Increasing IUD and Implant Use Among Those at Risk of a Subsequent Preterm Birth: A Randomized Controlled Trial of Postpartum Contraceptive Counseling.

OBJECTIVE: To assess the impact of contraceptive counseling on the uptake of long-acting reversible contraception (LARC), namely, intrauterine devices and the contraceptive implant, by 3 months postpartum among women with a recent preterm birth. DESIGN: We enrolled patients in a single-blinded, one-to-one, randomized, controlled trial to assess the impact of enhanced family planning counseling immediately after a viable preterm birth in the inpatient setting. Participants received either structured counseling with an emphasis on LARC by a family planning specialist (intervention) or routine postpartum care (control). We followed participants to the primary outcome of LARC use 3 months postpartum. RESULTS: We followed 121 participants for 3 months. Primary outcome data were available for 119 participants (61 intervention, 58 control). We found no demographic differences between the groups. Participants in the intervention group were significantly more likely to use LARC at 3 months postpartum compared with controls (51% vs. 31%; p < .05). For every six women who received the counseling intervention, one additional woman was using a LARC method at 3 months. CONCLUSIONS: After a preterm birth, brief LARC-focused, structured counseling before hospital discharge significantly increased LARC method use at 3 months postpartum.

The Longest Wait: Examining the Impact of Utah's 72-Hour Waiting Period for Abortion.

PURPOSE: To assess the impact of Utah's 2012 law increasing the mandatory abortion waiting period from 24 to 72 hours. METHODS: This paper includes two assessments of this change: (1) Comparison of the proportion of women returning for an abortion after counseling before and after the introduction of the 72-hour law and (2) self-reported wait times between abortion and procedure, distance traveled, financial expenditures, and perceived impact of the law in a subset of women who were surveyed. MAIN FINDINGS: Aggregate counseling and procedural data were available at three Utah clinics; 2,793 of 3,618 women (77%) returned for abortion procedures under the 72-hour law, compared with 2,513 of 3,130 (80%) in the previous year (p < .05). Among 307 women surveyed, 63% reported more than 7 days between signing the consent form and their procedure, and women frequently had to travel further to get their procedure than they did for the counseling. Close to two-thirds (62%) reported the 72-hour wait affected them negatively in some way, including the lost wages of needing to take extra time off work (47%), increased transportation cost (30%), lost wages by family or friend(s) (27%), and having to disclose their abortion to someone they would not had told without the waiting period (33%). CONCLUSION: Utah's extended waiting period showed a small reduction in the proportion of counseled women who returned for their abortion procedure statewide. Women who had abortions after the law was enacted reported several burdensome aspects of the law.

My Obstetrician Got Me Fired: How Work Notes Can Harm Pregnant Patients and What to Do About It.

Prenatal care providers are frequently asked to provide employment notes for their patients requesting medical leave or changes to work duties. Writing employment notes correctly can help patients negotiate for and obtain medically indicated workplace accommodations, allowing them to continue to work and earn an income. However, a poorly written or poorly timed note can jeopardize a patient's employment and salary. This commentary provides an overview of pregnancy-related employment laws and guidance in writing work accommodations letters that allow pregnant women to keep their jobs while maintaining a healthy pregnancy.

Increasing LARC utilization: any woman, any place, any time.

Intrauterine contraceptive devices and the progestin implant are the most effective long-acting reversible contraception (LARC) methods available for preventing unintended pregnancy. LARC devices are safe, non-user-dependent methods that have the highest rates of continuation and satisfaction of all reversible contraceptives. Use of these contraceptives remains low in the United States due to several barriers including: misperceptions among both providers and patients; cost barriers; and patient access to the devices. Increasing the opportunities for women to access LARC methods in the primary care, postabortion, and postpartum setting can be achieved by addressing the system, provider, and patient barriers that exist.

We should really keep in touch: predictors of the ability to maintain contact with contraception clinical trial participants over 12 months.

OBJECTIVES: This study assesses the ability to maintain contact with participants enrolled in an emergency contraception (EC) trial with 12 months of follow-up based on the modes of contact they provided at enrollment. STUDY DESIGN: Data came from a clinical trial offering women the copper intrauterine device or oral levonorgestrel for EC. A modified Poisson regression was used to assess predictors associated with the ability to contact study participants 12 months after enrollment. RESULTS: Data were available for 542 participants; 443 (82%) could be contacted at 12 months. Contact at 12 months was greatest for those whose preferred the method of contact was text messaging, e-mail or any (62/68; 91% contacted) and worst for the 18 who had a landline phone (only 7 contacted; 39%). After controlling for age, having an e-mail address, text messaging, language preference, type of EC chosen and insurance, preferred contact other than phone increased the likelihood of follow-up by 10% [risk ratio (RR) 1.1 95% confidence interval (CI) 1.0-1.2], while having a landline reduced a woman's likelihood of being contacted at 12 months by 50% compared to women with a contract cell (RR 0.5, 95% CI 0.3-1.0). CONCLUSION: The few women with a landline for contact had poor follow-up at 1 year, while women who preferred e-mail or text had the highest rate of follow-up. IMPLICATIONS: Understanding how best to reduce loss to follow-up is an essential component of conducting a contraceptive clinical trial. Improved participant retention maximizes internal validity and allows for important clinical outcomes, such as pregnancy, to be assessed.

Prevention of recurrent preterm birth: role of the neonatal follow-up program.

Preterm birth (PTB) is a public health crisis in need of effective preventative strategies. Multi-disciplinary Neonatal Follow-up Programs (NFPs) provide health services to preterm infants at high risk for developmental problems after discharge from US newborn intensive care units. We aimed to determine whether NFPs are a potentially effective venue for specialized maternal counseling and intervention aimed at reducing the high rate of recurrent PTB in this population. This prospective case series enrolled women with preterm children evaluated in the Utah Department of Health NFP, 2010-2012. Women were interviewed, received Maternal Fetal Medicine (MFM) counseling services, and maternal and neonatal records were abstracted. We assessed maternal demographics, medical history, and characteristics of the index pregnancy. We calculated the proportion of women with knowledge of PTB recurrence risk and available prevention strategies, and assessed current contraceptive use and reproductive plans. Ninety-six women with a history of early PTB (≤26 weeks and/or birth weight < 1,250 g) were evaluated. Nearly 1 in 5 women (19.8 %) evaluated reported sexual activity, desire to avoid pregnancy, and no current contraceptive use, and were therefore at imminent risk of unintended pregnancy. Of women without permanent contraception, only 24.3 % were aware of their individual PTB recurrence risk. Of women with a history of spontaneous PTB, only 4 % were aware of effective pharmacologic preventative strategies. Introduction of MFM consultation as part NFP multi-disciplinary services is a novel approach with the potential to reduce recurrent PTB in an exceptionally high-risk population.

The natural history of anteroposterior laxity and its role in knee osteoarthritis progression.

OBJECTIVE: To test the hypotheses that 1) osteoarthritic (OA) knees at more advanced stages have less anteroposterior (AP) laxity compared with OA knees at milder stages, 2) AP laxity decreases over time, and 3) the absence of a decrease in AP laxity is associated with greater progression of medial tibiofemoral OA. METHODS: The study group comprised 230 patients with knee OA (75% women, mean age 64 years, mean body mass index [BMI] 30 kg/m(2)). At baseline and 18 months, AP laxity was measured (in millimeters of tibial translation, under AP shear loading), and semiflexed AP knee radiographs (with knee position confirmed by fluoroscopy) were obtained. Osteophytes were graded for each compartment, using a scale of 0-4. Disease progression was measured as the amount of medial joint space loss between baseline and followup, using linear regression with generalized estimating equations. RESULTS: At baseline, measurements of AP laxity were lower in knees with a Kellgren/Lawrence (K/L) score of 4 (mean +/- SD 5.0 +/- 2.1 mm) than in those with a K/L score of 0-1 (mean +/- SD 7.1 +/- 2.6 mm). There was a weak negative correlation between osteophyte grade and AP laxity. In knees with a K/L score of 0-2, AP laxity was slightly lower at 18 months than at baseline. AP laxity at baseline was not a predictor of progression of OA. Knees without a decrease in AP laxity had a greater loss of medial joint space (0.22 mm greater, after adjusting for age, sex, and BMI) than did knees in which laxity decreased. CONCLUSION: AP laxity at baseline is not predictive of progression of OA. Although knees with a K/L score of 4 had less AP laxity than those with a K/L score of 0-1, most of this difference was attributable to the significant difference in AP laxity between knees with a K/L score of 0-1 and knees with a K/L score of 2 (i.e., definite osteophytes). Knees in which AP laxity decreased had less medial joint space loss than did knees without a decrease in AP laxity. The knee joint may successfully compensate for AP laxity; the absence of such compensation may have a deleterious effect.

Varus-valgus alignment in the progression of patellofemoral osteoarthritis.

OBJECTIVE: To test the hypotheses that lateral patellofemoral (PF) osteoarthritis (OA) progression is more common than medial PF OA progression, that varus alignment increases the likelihood of medial PF OA progression, and that valgus alignment increases the likelihood of lateral PF OA progression. METHODS: Patients with knee OA were recruited from the community. Inclusion criteria were definite osteophyte presence (i.e., Kellgren/Lawrence radiographic grade >/=2) in 1 or both knees and at least some difficulty with knee-requiring activity. Varus-valgus alignment (the angle formed by the intersection of the mechanical axes of the femur and tibia) was measured on a full-limb radiograph at baseline. To assess PF OA progression, weight-bearing skyline views of the PF compartment were obtained at baseline and at 18-month followup. Knees with the highest grade of PF narrowing at baseline were excluded from analysis. Logistic regression and generalized estimating equations were used; odds ratios (ORs) were adjusted for age, sex, and body mass index. RESULTS: Lateral PF OA progression, which occurred in 120 (30%) of 397 knees, was more common than was medial PF OA progression, which occurred in 60 knees (15%). Varus (versus nonvarus) alignment increased the odds of PF OA progression isolated to the medial PF compartment (adjusted OR 1.85, 95% confidence interval [95% CI] 1.00-3.44). Valgus alignment increased the odds of PF OA progression isolated to the lateral compartment (adjusted OR 1.64, 95% CI 1.01-2.66). CONCLUSION: Lateral PF OA progression was more common than medial progression, and varus-valgus alignment influenced the likelihood of PF OA progression in a compartment-specific manner. Interventions that address the stress imposed by alignment on the PF compartments may delay PF OA progression and should be developed.