Impact of Contraceptive Counseling in Clinical Settings: A Systematic Review

An Exploration of Contraceptive Choice Pathways in Adolescents and Young Adults

PURPOSE

To visualize contraceptive choice pathways among adolescent and young adults (AYA) designated female at birth (DFAB) as a means of exploring the relationships between current contraceptive use, desired contraceptive, and ultimately, chosen contraceptive method.

METHODS

A retrospective cross-sectional study was conducted of AYA DFAB (N = 2369), aged 14-24 years, presenting for initial visit at a contraceptive clinic with standardized efficacy-based counseling. Sankey diagrams were utilized to visualize patient flow through the contraceptive decision-making process. Outcomes of interest were current contraceptive method, desired contraceptive prior to contraceptive counseling, and then chosen contraception. Chi-Square tests were conducted to quantify the strength of the relationships identified by the Sankey diagrams.

RESULTS

Sankey diagrams demonstrated a fair amount of change from current contraceptive to desired contraceptive and from current contraceptive to chosen contraceptive. A stronger relationship was evident between desired contraceptive method and chosen method; most patients did not change their desired contraceptive after receiving counseling except AYA who were undecided about their desired contraceptive who flowed variably into all available methods. Chi-Square test assessing the association between desired and chosen contraceptive method was significant at P-value < .001, validating the patterns identified with the Sankey diagrams.

DISCUSSION

We identified distinct contraceptive decision-making pathways among AYA which could inform the framework for a more tailored counseling approach. These findings are aligned with national medical organizations' recommendations for provision of non-coercive, patient-centered contraceptive counseling to promote adolescent reproductive autonomy.

Do women with a previous unintended birth subsequently experience missed opportunities for postpartum family planning counseling? A multilevel mixed effects analysis

Client-provider communication about family planning (FP) remains an important strategy for preventing unintended pregnancy. Yet, the literature lacks empirical studies examining whether and how women's intendedness of a recent pregnancy may impact subsequent receipt of FP counseling. We investigated whether the intendedness of a recent pregnancy is associated with subsequent missed opportunities (MOs) for FP counseling, taking into account compositional and contextual factors. We performed a secondary analysis using pooled data from the 2016, 2017 and 2018 Performance Monitoring and Accountability 2020 cross-sectional surveys conducted in Nigeria, adjusting for complex design effects. Weighted multilevel logistic regression modeling was used to examine the relationships between pregnancy intention and MOs, overall and at the health facility, using two-level random intercept models. In the analytic sample of women within 24 months postpartum (N = 6479), nearly 60% experienced MOs for FP counseling overall and even 45% of those who visited a health facility visit in the past 12 months (N = 4194) experienced MOs. In the multivariable models adjusted for individual-/household- and community-level factors, women whose recent birth was either mistimed or unwanted were just as likely to have MOs for FP counseling as their counterparts whose pregnancy was intended (p > 0.05). Factors independently associated with a MOs include individual/household level factors such as level of education, exposure to FP media, household wealth index and contextual-level variables (geographic region). While evidence that pregnancy intendedness is associated with MOs for FP counseling remains inconclusive, efforts to mitigate these MOs requires prioritizing women's prior pregnancy intentions as well as equipping healthcare providers with the capacity need to provide high-quality client-centered FP counseling, particularly for women whose recent birth was unintended.

Unraveling the quality of implementation of sexual and reproductive health projects among adolescents and youths in low-income regions: a case study of the JADES 2 project in Niger in 2021

Introduction

many young people globally grapple with early pregnancies and sexually transmitted diseases (STD), especially in regions like Africa and particularly Niger due to high poverty rates. Various sexual and reproductive health (SRH) projects aim to address these challenges. This study evaluated the JADES 2 project's implementation of SRH services provided focusing on the quality of these services in Niger in 2021.

Methods

a cross-sectional evaluative study was conducted based on Donabedian and Bruce's theory from March 10 to August 15, 2021, in Niger. The evaluation was carried out through the analysis of supervision data, administration of questionnaires, and semi-structured interviews in 9 Integrated Health Centers and Youth-Friendly Centers. Across these sites, 203 adolescents and young people, as well as 9 healthcare workers involved in providing SRH services, were interviewed. The composite indicator in the field developed by the World Health Organization (WHO) in 2000 was used.

Results

the quality score estimated for the project was 67% indicating that the services provided was of good quality. The majority (56%) of surveyed people were very satisfied with the services received, and 65% were aware of at least two methods of preventing Sexually transmitted infections (STIs) and three methods of preventing early pregnancies.

Conclusion

the SRH services implemented are of acceptable quality. The study identified gaps in the process of service provision, particularly regarding confidentiality and the availability of inputs and medications.

A Mixed Methods Study of Contraceptive Counseling and Care at a Federally Qualified Health Center in Maryland

This study examined the experience of contraceptive counseling and care in a Federally Qualified Health Center in Maryland. Patients attending medical visits in 2021 were surveyed using the Interpersonal Quality of Family Planning scale to assess the quality of contraceptive counseling. Medical chart reviews were performed to identify alignment between contraceptive care received, and preferences patients had expressed. Primary care providers, reproductive health providers, and a subgroup of patients were interviewed to further contextualize survey and chart review findings. The average item score for the 94 survey participants was 4.39 (SD: 0.9) out of 5. Factor analysis showed high internal consistency reliability (alpha  =  0.96). Eighty percent of patients received contraceptive care that aligned with their preferences, 4% did not, and 16% lacked clear contraceptive preferences. Qualitative analysis revealed that patients desired more guidance from providers in selecting a contraceptive method, while providers noted logistical and insurance-related barriers to care. While the quality of contraceptive counseling was high, patient experience of care may be improved by implementing team-based care.

Interventions to support contraceptive choice and use: a global systematic map of systematic reviews

BACKGROUND

To review the highest level of available evidence, a systematic map identified systematic reviews that evaluated the effectiveness of interventions to improve contraception choice and increase contraception use.

METHODS

Systematic reviews published since 2000 were identified from searches of nine databases. Data were extracted using a coding tool developed for this systematic map. Methodological quality of included reviews was assessed using AMSTAR 2 criteria.

FINDINGS AND CONCLUSION

Fifty systematic reviews reported evaluations of interventions for contraception choice and use addressing three domains (individual, couples, community); Meta-analyses in 11 of the reviews mostly addressed interventions for individuals. We identified 26 reviews covering High Income Countries, 12 reviews covering Low Middle-Income Countries and the rest a mix of both. Most reviews (15) focussed on psychosocial interventions, followed by incentives (6) and m-health interventions (6). The strongest evidence from meta-analyses is for the effectiveness of motivational interviewing, contraceptive counselling, psychosocial interventions, school-based education, and interventions promoting contraceptive access, demand-generation interventions (community and facility based, financial mechanisms and mass media), and mobile phone message interventions. Even in resource constrained settings, community-based interventions can increase contraceptive use. There are gaps in the evidence on interventions for contraception choice and use, and limitations in study designs and lack of representativeness. Most approaches focus on individual women rather than couples or wider socio-cultural influences on contraception and fertility. This review identifies interventions which work to increase contraception choice and use, and these could be implemented in school, healthcare or community settings.

Psychological interventions decrease unintended pregnancies: A meta-analysis of randomized controlled trials

OBJECTIVE

Despite innovations in contraceptive methods, unintended pregnancies remain common. Researchers have examined psychological approaches to decrease unintended pregnancies through contraceptive use. These interventions have involved applying aspects of social cognitive theory, the health belief model and self-determination theory. Research findings on the effects of these psychological approaches show conflicting evidence. The aim of this meta-analysis was to clarify the impact of these psychological interventions on unintended pregnancies DESIGN: Meta-analysis of randomized controlled trials (RCTs) of psychological interventions intended to prevent unwanted pregnancies through an increase in the use of contraceptive methods METHODS: A systematic search of databases and article reference lists led to 26 relevant RCTs with a total of 31,222 participants RESULTS: The odds ratio for pregnancy in the psychological intervention condition = .83, 95% CI [.75, .93]. The results also showed that the longer an intervention's follow-up period was, the less the prevention effect. Quality assessment of included studies indicated that all used a treatment manual and reported attrition. It also showed that most studies reported the reasons for drop-out and assessed the facilitators' adherence to the intervention protocol. The proportion of variability due to chance amongst studies was I ²  = 22%. Duval and Tweedie's Trim and Fill showed a difference between the observed and the adjusted values. The adjusted value, representing a conservative estimate of effect size, was OR = .891, 95% CI [.777, .999] CONCLUSIONS: Altogether, these results support the efficacy of psychological interventions aimed at preventing unintended pregnancy through contraception.

Society of Family Planning Clinical Recommendations: Contraceptive Care in the Context of Pandemic Response

The coronavirus disease 2019 (COVID-19) pandemic has posed a burden to healthcare systems around the world and has changed the way people access health services, including contraception. This document sets forth guidance from the Society of Family Planning for providing contraceptive care in the context of the COVID-19 pandemic, including when access to healthcare is restricted due to pandemic response. It also outlines the role of telehealth for providing contraceptive care beyond the pandemic. Clinicians can use synchronous telemedicine visits and other forms of telehealth to provide many aspects of contraceptive care. Both audio-video and audio-only visits are acceptable forms of telemedicine. Access to permanent contraception should be maintained, especially in the postpartum period. Combined hormonal contraceptive (CHC) users who have asymptomatic or mild COVID-19 infection may continue their contraceptive method, while those admitted to the hospital with severe infection should suspend CHC use until they are clinically recovered. CHC users who take Paxlovid for mild-moderate COVID-19 infection can consider a back-up contraceptive method for the duration of therapy, but clinically relevant drug interactions are unlikely. Future research should examine contraceptive outcomes in people who receive care via telemedicine; and access to telemedicine among historically excluded populations such as adolescents, people of color, people of low socioeconomic status, disabled people, or people who do not speak English as a primary language.

Quality of Care in Family Planning Services: Differences Between Formal and Informal Settlements of Kira Municipality, Uganda

Background: Quality of care (QoC) of family planning (FP) affects contraceptive use, and it varies across types of urban settlement. This study assesses the difference in service delivery point (SDP) structural and process factors between formal and informal urban settlements, and the opinion of the client on the QoC in informal settlements. This is useful in creating an evidence base to advocate for better quality services for the most vulnerable in society. Methods: This was a cross-sectional survey that included SDPs of Kira municipality in Wakiso district, Uganda. Data were collected from all the service points in Kira municipality with the caretakers consented. In addition, using multi-stage sampling, 626 women of reproductive age (15-49 years) who lived in the informal settlements of Kira municipality were interviewed. Data were collected using structured questionnaires, descriptive analysis was carried out in Stata version 14.0, and Chi-square and t-tests were used to compare the informal with the formal settlements. Results: Formal settlements generally had more higher-level SDPs compared to informal settlements (value of p < 0.001). SDPs in the formal settlements provided more FP methods and had more community health workers (CHW) to support their work. Also, SDPs in the formal settlements were more likely to have long-term FP methods available and more likely to have trained personnel to insert and remove implants and IUDs compared to those in informal settlements. Additionally, more SDPs in the formal settlements provided counseling for permanent, long-term, and short-term FP methods. Of the 626 interviewed women, most of the women (68.6%) reported that they would not return to the previous FP provider or refer a friend to the same provider (72.7%). Conclusions: There is a lower quality FP services in the informal settlements with a commensurable effect on the client satisfaction with the services. Therefore, improving the quality of FP services in informal settlements should be a top priority. Improved quality of services could act as a motivation to increase the uptake of modern contraceptives in such settings.

Nothing so practical as theory: a rapid review of the use of behaviour change theory in family planning interventions involving men and boys

BACKGROUND

There is growing recognition of the need for interventions that effectively involve men and boys to promote family planning behaviours. Evidence suggests that the most effective behavioural interventions in this field are founded on theoretical principles of behaviour change and gender equality. However, there are few evidence syntheses on how theoretical approaches are applied in this context that might guide best practice in intervention development. This review addresses this gap by examining the application and reporting of theories of behaviour change used by family planning interventions involving men and boys.

METHODS

We adopted a systematic rapid review approach, scoping findings of a previously reported evidence and gap map of intervention reviews (covering 2007-2018) and supplementing this with searches of academic databases and grey literature for reviews and additional studies published between 2007 and 2020. Studies were eligible for inclusion if their title, abstract or keywords referred to a psychosocial or behavioural intervention targeting family planning behaviours, involved males in delivery, and detailed their use of an intervention theory of change.

RESULTS

From 941 non-duplicate records identified, 63 were eligible for inclusion. Most records referenced interventions taking place in low- and middle-income countries (65%). There was a range of intervention theories of change reported, typically targeting individual-level behaviours and sometimes comprising several behaviour change theories and strategies. The most commonly identified theories were Social Cognitive Theory, Social Learning Theory, the Theory of Planned Behaviour, and the Information-Motivation-Behaviour Skills (IMB) Model. A minority of records explicitly detailed gender-informed elements within their theory of change.

CONCLUSION

Our findings highlight the range of prevailing theories of change used for family planning interventions involving men and boys, and the considerable variability in their reporting. Programmers and policy makers would be best served by unified reporting and testing of intervention theories of change. There remains a need for consistent reporting of these to better understand how complex interventions that seek to involve men and boys in family planning may lead to behaviour change.

Adverse Childhood Experiences on Reproductive Plans and Adolescent Pregnancy in the Gulf Resilience on Women's Health Cohort

We investigated if adverse childhood experiences (ACEs) and ACE sub-types were associated with increased odds of planning to have children and adolescent pregnancy. The Gulf Resilience on Women’s Health (GROWH) is a diverse cohort of reproductive-age women living in southeastern Louisiana during the 2010 Deepwater Horizon oil spill. In our sample of 1482 women, we used multinomial logistic regression to model odds ratios of wanting future children and assessed effect measure modification by educational attainment. We also estimated odds ratios of adolescent pregnancy with binomial logistic regression. Exposure to ACEs increased odds of wanting future children across all ACE sub-types. Among women with lower educational attainment, three or more ACEs (overall, childhood, and adolescence) had over two times the odds of wanting future children. History of ACE and the various sub-types, except for emotional abuse, were associated with increased risk of adolescent pregnancy. ACEs may be linked to adolescent pregnancy and reproductive plans, and variations by educational status highlighted social discrepancies and importance of social context in evaluation and intervention.

A Novel Contraception Counseling and Shared Decision-Making Curriculum for Internal Medicine Residents

INTRODUCTION

Many women of reproductive age with complex medical conditions receive primary care through an internal medicine (IM) physician rather than an obstetrician/gynecologist. Long-acting reversible contraception methods are the most effective form of contraception; however, IM residents are not routinely trained in them. Infrequent training in, inadequate knowledge of, and discomfort with contraception counseling limit the counseling performed by IM residents. Shared decision-making (SDM) is a method of patient-centered communication that can improve communication about patient preferences and increase patient satisfaction with and adherence to contraception. We developed a curriculum to teach contraception counseling under the framework of SDM for IM residents.

METHODS

The curriculum focused on contraception counseling through the lens of SDM designed for IM and medicine/pediatrics residents (PGY 2-PGY 4). We adapted an existing seven-step model of SDM to fit elements of contraception counseling. The curriculum consisted of a didactic teaching session with integration of an instructional video and structured interactive discussion. The session lasted 60 minutes.

RESULTS

Fifty-eight residents participated in the curriculum. On pre- and postcurriculum surveys, residents reported improvement in contraception knowledge (overall mean precurriculum = 57%, postcurriculum = 70%, p < .001) and comfort with contraception counseling (overall mean precurriculum = 3.2, postcurriculum = 3.6, p < .01). Residents expressed strong support for SDM before and after the curriculum.

DISCUSSION

Based on the survey results, the curriculum successfully addressed gaps in residents' comfort with contraception counseling and knowledge of contraception side effects and efficacy.

Nonpharmacological interventions to improve the psychological well-being of women accessing abortion services and their satisfaction with care: A systematic review

How women perceive and experience abortion impacts their subsequent psychological well-being. This systematic review evaluated nonpharmacological interventions designed to support women undergoing abortion services and improve their psychological well-being and satisfaction with care. Searches were conducted in MEDLINE, CINAHL, the Cochrane Library, PsycINFO, Sociological Abstracts, Social Services Abstracts, and PTSD Pubs. All searches were limited to peer-reviewed articles published in English from January 2010 to February 2020. Two reviewers independently assessed study eligibility. Ten studies were included, involving four types of interventions: music therapy; social support; information support; and mandated waiting and counseling requirements on abortion access. Outcome measures were divided into four categories comprised of cognitive domains, emotional and psychological well-being, clinical symptoms, and satisfaction with care. However, there is limited evidence on intervention effects. Most studies report null or mixed intervention effects. Even though some positive effects on women's cognitive outcomes and satisfaction with care were seen, findings across studies were inconclusive. Findings also show that methodological limitations such as lack of theoretical basis, inadequate reporting and no power sample size calculation were apparent across studies. There is limited evidence about nonpharmacological interventions designed to improve women's satisfaction with abortion services or psychological outcomes subsequent to accessing abortion services. Well-designed interventions that meet the needs of service-users should be developed and rigorously tested.

Provider Counseling and Women's Family Planning Decisions in the Postpartum Period

Introduction: Provider counseling may influence women's postpartum family planning decisions. Materials and Methods: We conducted an anonymous Internet-based cross-sectional survey of postpartum women regarding multiple topics, including prenatal/postpartum care and family planning. We used multivariable logistic regression to determine associations between quantity of provider counseling (indexed as number of family planning topics discussed with a health care provider) and women's decisions regarding contraception and pregnancy spacing. Results: From January to May 2016, 2,850 women completed the survey and met inclusion criteria. Among this group, the majority were white (93%), ≥30 years (63%), and had obtained a college degree or higher (74%). Approximately half (49%) desired an interpregnancy interval (IPI) >2 years, and the minority (21%) used a highly effective contraceptive method (defined as long-acting reversible contraception or sterilization). The majority of women (56%) had received counseling on three to six family planning topics (defined as "more counseling" in regression models). Women who received more counseling were more likely to use a highly effective contraceptive method (adjusted odds ratio [AOR] 1.33, confidence interval [95% CI] 1.09-1.62) but were not more likely to desire an IPI >2 years (AOR 0.96, 95% CI 0.81-1.14). Desired IPI modified the association between provider counseling and contraception (p = 0.06 for interaction): Among those desiring an IPI >2 years, more counseling was associated with use of a highly effective contraceptive method (AOR 1.58, 95% CI 1.23-2.03), but this was not observed among those desiring a shorter IPI (AOR 1.05, 95% CI 0.73-1.49). Conclusions: Contraceptive decisions depend on both provider counseling and patient goals.

Contraceptive counseling practices and patient experience: Results from a cluster randomized controlled trial at Planned Parenthood

OBJECTIVES

Systematic reviews of contraceptive counseling interventions have shown inconsistent impact on patient outcomes. The current study assessed the effects of an evidence-informed contraceptive counseling staff training intervention on patient experience, contraceptive selection, and behavior over three months of follow-up.

STUDY DESIGN

We randomly assigned 10 Planned Parenthood health centers in the Southeastern US to intervention (staff received contraceptive counseling training) and control (usual counseling) groups. From December 2016-June 2017, patients completed surveys immediately post visit (n = 756) and one and three months after. We compared differences in patients' counseling experience (e.g., number of evidence-informed practices experienced, satisfaction with counseling), contraceptive selection, and behavior (e.g., method discontinuation, accurate pill use, condom use) between study groups using mixed effect models with health center specified as a random effect.

RESULTS

Seven hundred and fifty-six participants completed the baseline survey; 579 (77%) completed one or both follow-up surveys. The intervention group was more likely to report experiencing all evidence-informed counseling practices (adj. Prevalence Ratio [aPR] = 2.27, 95% CI 1.27, 4.04) with less variation in the number of practices and higher satisfaction with their counseling than the control group (p < 0.01). We found no sustained differences in contraceptive behaviors at both one- and three-month follow-up.

CONCLUSIONS

We found immediate positive effects of the intervention on patients' perceptions of their counseling experience and no differences in changes in contraceptive behavior over time between the study groups.

IMPLICATIONS

Evidence-based strategies to improve the quality of contraceptive care and subsequent outcomes, while centering patients' needs and preferences, are needed. The contraceptive counseling intervention offers a tool for increasing consistency in contraceptive counseling practices across health centers and improving patient satisfaction.

Contraceptive Behaviors in Polish Women Aged 18-35-a Cross-Sectional Study

The aim was to evaluate contraceptive behaviors, and factors affecting them, in the population of Polish-speaking women. A cross-sectional study was performed on 6763 women, current contraceptive users, aged 18 to 35. An anonymous and voluntary questionnaire written in Polish, containing 33 questions, was distributed online from January to February 2017. The Internet and doctors were the most popular sources of information about contraception (82% and 73%, respectively). Upon choosing contraception, women paid the most attention to its efficacy (85%) and its impact on health (59%). The most common methods were combined oral contraceptives (38%) and condoms (24%). In total, 51% had chosen hormonal contraception, of which 68% experienced side effects. The most frequent were decreased libido (39%) and weight gain (22%). Factors associated with the usage of hormonal or non-hormonal contraception were: education, relationship status, parenthood, number of sexual partners, frequency of intercourses, sources of information about contraception, and factors considered most important when choosing a contraceptive method. The choice between short-acting and long-acting reversible contraception was influenced by age, relationship status, parenthood, smoking, sources of information about contraception, and factors considered most important when choosing a contraceptive method. Wide access to contraception, high-quality education, and counselling should become priorities in family planning healthcare.

Understanding Women Veterans' Family Planning Counseling Experiences and Preferences to Inform Patient-Centered Care

BACKGROUND

Women veterans' unique experiences in the military and burden of health comorbidities increase their risk of adverse pregnancy outcomes and may influence their counseling needs related to planning or preventing pregnancy. We investigated women veterans' experiences of family planning counseling in the military and Veterans Affairs (VA) health care systems as well as their counseling preferences.

METHODS

We conducted 32 qualitative interviews among women veterans ages 18-44 years receiving primary care at the VA Puget Sound or VA Pittsburgh health care systems between March and June 2016 to explore their experiences and preferences related to counseling about pregnancy goals and planning and contraception. Transcripts were analyzed using inductive and deductive content analysis, and key themes were identified.

RESULTS

Nearly all participants described negative experiences in family planning counseling encounters in the military and/or VA, including perceptions of gender-based discrimination and pressure to choose certain contraceptive methods, perceived judgment of their reproductive choices, and a lack of continuity with providers. Some women also reported positive experiences in family planning encounters in the VA, including feeling respected, receiving comprehensive information about options, and having their perspectives and concerns elicited. Counseling preferences that emerged included that providers initiate and validate family planning discussions, establish trust and avoid judgment, elicit women's individual preferences, and engage them as equal partners in decision making.

CONCLUSIONS

Women veterans reported a spectrum of negative and positive experiences in family planning encounters in the military and VA that, in conjunction with their preferences, provide key insights for patient-centered reproductive health care in VA.

Trends in Receipt of Contraceptive Services: Young Women in the U.S., 2002-2015

INTRODUCTION

In order to understand adolescent girls' and young women's use of contraceptive services, this paper examines trends in receipt of contraceptive services, focusing on provider type and payment source.

METHODS

The analysis uses nationally representative data from females aged 15-25 years in the 2002, 2006-2010, and 2011-2015 National Surveys of Family Growth. In 2018, summary measures for receipt of any contraceptive service, the type of provider visited and payment used were created and compared across survey years and age groups (15-17 and 18-25 years).

RESULTS

From 2002 to 2011-2015, the proportion of adolescent girls aged 15-17 years relying on publicly funded clinics for contraceptive care fell from 47% to 24% (95% CI=38.4%, 55.0% and 95% CI=19.0%, 29.9%), whereas the proportion relying on private providers increased from 49% to 69% (95% CI=40.7%, 57.1% and 95% CI=61.6%, 76.2%). A significant, but smaller, shift away from clinics occurred among women aged 18-25 years. Over the same period, use of health insurance to pay for contraceptive services among all females aged 15-25 years increased from 68% to 81% (95% CI=64.7%, 71.3% and 95% CI=78.5%, 83.8%), whereas the proportion who had private insurance during the year, but did not use it to pay for contraceptive care, declined from 21% to 9% (95% CI=18.3%, 23.5% and 95% CI=6.8%, 10.7%).

CONCLUSIONS

Private providers now provide the bulk of contraceptive services to adolescent girls and young women, with reduced reliance on publicly funded clinics. Supporting private practices in providing confidential and comprehensive family planning services must be a priority. Publicly funded clinics remain an important safety-net provider of contraceptive care for adolescent girls and young women.

Family Planning Reminder Systems: An Updated Systematic Review

CONTEXT

The objective of this systematic review was to update a prior review and summarize the evidence on the impact of family planning reminder systems (e.g., daily text messages reminding oral contraception users to take a pill).

EVIDENCE ACQUISITION

Multiple databases, including PubMed, were searched during 2016-2017 for articles published from March 1, 2011, to November 30, 2016, describing studies of reminder systems.

EVIDENCE SYNTHESIS

The search strategy identified 24,953 articles, of which two studies met the inclusion criteria. In total with the initial review, four studies (including two RCTs) examined reminder systems among oral contraception users, with two of three that examined correct use finding a statistically significant positive impact, and one RCT finding a positive impact on knowledge and continuation. Of three studies (including two RCTs) that examined reminder systems among depot medroxyprogesterone acetate users, one of three that examined correct use found a statistically significant positive impact on timely injections at 3 months, and one study found no effect on continued use at 12 months.

CONCLUSIONS

Although this review found mixed support for the effectiveness of reminder systems on family planning behaviors, the highest quality evidence yielded null findings related to correct use of oral contraception and timely depot medroxyprogesterone acetate injections beyond 3 months, and found positive findings related to oral contraception continuation and knowledge. Future studies would be strengthened by objectively measuring outcomes and examining additional contraceptive methods and outcomes at least 12 months post-intervention.

THEME INFORMATION

This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Contraceptive Counseling in Clinical Settings: An Updated Systematic Review

CONTEXT

The objective of this systematic review was to update a prior review and summarize the evidence (newly identified and cumulative) on the impact of contraceptive counseling provided in clinical settings.

EVIDENCE ACQUISITION

Multiple databases, including PubMed, were searched during 2016-2017 for articles published from March 1, 2011, to November 30, 2016.

EVIDENCE SYNTHESIS

The search strategy identified 24,953 articles; ten studies met inclusion criteria. Two of three new studies that examined contraceptive counseling interventions (i.e., enhanced models to standard of care) among adolescents and young adults found a statistically significant positive impact on at least one outcome of interest. Five of seven new studies that examined contraceptive counseling, in general, or specific counseling interventions or aspects of counseling (e.g., personalization) among adults or mixed populations (adults and adolescents) found a statistically significant positive impact on at least one outcome of interest. In combination with the initial review, six of nine studies among adolescents and young adults and 16 of 23 studies among adults or mixed populations found a statistically significant positive impact of counseling on at least one outcome of interest.

CONCLUSIONS

Overall, evidence supports the utility of contraceptive counseling, in general, and specific interventions or aspects of counseling. Promising components of contraceptive counseling were identified. The following would strengthen the evidence base: improved documentation of counseling content and processes, increased attention to the relationships between client experiences and behavioral outcomes, and examining the comparative effectiveness of different counseling approaches to identify those that are most effective.

THEME INFORMATION

This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Client Preferences for Contraceptive Counseling: A Systematic Review

CONTEXT

Providers can help clients achieve their personal reproductive goals by providing high-quality, client-centered contraceptive counseling. Given the individualized nature of contraceptive decision making, provider attention to clients' preferences for counseling interactions can enhance client centeredness. The objective of this systematic review was to summarize the evidence on what preferences clients have for the contraceptive counseling they receive.

EVIDENCE ACQUISITION

This systematic review is part of an update to a prior review series to inform contraceptive counseling in clinical settings. Sixteen electronic bibliographic databases were searched for studies related to client preferences for contraceptive counseling published in the U.S. or similar settings from March 2011 through November 2016. Because studies on client preferences were not included in the prior review series, a limited search was conducted for earlier research published from October 1992 through February 2011.

EVIDENCE SYNTHESIS

In total, 26 articles met inclusion criteria, including 17 from the search of literature published March 2011 or later and nine from the search of literature from October 1992 through February 2011. Nineteen articles included results about client preferences for information received during counseling, 13 articles included results about preferences for the decision-making process, 13 articles included results about preferences for the relationship between providers and clients, and 11 articles included results about preferences for the context in which contraceptive counseling is delivered.

CONCLUSIONS

Evidence from the mostly small, qualitative studies included in this review describes preferences for the contraceptive counseling interaction. Provider attention to these preferences may improve the quality of family planning care; future research is needed to explore interventions designed to meet preferences.

THEME INFORMATION

This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Impact of Contraceptive Education on Knowledge and Decision Making: An Updated Systematic Review

CONTEXT

Educational interventions can help individuals increase their knowledge of available contraceptive methods, enabling them to make informed decisions and use contraception correctly. This review updates a previous review of contraceptive education.

EVIDENCE ACQUISITION

Multiple databases were searched for articles published March 2011-November 2016. Primary outcomes were knowledge, participation in and satisfaction/comfort with decision making, attitudes toward contraception, and selection of more effective methods. Secondary outcomes included contraceptive behaviors and pregnancy. Excluded articles described interventions that had no comparison group, could not be conducted feasibly in a clinic setting, or were conducted outside the U.S. or similar country.

EVIDENCE SYNTHESIS

A total of 24,953 articles were identified. Combined with the original review, 37 articles met inclusion criteria and described 31 studies implementing a range of educational approaches (interactive tools, written materials, audio/videotapes, and text messages), with and without healthcare provider feedback, for a total of 36 independent interventions. Of the 31 interventions for which knowledge was assessed, 28 had a positive effect. Fewer were assessed for their effect on attitudes toward contraception, selection of more effective methods, contraceptive behaviors, or pregnancy-although increased knowledge was found to mediate additional outcomes (positive attitudes toward contraception and contraceptive continuation).

CONCLUSIONS

This systematic review is consistent with evidence from the broader healthcare field in suggesting that a range of interventions can increase knowledge. Future studies should assess what aspects are most effective, the benefits of including provider feedback, and the extent to which educational interventions can facilitate behavior change and attainment of reproductive health goals.

THEME INFORMATION

This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.

Client and provider factors associated with integration of family planning services among maternal and reproductive health clients in Kigoma Region, Tanzania: a cross-sectional study, April-July 2016

BACKGROUND

Integration of family planning (FP) services into non-FP care visits is an essential strategy for reducing maternal and neonatal mortality through reduction of short birth intervals and unplanned pregnancies.

METHODS

Cross-sectional surveys were conducted across 61 facilities in Kigoma Region, Tanzania, April-July 2016. Multilevel, mixed effects logistic regression analyses were conducted on matched data from providers (n = 330) and clients seeking delivery (n = 935), well-baby (n = 272), pregnancy loss (PL; n = 229), and other routine (postnatal, HIV/STI, other; n = 69) services. Outcomes of interest included receipt of FP information and a modern FP method (significance level p < 0.05).

RESULTS

Clients had significantly greater odds of receiving FP information if the primary reason for seeking care was for PL versus (vs) any other types of care (aOR 1.97), had four or more pregnancies vs fewer (aOR 1.78), and had had a FP discussion with their partner vs no FP discussion (aOR 1.73). Clients had lower odds of receiving FP information if they were aged 40-49 vs 15-19 (aOR 0.50) and reported attending religious services at least weekly vs less frequently (aOR 0.61). Clients of providers who perceived that in-service training had helped vs had not helped job performance (aOR 2.27), and clients of providers having high vs low recent FP training index scores (aOR 1.58) had greater odds of receiving FP information. Clients had greater odds of receiving a modern method when they received information on two or more vs fewer methods (aOR 7.13), had had a FP discussion with their partner vs no discussion (aOR 5.87), if the primary reason for seeking care was for PL vs any other types of care (aOR 4.08), had zero vs one or more live births (aOR 3.92), made their own FP decisions vs not made own FP decisions (aOR 3.17), received FP information from two or more vs fewer sources (aOR 3.12), and were in the middle or high vs the low wealth tercile (aOR 1.99 and 2.30, respectively). Well-baby care clients, Other routine services clients, and married clients had significantly lower odds of receiving a method (aOR 0.14; aOR 0.08; and aOR 0.41, respectively) compared to their counterparts.

CONCLUSIONS

Strategies that better integrate FP into routine care visits, encourage women to have FP discussions with their partners and providers, increase FP training among providers, and expand FP options and sources of information may help reduce the unmet need for FP, and ultimately lower maternal and neonatal mortality.

Effects of immediate postpartum contraceptive counseling on long-acting reversible contraceptive use in adolescents

BACKGROUND

Adolescent pregnancy is a global public health problem, particularly repeated pregnancy. The best strategy to lower prevalence of adolescent pregnancy and repeated pregnancy is promoting highly effective long-acting contraceptive methods along with special counseling programs. Long-acting reversible contraception (LARC) is the ideal contraceptive of choice for adolescents. It is not known whether immediate postpartum contraceptive counseling increases postpartum LARC use in adolescents.

OBJECTIVE

To compare LARC use between immediate and conventional postpartum contraceptive counseling and discover predictive factors of postpartum LARC use.

MATERIALS AND METHODS

This prospective, randomized controlled trial was conducted among postpartum adolescents at Department of Obstetrics and Gynecology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand, from 1 July 2016 to 31 March 2017. The participants were assigned to receive immediate postpartum contraceptive counseling or conventional postpartum contraceptive counseling. The primary outcome was postpartum LARC use. The secondary outcome was predictive factors for LARC use in postpartum adolescents.

RESULTS

Of the 233 postpartum adolescents, postpartum LARC use was 87 of 118 (73.7%) in the immediate postpartum counseling group and 49 of 115 (42.6%) in the conventional postpartum counseling group (odds ratio 3.780, 95% CI 2.18-6.57, p<0.001). A significant predictive factor for LARC use in postpartum adolescents was immediate postpartum counseling (odds ratio 3.67, 95% CI 2.10-6.41, p<0.001).

CONCLUSION

Immediate postpartum contraceptive counseling led to a significant increase in postpartum use of LARC in adolescents, when compared with conventional (4-6 weeks) postpartum contraceptive counseling. Adolescent mothers who received immediate postpartum counseling were 3.67 times more likely to use LARC than those who received conventional postpartum counseling.

Quality of care in family planning services in Senegal and their outcomes

BACKGROUND

High quality of care in family planning (FP) services has been found to be associated with increased and continued use of contraceptive methods. The interpersonal skills and technical competence of the provider is one of the main components of quality of care. To study the process component of quality of care, the distribution of the FP counseling topics was examined by client, provider and facility characteristics. To assess the outcomes of quality of care, client satisfaction and their knowledge of their method's protection from STIs were used. This study examined the factors associated with these outcomes with a focus on provider counseling and training.

METHODS

Data from the 2012-2013 Senegal Service Provision Assessment survey was used for the analysis. The survey included a representative sample of the health facilities in Senegal and collects data by observing the clients' FP visits and conducting exit interviews. The main outcomes of interest were provider's counseling in FP, client's satisfaction with FP services and client's knowledge of their method's protection from STIs. Several covariates were used in the analysis which represent client, provider and facility characteristics.

RESULTS

The level of counseling was inadequate-- very low proportions of providers that performed different types of counseling. Counseling was more likely to be provided to new than returning clients. Approximately 84% of the clients were very satisfied with services but only 58% had correct knowledge of their method's protection from STIs. Clients were significantly less likely to be very satisfied when their providers counseled on side effects and when to return, and counseling provided on method's protection from STIs did not significantly improve knowledge in this area. Clients seen by a provider with FP training had almost twice the odds of having correct knowledge about their method's protection from STIs compared with clients seen by a provider with no recent training.

CONCLUSIONS

The percentage of providers offering FP counseling to their clients was relatively low and was ineffective on the client-focused outcomes. Interventions may be required for more effective counseling methods that are client-centered as well as providing more FP training to providers.

Contraceptive Knowledge Assessment: validity and reliability of a novel contraceptive research tool

OBJECTIVES

Clinicians and researchers need an accurate tool assessing contraceptive knowledge in order to understand the effectiveness of teaching efforts. However, most widely used indices are outdated. The objective of this study is to create an evidence-based assessment tool and determine its validity and reliability for measuring contraceptive knowledge.

STUDY DESIGN

The study team developed the 25-question multiple-choice tool entitled the Contraceptive Knowledge Assessment (CKA). Expert reviewers examined content validity and semistructured patient interviews acquired feedback on subject matter and comprehension. A two-tiered approach explored criterion validity via (1) comparison with the gold standard (Contraceptive Knowledge Inventory) and (2) comparison between groups with lower and higher contraceptive knowledge. Repeat testing after 2-4 weeks evaluated test-retest reliability.

RESULTS

Six experts and seven patients provided feedback on the initial CKA. One hundred two reproductive-aged male and female patients and 27 medical students completed the final CKA with an overall mean patient score of 9/25 (36%). The mean score on the CKA was higher than the mean score on the gold standard (9.1 vs. 5.8, p<.001). Patients scored lower on the CKA than did medical students (9.1 [36.4%] vs.19.4 [77.6%], p<.005). There were no differences within patients' results with repeat testing over time (p=.667).

CONCLUSIONS

The CKA is a valid and reliable tool to measure a patient's level of knowledge regarding contraception. This research tool may allow for the assessment of baseline knowledge, educational gaps, and improvement after an intervention. Knowledge may be lower than previous studies suggest, signifying need for improved education on contraception and better understanding of the relationship between knowledge and behavior change.

IMPLICATIONS

The CKA provides an evidence-based, reliable, and validated assessment of contraceptive knowledge. This modern tool may help to determine the effectiveness of interventions to improve education on contraception.

Four aspects of the scope and quality of family planning services in US publicly funded health centers: Results from a survey of health center administrators

OBJECTIVES

This study aims to describe aspects of the scope and quality of family planning services provided by US publicly funded health centers before the release of relevant federal recommendations.

STUDY DESIGN

Using nationally representative survey data (N=1615), we describe four aspects of service delivery: family planning services provided, contraceptive methods provided onsite, written contraceptive counseling protocols and youth-friendly services. We created a count index for each issue and used multivariable ordered logistic regression to identify health center characteristics associated with scoring higher on each.

RESULTS

Half of the sample received Title X funding and about a third each were a community health center or health department clinic. The vast majority reported frequently providing contraceptive services (89%) and STD services (87%) for women in the past 3 months. Service provision to males was substantially lower except for STD screening. A total of 63% and 48% of health centers provided hormonal IUDs and implants onsite in the past 3 months, respectively. Forty percent of health centers included all five recommended contraceptive counseling practices in written protocols. Of youth-friendly services, active promotion of confidential services was among the most commonly reported (83%); offering weekend/evening hours was among the least (42%). In multivariable analyses, receiving Title X funding, having larger volumes of family planning clients and being a Planned Parenthood clinic were associated with higher scores on most indices.

CONCLUSION

Many services were consistent with the recommendations for providing quality family planning services, but there was room for improvement across domains and health centers types.

IMPLICATIONS STATEMENT

As assessed in this paper, the scope and quality of these family planning services was relatively high, particularly among Planned Parenthood clinics and Title X-funded centers. However, results point to important areas for improvement. Future studies should assess change as implementation of recent family planning service recommendations continues.

Impact of Reminder Systems in Clinical Settings to Improve Family Planning Outcomes: A Systematic Review

CONTEXT

This systematic review evaluated the evidence on the impact of family planning reminder systems-interventions intended to remind patients of behaviors to achieve reproductive health goals (e.g., daily text messages reminding oral contraceptive [OC] users to take a pill)-to provide information to guide national recommendations on quality family planning services.

EVIDENCE ACQUISITION

Multiple databases including PubMed were searched during 2010-2011 for peer-reviewed articles published in English from January 1985 through February 2011 describing studies evaluating reminder systems to improve family planning outcomes. Studies were excluded if they focused primarily on HIV or sexually transmitted infection prevention, focused solely on men, or were conducted outside the U.S., Europe, Australia, or New Zealand.

EVIDENCE SYNTHESIS

The initial search identified 16,129 articles, five of which met the inclusion criteria. Three studies examined the impact of OC reminder systems; two found a statistically significant positive impact on correct use. Two studies examined the impact of reminder systems among depot medroxyprogesterone acetate (DMPA) users; one found a statistically significant positive impact on correct use.

CONCLUSIONS

Although mixed support was found for the effectiveness of reminder system interventions on correct use of OCs and DMPA, the highest-quality evidence yielded null findings. The evidence base would be strengthened by the development of additional studies, especially RCTs, which objectively measure outcomes, examine additional contraceptive methods, and have sufficient sample sizes to detect behavioral outcomes at least 12 months post-intervention.

Systematic Review Evidence Methodology: Providing Quality Family Planning Services

From 2010 to 2014, CDC and the Office of Population Affairs at the USDHHS collaborated on the development of clinical recommendations for providing quality family planning services. A high priority was placed on the use of existing scientific evidence in developing the recommendations, in accordance with IOM guidelines for how to develop "trustworthy" clinical practice guidelines. Consequently, a series of systematic reviews were developed using a transparent and reproducible methodology aimed at ensuring that the clinical practice guidelines would be based on evidence collected in the most unbiased manner possible. This article describes the methodology used in conducting these systematic reviews, which occurred from mid-2011 through 2012.

Impact of Contraceptive Education on Contraceptive Knowledge and Decision Making: A Systematic Review

CONTEXT

Educational interventions can help increase knowledge of available contraceptive methods, enabling individuals to make informed decisions and use contraception more effectively. This systematic review evaluated contraceptive education interventions to guide national recommendations on quality family planning services.

EVIDENCE ACQUISITION

Three databases (CINAHL, PubMed, and PsycINFO) were searched from 1985 through 2012 for peer-reviewed articles on educational interventions, with supplemental searches conducted through 2015. Primary outcomes were knowledge, participation in and comfort with decision making, and attitudes toward contraception. Secondary outcomes included contraceptive use behaviors and unintended pregnancy.

EVIDENCE SYNTHESIS

Database searches in 2011 identified 5,830 articles; 17 met inclusion criteria and were abstracted into evidence tables. Searches in 2012 and 2015 identified four additional studies. Studies used a wide range of tools (decision aids, written materials, audio/videotapes, and interactive games), with and without input from a healthcare provider or educator. Of 15 studies that examined the impact of educational interventions on knowledge, 14 found significant improvement using a range of tools, with and without input from a healthcare provider or educator. Fewer studies evaluated outcomes related to decision making, attitudes toward contraception, contraceptive use behaviors, or unintended pregnancy.

CONCLUSIONS

Results from this systematic review are consistent with evidence from the broader healthcare field suggesting that a range of educational interventions can increase knowledge. Future studies should assess what aspects of educational interventions are most effective, the extent to which it is necessary to include a healthcare provider or educator, and the extent to which educational interventions can impact behaviors.