudes towards contraceptives affect their willingness to accept a novel HIV prevention product in the form of a vaginal ring; pre-emptive counseling to address women’s concerns may encourage acceptance.

Major finding: Women surveyed about their experience using a monthly dapivirine vaginal ring reported side effects related to menses, and expressed some concern about the long-term impact of the ring and contraception use on fertility.

Study details: The data come from a subset of 214 women of childbearing age enrolled in the ASPIRE trial at 15 sites in Malawi, South Africa, Uganda, and Zambia who received a monthly dapivirine vaginal ring designed for HIV prevention.

Disclosures: The study was supported by the e National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health. The vaginal rings were supplied by the International Partnership for Microbicides (IPM). The researchers had no financial conflicts to disclose.

Source: Leslie J et al. BMC Womens Health. 2021 Apr 23. doi: 10.1186/s12905-021-01321-5.

Key clinical point: Women’s attitudes towards contraceptives affect their willingness to accept a novel HIV prevention product in the form of a vaginal ring; pre-emptive counseling to address women’s concerns may encourage acceptance.

Major finding: Women surveyed about their experience using a monthly dapivirine vaginal ring reported side effects related to menses, and expressed some concern about the long-term impact of the ring and contraception use on fertility.

Study details: The data come from a subset of 214 women of childbearing age enrolled in the ASPIRE trial at 15 sites in Malawi, South Africa, Uganda, and Zambia who received a monthly dapivirine vaginal ring designed for HIV prevention.

Disclosures: The study was supported by the e National Institute of Allergy and Infectious Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institute of Mental Health. The vaginal rings were supplied by the International Partnership for Microbicides (IPM). The researchers had no financial conflicts to disclose.

Source: Leslie J et al. BMC Womens Health. 2021 Apr 23. doi: 10.1186/s12905-021-01321-5.

Key clinical point: Women who used progestin-only contraceptives experienced significantly greater weight gain than those using nonhormonal copper intrauterine devices.

Major finding: After 18 months, all treatment groups gained weight, but the average gain in the DMPA-IM group (3.5 kg) was significantly higher compared with both the LNG implant group (2.4 kg) and copper IUD group (1.5 kg).

Study details: The data come from a secondary analysis of women enrolled in the Evidence for Contraceptive options and HIV Outcomes (ECHO) trial and included 7,829 women aged 16-35 years seen at 12 sites in Kenya, South Africa, and Zambia between December 2015 and October 2018. Of these, 2,609 received intramuscular depot medroxyprogesterone acetate (DMPA-IM), 2,613 received a levonorgestrel (LNG) implant, and 2,607 received a copper intrauterine device (IUD).

Disclosures: The study was supported by the Bill & Melinda Gates Foundation, US Agency for International Development (USAID) and the President's Emergency Plan for AIDS Relief, Swedish International Development Cooperation Agency, South African Medical Research Council, and UNFPA.

Source: Beksinska M et al. EClinicalMedicine. 2021 Apr 6. doi: 0.1016/j.eclinm.2021.100800.

Key clinical point: Women who used progestin-only contraceptives experienced significantly greater weight gain than those using nonhormonal copper intrauterine devices.

Major finding: After 18 months, all treatment groups gained weight, but the average gain in the DMPA-IM group (3.5 kg) was significantly higher compared with both the LNG implant group (2.4 kg) and copper IUD group (1.5 kg).

Study details: The data come from a secondary analysis of women enrolled in the Evidence for Contraceptive options and HIV Outcomes (ECHO) trial and included 7,829 women aged 16-35 years seen at 12 sites in Kenya, South Africa, and Zambia between December 2015 and October 2018. Of these, 2,609 received intramuscular depot medroxyprogesterone acetate (DMPA-IM), 2,613 received a levonorgestrel (LNG) implant, and 2,607 received a copper intrauterine device (IUD).

Disclosures: The study was supported by the Bill & Melinda Gates Foundation, US Agency for International Development (USAID) and the President's Emergency Plan for AIDS Relief, Swedish International Development Cooperation Agency, South African Medical Research Council, and UNFPA.

Source: Beksinska M et al. EClinicalMedicine. 2021 Apr 6. doi: 0.1016/j.eclinm.2021.100800.

Key clinical point: Women who used progestin-only contraceptives experienced significantly greater weight gain than those using nonhormonal copper intrauterine devices.

Major finding: After 18 months, all treatment groups gained weight, but the average gain in the DMPA-IM group (3.5 kg) was significantly higher compared with both the LNG implant group (2.4 kg) and copper IUD group (1.5 kg).

Study details: The data come from a secondary analysis of women enrolled in the Evidence for Contraceptive options and HIV Outcomes (ECHO) trial and included 7,829 women aged 16-35 years seen at 12 sites in Kenya, South Africa, and Zambia between December 2015 and October 2018. Of these, 2,609 received intramuscular depot medroxyprogesterone acetate (DMPA-IM), 2,613 received a levonorgestrel (LNG) implant, and 2,607 received a copper intrauterine device (IUD).

Disclosures: The study was supported by the Bill & Melinda Gates Foundation, US Agency for International Development (USAID) and the President's Emergency Plan for AIDS Relief, Swedish International Development Cooperation Agency, South African Medical Research Council, and UNFPA.

Source: Beksinska M et al. EClinicalMedicine. 2021 Apr 6. doi: 0.1016/j.eclinm.2021.100800.

Key clinical point: Hispanic patients with a higher level of English language acculturation were less likely to use birth control and may require a more detailed discussion of the options for family planning.

Major finding: Hispanic women who reported using birth control had significantly lower English language acculturation compared to those who reported no birth control

Study details: The data come from surveys of 225 Hispanic women that combined the number of years lived in the U.S., the Short Acculturation Scale for Hispanics, and questions about family planning behaviors.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Chamberlain R et al. Kans J Med. 2021 Apr 19. doi: 10.17161/kjm.vol1414845.

Key clinical point: Hispanic patients with a higher level of English language acculturation were less likely to use birth control and may require a more detailed discussion of the options for family planning.

Major finding: Hispanic women who reported using birth control had significantly lower English language acculturation compared to those who reported no birth control

Study details: The data come from surveys of 225 Hispanic women that combined the number of years lived in the U.S., the Short Acculturation Scale for Hispanics, and questions about family planning behaviors.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Chamberlain R et al. Kans J Med. 2021 Apr 19. doi: 10.17161/kjm.vol1414845.

Key clinical point: Hispanic patients with a higher level of English language acculturation were less likely to use birth control and may require a more detailed discussion of the options for family planning.

Major finding: Hispanic women who reported using birth control had significantly lower English language acculturation compared to those who reported no birth control

Study details: The data come from surveys of 225 Hispanic women that combined the number of years lived in the U.S., the Short Acculturation Scale for Hispanics, and questions about family planning behaviors.

Disclosures: The study received no outside funding. The researchers had no financial conflicts to disclose.

Source: Chamberlain R et al. Kans J Med. 2021 Apr 19. doi: 10.17161/kjm.vol1414845.

Immediate postpartum long-acting reversible contraception (LARC) represents a safe and effective contraceptive strategy. Despite national guidelines recommending universal patient access, hospitals face significant barriers to offering inpatient LARCs. It is unclear why some hospitals successfully implement immediate postpartum LARCs, while others do not.

Moniz et al conducted a comparative, multiple case study of immediate postpartum LARC implementation at eleven “early adopter” U.S. hospitals and analyzed each hospital’s implementation strategy to produce generalizable knowledge about how and under what circumstances implementation of immediate postpartum LARCs unfold successfully. Between 2017-2018, the authors conducted single-day site visits and 78 semi-structured interviews with a variety of stakeholders (clinician champions, nurses, pharmacists, revenue cycle staff, and hospital administration). On average, sites used 18 (range 11-22) implementation strategies, including assessing institutional readiness for, and barriers to, implementation of immediate postpartum LARC, engaging reproductive justice experts and community resources to address social determinants of health, involving patients in implementation planning, and developing quality monitoring processes to evaluate clinical processes and outcomes. The researchers found that successful implementation of immediate postpartum LARC required three essential conditions: effective implementation champions who are supported by a multidisciplinary implementation team; creating an enabling financial environment; and engaging hospital administration. Additional findings from this study call for more support for individuals leading change in complex care settings, intentionally designing implementation interventions that take into account local contextual influences, and meaningfully engaging patients in the implementation process.

Of postpartum women, 61% in low- and middle-income countries (LMIC) have an unmet contraceptive need and many face high rates of short interpregnancy intervals (Moore). Additionally, 51%-96% of postpartum women in LMIC use short-acting methods of contraception (Moore), further highlighting the need for increased access to immediate postpartum LARC in LMIC. Data on the use and continuation of immediate postpartum LARC in LMIC is limited. Marchin et al conducted a systematic review and meta-analysis to determine 6-month continuation rates of immediate postpartum LARCs among women in 69 low-income countries that were enrolled in the Family Planning 2020 initiative. The meta-analysis ultimately focused on the copper IUD due to the absence of relevant studies on other LARC methods. The meta-analysis of 12 studies resulted in a pooled 6-month continuation rate for immediate postpartum copper IUDs of 87%, a rate comparable to continuation rates found in higher-income countries. This estimate had significant heterogeneity between studies. Secondary outcomes of expulsion, removal, and infection rates were low at 6%, 5%, and 0.2% respectively. High 6-month continuation rates and a low rate of adverse outcomes suggest immediate postpartum copper IUD insertion represents a feasible and acceptable postpartum contraceptive option for women living in LMIC.

In cases where contraception methods fail, are used incorrectly, or are not used at all, emergency contraception (EC) can be used after intercourse to prevent pregnancy. Timely access to, and accurate knowledge of, EC are especially important for rural women who are more likely to experience an unintended pregnancy resulting in a live birth compared to urban women. Milkowski et al analyzed publicly available data from the National Survey of Family Growth to estimate differences in oral EC use, access, and counseling by rural-urban county of residence among U.S. women aged 15-44 years. 10% of rural and 19% of urban women who had ever been sexually active reported ever using EC pills. Over the course of the study period (2006-2017), the percentage of women reporting ever-use of EC increased linearly in both rural and urban populations, with the prevalence of EC ever-use more than doubling in each group. This observation likely reflects an overall increase in EC use during a time period in which the federal government enacted several policies to improve access to EC. The study findings also highlight the need for improved patient counseling on EC. While the overall prevalence of EC counseling was low among all women, rural women were less likely to have received counseling on EC when compared to urban women.

Although many studies report weight gain in users of progestin-only hormonal contraception (POC), a recent Cochrane systematic review found that there was insufficient evidence to determine the effect of POCs on weight (Lopez). Beksinska et al conducted a secondary analysis of prospective weight change among women enrolled in the Evidence for Contraceptive options and HIV Outcomes (ECHO) trial, which was an open label, prospective, randomized multicenter trial that compared the risk of HIV acquisition among women randomized to injectable contraception (DMPA), the copper IUD, or a second generation two rod levonorgestrel (LNG) implant Jadelle^Ò. This trial was conducted at 12 sites across four African countries between 2015 and 2018. Eligible study participants were nonpregnant, HIV negative, sexually active women aged 16-35 years who desired contraception. The final sample size included 7,014 women randomly assigned to receive DMPA (2,293), the LNG implant (2,372), or the copper IUD (2,349). Using a standardized protocol and calibrated equipment across all study sites, weight and height were measured at baseline and at study exit at 12, 15, or 18 months. The mean weight increased amongst all three contraceptive groups and was significantly different in magnitude, with the largest gain in the DMPA group (3.5 kg), 2.4 kg in the LNG implant group, and 1.5 kg in the copper IUD group. Unlike copper IUD users, women in the DMPA and LNG implant group continued to gain weight after 1 year of contraceptive use. It is noteworthy that, regardless of contraceptive method allocation, not all women gained weight and a small proportion of women lost weight. When choosing a contraceptive method, women using POCs should be counselled about the potential side effect of weight gain.

References:
Moniz MH, Bonawitz K, Wetmore MK, et al. Implementing immediate postpartum contraception: a comparative case study at 11 hospitals. Implement Sci Commun. 2021;2(1):42. Published 2021 Apr 12.

Moore Z, Pfitzer A, Gubin R, et al. Missed opportunities for family planning: an analysis of pregnancy risk and contraceptive method use among postpartum women in 21 low- and middle-income countries. Contraception 92 (2015): 31–39.
 

Marchin A, Moss A, Harrison M. A Meta-Analysis of Postpartum Copper IUD Continuation Rates in Low- and Middle-Income Countries. J Womens Health Dev. 2021;4(1):36-46.

Milkowski CM, Ziller EC, Ahrens KA. Rural-urban residence and emergency contraception use, access, and counseling in the United States, 2006-2017. Contracept X. 2021;3:100061.

Lopez L.M., Ramesh S., Chen M. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev. 2016 doi: 10.1002/14651858.CD008815.pub2.

Beksinska et al. “Weight change among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: Findings from a randomised, multicentre, open-label trial. EClinicalMedicine. 2021;34:100800.

Immediate postpartum long-acting reversible contraception (LARC) represents a safe and effective contraceptive strategy. Despite national guidelines recommending universal patient access, hospitals face significant barriers to offering inpatient LARCs. It is unclear why some hospitals successfully implement immediate postpartum LARCs, while others do not.

Moniz et al conducted a comparative, multiple case study of immediate postpartum LARC implementation at eleven “early adopter” U.S. hospitals and analyzed each hospital’s implementation strategy to produce generalizable knowledge about how and under what circumstances implementation of immediate postpartum LARCs unfold successfully. Between 2017-2018, the authors conducted single-day site visits and 78 semi-structured interviews with a variety of stakeholders (clinician champions, nurses, pharmacists, revenue cycle staff, and hospital administration). On average, sites used 18 (range 11-22) implementation strategies, including assessing institutional readiness for, and barriers to, implementation of immediate postpartum LARC, engaging reproductive justice experts and community resources to address social determinants of health, involving patients in implementation planning, and developing quality monitoring processes to evaluate clinical processes and outcomes. The researchers found that successful implementation of immediate postpartum LARC required three essential conditions: effective implementation champions who are supported by a multidisciplinary implementation team; creating an enabling financial environment; and engaging hospital administration. Additional findings from this study call for more support for individuals leading change in complex care settings, intentionally designing implementation interventions that take into account local contextual influences, and meaningfully engaging patients in the implementation process.

Of postpartum women, 61% in low- and middle-income countries (LMIC) have an unmet contraceptive need and many face high rates of short interpregnancy intervals (Moore). Additionally, 51%-96% of postpartum women in LMIC use short-acting methods of contraception (Moore), further highlighting the need for increased access to immediate postpartum LARC in LMIC. Data on the use and continuation of immediate postpartum LARC in LMIC is limited. Marchin et al conducted a systematic review and meta-analysis to determine 6-month continuation rates of immediate postpartum LARCs among women in 69 low-income countries that were enrolled in the Family Planning 2020 initiative. The meta-analysis ultimately focused on the copper IUD due to the absence of relevant studies on other LARC methods. The meta-analysis of 12 studies resulted in a pooled 6-month continuation rate for immediate postpartum copper IUDs of 87%, a rate comparable to continuation rates found in higher-income countries. This estimate had significant heterogeneity between studies. Secondary outcomes of expulsion, removal, and infection rates were low at 6%, 5%, and 0.2% respectively. High 6-month continuation rates and a low rate of adverse outcomes suggest immediate postpartum copper IUD insertion represents a feasible and acceptable postpartum contraceptive option for women living in LMIC.

In cases where contraception methods fail, are used incorrectly, or are not used at all, emergency contraception (EC) can be used after intercourse to prevent pregnancy. Timely access to, and accurate knowledge of, EC are especially important for rural women who are more likely to experience an unintended pregnancy resulting in a live birth compared to urban women. Milkowski et al analyzed publicly available data from the National Survey of Family Growth to estimate differences in oral EC use, access, and counseling by rural-urban county of residence among U.S. women aged 15-44 years. 10% of rural and 19% of urban women who had ever been sexually active reported ever using EC pills. Over the course of the study period (2006-2017), the percentage of women reporting ever-use of EC increased linearly in both rural and urban populations, with the prevalence of EC ever-use more than doubling in each group. This observation likely reflects an overall increase in EC use during a time period in which the federal government enacted several policies to improve access to EC. The study findings also highlight the need for improved patient counseling on EC. While the overall prevalence of EC counseling was low among all women, rural women were less likely to have received counseling on EC when compared to urban women.

Although many studies report weight gain in users of progestin-only hormonal contraception (POC), a recent Cochrane systematic review found that there was insufficient evidence to determine the effect of POCs on weight (Lopez). Beksinska et al conducted a secondary analysis of prospective weight change among women enrolled in the Evidence for Contraceptive options and HIV Outcomes (ECHO) trial, which was an open label, prospective, randomized multicenter trial that compared the risk of HIV acquisition among women randomized to injectable contraception (DMPA), the copper IUD, or a second generation two rod levonorgestrel (LNG) implant Jadelle^Ò. This trial was conducted at 12 sites across four African countries between 2015 and 2018. Eligible study participants were nonpregnant, HIV negative, sexually active women aged 16-35 years who desired contraception. The final sample size included 7,014 women randomly assigned to receive DMPA (2,293), the LNG implant (2,372), or the copper IUD (2,349). Using a standardized protocol and calibrated equipment across all study sites, weight and height were measured at baseline and at study exit at 12, 15, or 18 months. The mean weight increased amongst all three contraceptive groups and was significantly different in magnitude, with the largest gain in the DMPA group (3.5 kg), 2.4 kg in the LNG implant group, and 1.5 kg in the copper IUD group. Unlike copper IUD users, women in the DMPA and LNG implant group continued to gain weight after 1 year of contraceptive use. It is noteworthy that, regardless of contraceptive method allocation, not all women gained weight and a small proportion of women lost weight. When choosing a contraceptive method, women using POCs should be counselled about the potential side effect of weight gain.

References:
Moniz MH, Bonawitz K, Wetmore MK, et al. Implementing immediate postpartum contraception: a comparative case study at 11 hospitals. Implement Sci Commun. 2021;2(1):42. Published 2021 Apr 12.

Moore Z, Pfitzer A, Gubin R, et al. Missed opportunities for family planning: an analysis of pregnancy risk and contraceptive method use among postpartum women in 21 low- and middle-income countries. Contraception 92 (2015): 31–39.
 

Marchin A, Moss A, Harrison M. A Meta-Analysis of Postpartum Copper IUD Continuation Rates in Low- and Middle-Income Countries. J Womens Health Dev. 2021;4(1):36-46.

Milkowski CM, Ziller EC, Ahrens KA. Rural-urban residence and emergency contraception use, access, and counseling in the United States, 2006-2017. Contracept X. 2021;3:100061.

Lopez L.M., Ramesh S., Chen M. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev. 2016 doi: 10.1002/14651858.CD008815.pub2.

Beksinska et al. “Weight change among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: Findings from a randomised, multicentre, open-label trial. EClinicalMedicine. 2021;34:100800.

Immediate postpartum long-acting reversible contraception (LARC) represents a safe and effective contraceptive strategy. Despite national guidelines recommending universal patient access, hospitals face significant barriers to offering inpatient LARCs. It is unclear why some hospitals successfully implement immediate postpartum LARCs, while others do not.

Moniz et al conducted a comparative, multiple case study of immediate postpartum LARC implementation at eleven “early adopter” U.S. hospitals and analyzed each hospital’s implementation strategy to produce generalizable knowledge about how and under what circumstances implementation of immediate postpartum LARCs unfold successfully. Between 2017-2018, the authors conducted single-day site visits and 78 semi-structured interviews with a variety of stakeholders (clinician champions, nurses, pharmacists, revenue cycle staff, and hospital administration). On average, sites used 18 (range 11-22) implementation strategies, including assessing institutional readiness for, and barriers to, implementation of immediate postpartum LARC, engaging reproductive justice experts and community resources to address social determinants of health, involving patients in implementation planning, and developing quality monitoring processes to evaluate clinical processes and outcomes. The researchers found that successful implementation of immediate postpartum LARC required three essential conditions: effective implementation champions who are supported by a multidisciplinary implementation team; creating an enabling financial environment; and engaging hospital administration. Additional findings from this study call for more support for individuals leading change in complex care settings, intentionally designing implementation interventions that take into account local contextual influences, and meaningfully engaging patients in the implementation process.

Of postpartum women, 61% in low- and middle-income countries (LMIC) have an unmet contraceptive need and many face high rates of short interpregnancy intervals (Moore). Additionally, 51%-96% of postpartum women in LMIC use short-acting methods of contraception (Moore), further highlighting the need for increased access to immediate postpartum LARC in LMIC. Data on the use and continuation of immediate postpartum LARC in LMIC is limited. Marchin et al conducted a systematic review and meta-analysis to determine 6-month continuation rates of immediate postpartum LARCs among women in 69 low-income countries that were enrolled in the Family Planning 2020 initiative. The meta-analysis ultimately focused on the copper IUD due to the absence of relevant studies on other LARC methods. The meta-analysis of 12 studies resulted in a pooled 6-month continuation rate for immediate postpartum copper IUDs of 87%, a rate comparable to continuation rates found in higher-income countries. This estimate had significant heterogeneity between studies. Secondary outcomes of expulsion, removal, and infection rates were low at 6%, 5%, and 0.2% respectively. High 6-month continuation rates and a low rate of adverse outcomes suggest immediate postpartum copper IUD insertion represents a feasible and acceptable postpartum contraceptive option for women living in LMIC.

In cases where contraception methods fail, are used incorrectly, or are not used at all, emergency contraception (EC) can be used after intercourse to prevent pregnancy. Timely access to, and accurate knowledge of, EC are especially important for rural women who are more likely to experience an unintended pregnancy resulting in a live birth compared to urban women. Milkowski et al analyzed publicly available data from the National Survey of Family Growth to estimate differences in oral EC use, access, and counseling by rural-urban county of residence among U.S. women aged 15-44 years. 10% of rural and 19% of urban women who had ever been sexually active reported ever using EC pills. Over the course of the study period (2006-2017), the percentage of women reporting ever-use of EC increased linearly in both rural and urban populations, with the prevalence of EC ever-use more than doubling in each group. This observation likely reflects an overall increase in EC use during a time period in which the federal government enacted several policies to improve access to EC. The study findings also highlight the need for improved patient counseling on EC. While the overall prevalence of EC counseling was low among all women, rural women were less likely to have received counseling on EC when compared to urban women.

Although many studies report weight gain in users of progestin-only hormonal contraception (POC), a recent Cochrane systematic review found that there was insufficient evidence to determine the effect of POCs on weight (Lopez). Beksinska et al conducted a secondary analysis of prospective weight change among women enrolled in the Evidence for Contraceptive options and HIV Outcomes (ECHO) trial, which was an open label, prospective, randomized multicenter trial that compared the risk of HIV acquisition among women randomized to injectable contraception (DMPA), the copper IUD, or a second generation two rod levonorgestrel (LNG) implant Jadelle^Ò. This trial was conducted at 12 sites across four African countries between 2015 and 2018. Eligible study participants were nonpregnant, HIV negative, sexually active women aged 16-35 years who desired contraception. The final sample size included 7,014 women randomly assigned to receive DMPA (2,293), the LNG implant (2,372), or the copper IUD (2,349). Using a standardized protocol and calibrated equipment across all study sites, weight and height were measured at baseline and at study exit at 12, 15, or 18 months. The mean weight increased amongst all three contraceptive groups and was significantly different in magnitude, with the largest gain in the DMPA group (3.5 kg), 2.4 kg in the LNG implant group, and 1.5 kg in the copper IUD group. Unlike copper IUD users, women in the DMPA and LNG implant group continued to gain weight after 1 year of contraceptive use. It is noteworthy that, regardless of contraceptive method allocation, not all women gained weight and a small proportion of women lost weight. When choosing a contraceptive method, women using POCs should be counselled about the potential side effect of weight gain.

References:
Moniz MH, Bonawitz K, Wetmore MK, et al. Implementing immediate postpartum contraception: a comparative case study at 11 hospitals. Implement Sci Commun. 2021;2(1):42. Published 2021 Apr 12.

Moore Z, Pfitzer A, Gubin R, et al. Missed opportunities for family planning: an analysis of pregnancy risk and contraceptive method use among postpartum women in 21 low- and middle-income countries. Contraception 92 (2015): 31–39.
 

Marchin A, Moss A, Harrison M. A Meta-Analysis of Postpartum Copper IUD Continuation Rates in Low- and Middle-Income Countries. J Womens Health Dev. 2021;4(1):36-46.

Milkowski CM, Ziller EC, Ahrens KA. Rural-urban residence and emergency contraception use, access, and counseling in the United States, 2006-2017. Contracept X. 2021;3:100061.

Lopez L.M., Ramesh S., Chen M. Progestin-only contraceptives: effects on weight. Cochrane Database Syst Rev. 2016 doi: 10.1002/14651858.CD008815.pub2.

Beksinska et al. “Weight change among women using intramuscular depot medroxyprogesterone acetate, a copper intrauterine device, or a levonorgestrel implant for contraception: Findings from a randomised, multicentre, open-label trial. EClinicalMedicine. 2021;34:100800.