A motivational interviewing-based counseling intervention to increase postabortion uptake of contraception: A pilot randomized controlled trial

Patient-Centered Care in Action: How Clinicians Respond to Patient Dissatisfaction with Contraceptive Side Effects

Patient-centered care is widely cited as a component of quality contraceptive health care, but its operationalization in clinical interaction is contested. This article examines patient-centered care as an interactional phenomenon using the case of patient dissatisfaction with side effects of hormonal contraceptive medications. Drawing on transcript data from 109 tape-recorded reproductive health visits, I find that provider responses to treatment dissatisfaction range from patient-centered to relatively authoritarian. Providers typically offer patient-centered responses that validate patient experiences and integrate them into contraceptive counseling and method selection. At the same time, explicit communication about patients' contraceptive priorities is rare. In its absence, providers use patient-centered communication to smooth the interactional path toward uptake of highly effective hormonal methods, mostly ignoring the possibility that some patients may prefer less effective methods. Patient-centered contraceptive care was circumscribed by the clinical goal of pregnancy prevention.

Trends in different contraception methods among women attending the Melbourne Sexual Health Centre from 2011 to 2020

OBJECTIVES

The efficacy and availability of contraception have changed in the last several decades; however, unintended pregnancies continue to be an issue in Australia. This study aimed to describe trends in contraception in women attending a sexual health service over 9 years.

STUDY DESIGN

Repeated cross-sectional study.

METHODS

Women aged 16-49 years attending Melbourne Sexual Health Centre between 2011 and 2020 were included. Women were asked what methods of contraception they currently use. Contraception were categorised into long-acting reversible contraception (LARC; e.g. intrauterine devices and implants classified as highly effective), moderately effective contraception (e.g. oral contraception pill), less effective contraception (e.g. condom and withdrawal) and no contraception, as defined by US Centers for Disease Control and Prevention guidelines. Multivariable logistic regression was used to examine the factors associated with the use of moderate-high-efficacy contraception.

RESULTS

A total of 38,288 women were included with a median age of 25 (interquartile range: 22-29). Between 2011 and 2020, there was a decreasing trend in condom (63.3%-56.1%; Ptrend <0.001) and oral contraception (27.2%-20.5%; Ptrend <0.001) use, whilst there was an increasing trend in the use of LARCs: implant (4.6%-6.0%; Ptrend = 0.002) and intrauterine device (2.8%-11.8%; Ptrend <0.001). Increasing age was associated with decreased odds of using moderate-high-efficacy contraception (Ptrend <0.001). Compared with Oceanian-born women, Asian (adjusted odds ratios [aOR] = 0.63, 95% confidence interval [CI]: 0.56-0.72) and Middle Eastern-born women (aOR = 0.60, 95% CI: 0.48-0.74) had lower odds of using moderate-high-efficacy contraception, whilst European (aOR = 1.23, 95% CI:1.07-1.41) and North American-born women (aOR = 1.51, 95% CI: 1.22-1.87) had higher odds of using moderate-high-efficacy contraception.

CONCLUSIONS

Between 2011 and 2020, LARC use has increased, whilst less effective contraceptives, such as condom and oral contraception, have decreased among women at Melbourne Sexual Health Centre. Further research is required to understand age and ethnic disparities in contraception methods for future family planning programmes.

Promoting long-acting reversible contraception among post-abortion clients with a provider-comparison intervention: a cluster randomized controlled trial in Nepal

BACKGROUND

Although long-acting reversible contraception (LARC) is more effective and longer lasting than short-acting methods, uptake remains low among post-abortion clients. Using a stepped-wedge, cluster-randomized trial, we evaluate the impact of a provider-level peer-comparison intervention to encourage choice of LARC in Nepal among post-abortion clients.

METHODS

The intervention used prominently displayed monthly posters comparing the health clinic's previous month performance on LARC uptake against peer clinics. To understand how the intervention affected behavior, while ensuring voluntarism and informed choice, we used mystery client visits, in-depth provider interviews, and client exit survey data. The trial examined 17,680 post-abortion clients in 36 clinics in Nepal from July 2016 to January 2017. The primary outcome was the proportion of clients receiving LARCs. Statistical analysis used ordinary least squares (OLS) regression with ANCOVA estimation to assess the intervention's impact on LARC uptake while controlling for client- and clinic-level characteristics.

RESULTS

The intervention increased LARC use among post-abortion clients by 6.6% points [95% CI: 0.85 to 12.3, p-value < 0.05], a 29.5% increase in LARC use compared to control clinics. This effect persisted after the formal experiment ended. Analysis of provider and client experiences showed that the behavioral intervention generated significant change in providers' counseling practices, motivated the sharing of best practices. Quality of care indicators either remained stable or improved.

CONCLUSION

We find that a provider-level behavioral intervention increases LARC uptake among post-abortion clients. This type of intervention represents a low-cost option to contribute to reducing unmet need for contraception through provider behavior change.

Mapping Long-acting Reversible Contraceptive Interventions to the Social Ecological Model: A Scoping Review

INTRODUCTION

Long-acting reversible contraception (LARC) is one option for preventing unintended pregnancies and short interpregnancy intervals. Efforts to increase access to contraception may benefit from applying the social ecological model (SEM), a framework that considers individual, interpersonal, organizational, community, and policy influences on behavior. We aimed to summarize findings from interventions on LARC use and map interventions to SEM levels.

METHODS

We conducted a scoping review of the 2010-2020 literature in PubMed/MEDLINE and Embase databases to summarize interventions that did and did not increase LARC use. Although increasing LARC use is not an appropriate goal from a reproductive autonomy standpoint, it is the stated goal of much of the research conducted to date and typically indicates an improvement in access. We mapped these interventions to SEM levels and categorized their strategies: cost support, patient counseling, administrative support, provider training, and other.

RESULTS

Of 27 interventions reviewed, 17 (63%) increased LARC use. We observed a greater proportion of interventions that increased LARC uptake among those with strategies implemented at policy (8/10 [80%]) or organizational (14/19 [74%]) SEM levels compared with interventions implemented at other SEM levels. When both individual and organizational SEM-level components were implemented, five of six interventions (83%) increased uptake. All five interventions with both organizational- and policy-level components increased LARC use. Among the 27 interventions, patient counseling (n = 12) and cost support (n = 12) were common strategies. Five of 12 interventions (42%) involving patient counseling and 11 of 12 (92%) involving cost support increased LARC use.

CONCLUSIONS

Organizational and policy SEM components and cost support strategies were most prevalent in interventions that increased LARC use. Future interventions to improve access to contraception, while respecting patient autonomy, could incorporate more than one SEM level.

Motivational interviewing for family planning and reducing risky sexual behavior among incarcerated men nearing release: A randomized controlled pilot study

Incarcerated men are at high risk for sexually transmitted infections (STIs) and unintended partner pregnancy postrelease. Limited research has been invested in developing and testing treatments targeting risky sexual behavior and unwanted pregnancy for this at-risk population. Motivational interviewing (MI) is a promising behavioral intervention for decreasing risky sexual behaviors. This study assessed the feasibility and acceptability of MI for family planning and risky sexual behaviors with incarcerated men nearing release. Preliminary efficacy of the MI intervention was also compared to an educational control group. Thirty-two men were assessed at baseline and randomized to one 90-min session. Assessment occurred 2 months after release. MI was feasibly administered, and participants were highly satisfied with both treatments. In addition, those who received MI reported higher rates of condom use with casual partners, higher rates of partner use of hormonal contraceptives, and slightly higher rates of sex that was protected against pregnancy. Increases are readiness to discuss family planning with sexual partners, as well as reported frequency of these discussions, and increases in family planning knowledge were also found in those randomized to MI. The findings from this study indicate the need to further assess MI with this population with a full-scale clinical trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effectiveness and Harms of Contraceptive Counseling and Provision Interventions for Women : A Systematic Review and Meta-analysis

BACKGROUND

The effectiveness and harms of contraceptive counseling and provision interventions are unclear.

PURPOSE

To evaluate evidence of the effectiveness of contraceptive counseling and provision interventions for women to increase use of contraceptives and reduce unintended pregnancy, as well as evidence of their potential harms.

DATA SOURCES

English-language searches of Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE (1 January 2000 to 3 February 2022) and reference lists of key studies and systematic reviews.

STUDY SELECTION

Randomized controlled trials of interventions providing enhanced contraceptive counseling, contraceptives, or both versus usual care or an active control.

DATA EXTRACTION

Dual extraction and quality assessment of studies; results combined using a profile likelihood random-effects model.

DATA SYNTHESIS

A total of 38 trials (43 articles [25 472 participants]) met inclusion criteria. Contraceptive use was higher with various counseling interventions (risk ratio [RR], 1.39 [95% CI, 1.16 to 1.72]; I 2 = 85.3%; 10 trials), provision of emergency contraception in advance of use (RR, 2.12 [CI, 1.79 to 2.36]; I 2 = 0.0%; 8 trials), and counseling or provision postpartum (RR, 1.15 [CI, 1.01 to 1.52]; I 2 = 6.6%; 5 trials) or at the time of abortion (RR, 1.19 [CI, 1.09 to 1.32]; I 2 = 0.0%; 5 trials) than with usual care or active controls in multiple clinical settings. Pregnancy rates were generally lower with interventions, although most trials were underpowered and did not distinguish pregnancy intention. Interventions did not increase risk for sexually transmitted infections (STIs) (RR, 1.05 [CI, 0.87 to 1.25]; I 2 = 0.0%; 5 trials) or reduce condom use (RR, 1.03 [CI, 0.94 to 1.13]; I 2 = 0.0%; 6 trials).

LIMITATION

Interventions varied; few trials were adequately designed to determine unintended pregnancy outcomes.

CONCLUSION

Contraceptive counseling and provision interventions that provide services beyond usual care increase contraceptive use without increasing STIs or reducing condom use. Contraceptive care in clinical practice could be improved by implementing enhanced contraceptive counseling, provision, and follow-up; providing emergency contraception in advance; and delivering contraceptive services immediately postpartum or at the time of abortion.

PRIMARY FUNDING SOURCE

Resources Legacy Fund. (PROSPERO: CRD42020192981).

Incorporating Black women’s perspectives into long-acting reversible contraception implementation

Objective

To study urban, predominantly Black women’s expressed opinions and beliefs related to the use of contraceptives to better inform implementation strategies designed to increase the use of highly effective contraceptives among minoritized and low-income women.

Design

Focus group interviews with women, in conjunction with a community-based organization providing programs for underserved women with a mission of improved women and infant health.

Setting

Focus groups were conducted, and women were recruited from clinical sites in predominantly African American urban neighborhoods in a southeastern US city.

Patient(s)

Self-identified 18–35-year-old women recruited from clinical sites in the urban core of the city with an 80% African American population.

Intervention(s)

No interventions tested.

Main Outcome Measure(s)

Black women’s opinions and concerns about contraception.

Results

Key insights from the focus group results for healthcare providers include the following: the importance of framing discussions with patients within the context of the patients’ goals; need to acknowledge and respect the support systems that women rely on for child birthing and childcare; recognition of the clinician’s role as a trusted and respected source of information; and need to understand and be prepared to address much of the inaccurate and misleading information that can interfere with the patients’ optimal choices for contraception.

Conclusions

A critical component for applying the implementation science theory to increase the use of evidence-based practices, such as implementation of highly effective contraceptives, requires understanding women’s perspectives of the factors influencing their decisions to use highly effective contraceptives. This study provides important insights into the following: the potential barriers inherent in minoritized women’s concerns about contraceptives and how these insights can inform implementation strategies such as patient-centered counseling and education to overcome those barriers.

Developing contraceptive services for immigrant women postpartum - a case study of a quality improvement collaborative in Sweden

Background

Immigrant women use less effective contraceptive methods and have a higher risk of unintended pregnancies. Maternal health care services offer a central opportunity to strengthen contraceptive services, especially among immigrants. This study aimed to evaluate a Quality Improvement Collaborative QIC. Its objective was to improve contraceptive services for immigrant women postpartum, through health care professionals’ (HCPs) counselling and a more effective choice of contraceptive methods.

Methods

The pilot study was designed as an organisational case study including both qualitative and quantitative data collection and analysis. Midwives at three maternal health clinics (MHCs) in Stockholm, Sweden participated in a QIC during 2018–2019. In addition, two recently pregnant women and a couple contributed user feedback. Data on women’s choice of contraceptive method at the postpartum visit were registered in the Swedish Pregnancy Register over 1 year.

Results

The participating midwives decided that increasing the proportion of immigrant women choosing a more effective contraceptive method postpartum would be the goal of the QIC. Evidence-based changes in contraceptive services, supported by user feedback, were tested in clinical practice during three action periods. During the QIC, the proportion of women choosing a more effective contraceptive method postpartum increased at an early stage of the QIC. Among immigrant women, the choice of a more effective contraception increased from 30 to 47% during the study period. Midwives reported that their counselling skills had developed due to participation in the QIC, and they found using a register beneficial for evaluating women’s choice of contraceptive methods.

Conclusions

The QIC, supported by a register and user feedback, helped midwives to improve their contraceptive services during the pregnancy and postpartum periods. Immigrant women’s choice of a more effective contraceptive method postpartum increased during the QIC. This implies that a QIC could increase the choice of a more effective contraception of postpartum contraception among immigrants.

Motivational interviewing to reduce risky sexual behaviors among at-risk male youth: A randomized controlled pilot study

BACKGROUND

Despite male youth taking more sexual risks that lead to unwanted partner pregnancy and/or sexually transmitted infections (STIs), research evaluating interventions for risky sex has focused almost exclusively on adolescent and adult females. With STIs among male youth on the rise, behavioral interventions that target risky sex among male youth are needed.

PURPOSE

A randomized controlled pilot study was conducted to examine the feasibility and acceptability of two manualized behavioral interventions for sexually active male youth.

METHODS

Sexually active at-risk male youth (N = 27) were recruited and randomized to receive one session of motivational interviewing (MI) or didactic educational counseling (DEC). Assessment interviews were conducted prior to and 3 months following the intervention session.

RESULTS

Support for the feasibility and acceptability of delivering behavioral interventions to reduce risky sexual behaviors among at-risk male youth was found. Compared to participants in DEC at follow-up, participants in MI reported having significantly fewer sexual encounters with casual partners, used substances at the time of sex significantly less often with all partners and casual partners, and reported fewer incidents of using substances at the time of sex without a condom with all partners. Conversely, participants who received MI used substances at the time of sex with main partners and used substances at the time of sex without a condom more often with main partners at follow-up compared to participants who received DEC.

CONCLUSIONS

Results of the pilot study support conducting a larger randomized controlled trial to examine treatment effects. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Leveraging the Client-Provider Interaction to Address Contraceptive Discontinuation: A Scoping Review of the Evidence That Links Them

Despite considerable investment and effort, unmet need for contraception remains an obstacle to improved family planning outcomes. One influencing factor is the frequency of contraceptive discontinuation among users who desire to prevent pregnancy, often due to method-related concerns and side effects. Contraceptive users have the right to be supported during counseling to voluntarily choose methods that align with their individual needs and preferences. Contraceptive counseling, as a key component of quality of care, is particularly important for providers to reduce unmet need among their clients. This scoping review examined the state of the evidence on contraceptive counseling and its impact on discontinuation. The review first examines the association between quality of care and contraceptive discontinuation, then looks to what the current body of evidence suggests are women's contraceptive counseling priorities, and lastly, explores whether specific counseling tools and approaches have been evaluated with discontinuation as an outcome. The results identified general principles and priorities for good counseling including person-centeredness, client-tailored information exchange, clear and concise information on side effects and bleeding changes, reducing providers' implicit and explicit biases, and trust and respect between the client and provider. The review of the literature also found that evidence to support the use of specific counseling tools and approaches to reduce contraceptive discontinuation is insufficient; research should be designed to determine which specific elements of the client-provider interaction can be improved to significantly impact contraceptive discontinuation. This evidence could inform how the global community of practice might improve and leverage specific counseling approaches and tools to address the most common predictors of discontinuation.

Peri-abortion contraceptive counseling: A systematic review of randomized controlled trials

Objective

To assess the effects of peri-abortion contraceptive counseling interventions.

Methods

We performed a systematic review of randomized controlled trials (RCTs) that compared the effect of different types of peri-abortion contraceptive counseling interventions and were published as original papers in scientific journals. The literature search was performed in June 2021 in PubMed, Central Cochrane Library (CENTRAL), Scopus, and Google Scholar; without restrictions in language or publication date. Two independent authors identified studies that met the inclusion and exclusion criteria and extracted the data. The risk of bias was assessed using the Cochrane tool, and evidence certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Whenever possible, meta-analyses were performed. The protocol was registered at PROSPERO (CRD42020187354).

Results

Eleven RCTs were eligible for inclusion (published from 2004 to 2017), from which nine compared enhanced versus standard counseling. Pooled estimates showed that, compared to standard counseling, enhanced counseling was associated with a higher incidence of effective contraceptive use (>3 months) (relative risk [RR], 1.12; 95% confidence interval [CI], 1.09–1.16), although no significant difference was found in the incidence of long-acting reversible contraceptive use (RR, 1.25; 95% CI, 0.68–2.29), contraceptive uptake (RR, 1.06; 95% CI, 0.98–1.15), and obstetric event occurrence (RR, 0.91; 95% CI, 0.57–1.47). Certainty of evidence was very low for all outcomes. In addition, two studies compared contraceptive counseling provided by physicians versus that provided by non-physicians, which did not show significant differences.

Conclusions

Enhanced contraceptive counseling may favor effective contraceptive use but may not affect the rate of obstetric event occurrence. Also, the studies did not find a difference in the effects of counseling interventions given by different providers. Since evidence certainty was very low, future well-designed RCTs are needed to make informed decisions.

Registration

The study protocol was registered at PROSPERO (CRD42020187354).

Women's post-abortion contraceptive use: Are predictors the same for immediate and future uptake of contraception? Evidence from Ghana

This study seeks to identify the socio-demographic, reproductive, partner-related, and facility-level characteristics associated with women’s immediate and subsequent use of post-abortion contraception in Ghana. Secondary data from the 2017 Ghana Maternal Health Survey were utilized in this study. The weighted data comprised 1,880 women who had ever had an abortion within the five years preceding the survey. Binary logistic regression analyses were performed to examine the associations between the predictor and outcome variables. Health provider and women’s socio-demographic characteristics were significantly associated with women’s use of post-abortion contraception. Health provider’s counselling on family planning prior to or after abortion and place of residence were associated with both immediate and subsequent post-abortion uptake of contraception. Among subsequent post-abortion contraceptive users, older women (35–49), women in a union, and women who had used contraception prior to becoming pregnant were strong predictors. Partner-related and reproductive variables did not predict immediate and subsequent use of contraception following abortion. Individual and structural/institutional level characteristics are important in increasing women’s acceptance and use of contraception post abortion. Improving and intensifying family planning counselling services at the health facility is critical in increasing contraceptive prevalence among abortion seekers.

Impact of contraceptive counseling on Texans who can and cannot receive no-cost post-abortion contraception

OBJECTIVE

To assess optimal timing, patient satisfaction, and 1-year contraceptive continuation associated with contraceptive counseling among Texans who could and could not receive no-cost long-acting reversible contraception (LARC) via a specialized funding program.

STUDY DESIGN

In this prospective study conducted between October 2014 and March 2016, we evaluated participants' desire for contraceptive counseling during abortion visits, impact of counseling on change in contraceptive preference, satisfaction with counseling, and 1-year postabortion contraceptive continuation. We stratified participants into 3 groups by income, insurance status, and eligibility for no-cost LARC: (1) low-income eligible, (2) low-income ineligible, and (3) higher-income and/or insured ineligible. We examined the association between contraceptive counseling rating and 1-year method continuation by program eligibility and post-abortion contraceptive type.

RESULTS

Among 428 abortion patients, 68% wanted to receive contraceptive counseling at their first abortion visit. Counseling led to a contraceptive preference change for 34%. Of these, 21% low-income eligible participants received a more effective method than initially desired, 10% received a less effective method, and 69% received the method they initially desired. No low-income ineligible participants received a more effective method than they initially desired, 55% received a less effective method, and 45% received the method they initially desired. Five percent of higher-income eligible participants received a more effective method than they initially desired, 48% received a less effective method, and 47% received the method they initially desired. Highest counseling rating was reported by 51%. Compared to those providing a lower rating in each group, highest counseling rating was significantly associated with lower 1-year contraceptive discontinuation for low-income eligible participants (aHR 0.34, 95% CI 0.14, 0.81), but not for low-income ineligible (aHR 1.56, 95% CI 0.83, 2.91) and higher-income (aHR 0.73, 95% CI 0.47,1.13) participants. Additionally, 1-year contraceptive continuation was associated with highest counseling rating (OR 1.72, 95% CI 1.09, 2.72) and post-abortion LARC use (OR 11.70, 95% CI 6.37, 21.48) in unadjusted models, but only postabortion LARC in adjusted models (aOR 1.55, 95% CI 0.90, 2.66 for highest counseling rating vs. aOR 11.83, 95% CI 6.29, 22.25 for postabortion LARC use).

CONCLUSIONS

In Texas, where access to affordable postabortion contraception is limited, high quality contraceptive counseling is associated with 1-year contraceptive continuation only among those eligible for no-cost methods.

IMPLICATIONS

State policies which restrict access to affordable post-abortion contraception limit the beneficial impact of patient-centered counseling and impede patients' ability to obtain their preferred method.

Professional counseling in women with serious mental illness: achieving a shift toward a more effective contraceptive method

OBJECTIVES

Mental disorders in reproductive-aged women have significant implications for the risk of unintended pregnancies. The objective of this study is to assess the professional counseling in clinical practice based on motivational interview in women with serious mental illness (SMI) in order to achieve a change to a more effective contraceptive method.

STUDY DESIGN

A prospective observational cohort study (2012-2017) was conducted in a convenience sample of women with severe-moderate psychiatric disorders (n = 91). Information related to psychiatric health, contraceptive use, sexual and reproductive health and socio-demographics was collected. To assess the variation in the contraceptive method, follow-up visits were planned before and after medical counseling. All participants underwent an evidence-based individual motivational interview for contraception counseling. A multivariate logistic model was carried out to identify the factors involved in changing to a more effective contraceptive method.

RESULTS

After evidence-based counseling, 51.6% of participants changed their contraceptive method to a more effective one. This change was associated with gender violence (β coefficient = 1.58, p value = .006). The relation between changing to a more effective contraceptive method and both previous abortions and having children was also positive, although the coefficients did not reach statistical significance.

CONCLUSIONS

Evidence-based contraception counseling in clinical practice, based on an adapted protocol to patients with SMI, has shown, in this study, to be adequate to promote the shift to more effective contraceptive methods, avoiding the need of daily compliance in this population. Gender violence has been significantly associated with the shift to very high effectiveness methods as well as previous abortions and having children, not significantly.

Knowledge and Attitudes About Sterilization and Long-Acting Reversible Contraception

OBJECTIVES

To describe understanding of the irreversible nature of permanent contraception and knowledge and attitudes about long-acting reversible contraception (LARC) among individuals seeking and not seeking permanent contraception.

METHODS

We performed a cross-sectional survey among patients with Medicaid insurance attending an obstetrics and gynecology clinic in [location]. The survey consisted of 20 true/false and Likert questions assessing knowledge and perceptions about permanent contraception and LARC. Sixty-seven participants were needed to detect a small-to-medium Cohen's effect size f² = 0.20, with 95% power and alpha = 0.05.

RESULTS

Ninety potential participants were contacted and 67 were recruited. Forty-three participants desired permanent contraception and 24 did not. Approximately half of all participants were not aware that permanent contraception is irreversible. Participants who desired permanent contraception had lower LARC knowledge scores (62% correct versus 70%, p = 0.042) and more negative perceptions about LARC (54% versus 38%, p = 0.048). Fewer participants desiring permanent contraception identified LARC efficacy as equal to permanent contraception (32% versus 83%, p < 0.01), and fewer would consider using LARC (intrauterine device: 23% versus 58%, p < 0.01; implant: 16% versus 46%, p < 0.01). These differences persisted in multivariable models adjusting for age, gravidity, and parity.

CONCLUSIONS FOR PRACTICE

Individuals who desire permanent contraception may not be aware of its permanence, or of equally effective alternatives. They were also found to have more negative perceptions of LARC in our sample. Additional research is needed to understand factors underlying these differences. Counseling practices should be tailored to ensure accurate knowledge about permanent contraception and LARC for all people seeking to avoid pregnancy.

Acceptability of immediate postpartum and post-abortion long-acting reversible contraception provision to adolescents: A systematic review

INTRODUCTION

Long-acting reversible contraception (LARC) methods are safe for adolescents and provide the greatest assurance against rapid repeated pregnancy when inserted during the immediate postpartum (IPP) and immediate post-abortion (IPA) period. Despite increasing enthusiasm for IPP/IPA LARC insertion, adolescents' preferences and experiences have seldom been examined. The objective of this review was to examine the attitudes of adolescents (aged 10-19 years) towards IPP/IPA LARC, their experiences and perceptions around having an LARC device fitted IPP/IPA and the factors involved in decision-making to use, not use or discontinue IPP/IPA LARC.

MATERIAL AND METHODS

In January 2021, we searched seven bibliographic databases for original research articles published in English, from the year 2000. Studies of any design focused on IPP/IPA LARC were eligible for inclusion. Three of the authors assessed articles for eligibility and extracted data relevant to the outcomes of the review. Joanna Briggs Institute Critical Appraisal Tools were used to assess methodological quality. Key themes emerging from the data were synthesized and reported narratively.

RESULTS

We identified 10 relevant articles, four of which were entirely adolescent-focused. Only three addressed IPA LARC. IPP availability was important for ensuring access to LARC postpartum. Attitudes towards LARC IPP were associated with adolescents' sociodemographic characteristics and positive perceptions related to the long duration of action. Determinants of discontinuation and nonuse included poor-quality contraceptive counseling, intolerable side effects and subsequent distress, misconceptions about LARC safety IPP and the influence of partners and community on autonomy. No factors involved in IPA LARC decision-making were available. Limited evidence demonstrated that adolescents may favor contraceptive implants over intrauterine devices, and in certain contexts may face greater barriers to IPA LARC access than adult women do.

CONCLUSIONS

Immediate insertion of LARC postpartum appears acceptable to adolescents who do not experience side effects and those with the opportunity to make autonomous contraception decisions. This important topic has been addressed in few studies involving an entirely adolescent population. Very limited evidence is available on IPA LARC. Further research on adolescents' lived experiences of IPP/IPA LARC access and use is necessary to inform the provision of person-centered care when assisting adolescents' contraceptive choice following pregnancy.

A systematic review of the effectiveness of counselling strategies for modern contraceptive methods: what works and what doesn't?

AIM

The aim of this systematic review was to synthesise the evidence on the comparative effectiveness of different counselling strategies for modern contraception on contraceptive behaviour and satisfaction, and to examine their advantages and disadvantages.

METHODS

Six electronic databases (Medline, Embase, Global Health, Popline, CINAHL Plus, and Cochrane Library) were searched to identify publications comparing two or more contraceptive counselling strategies and reporting quantitative results on contraceptive use, uptake, continuation or switching, or client satisfaction. Studies of women or couples from any country, published in English since 1990 were considered.

RESULTS

A total of 63 publications corresponding to 61 studies met the inclusion criteria. There was substantial heterogeneity in study settings, interventions and outcome measures. Interventions targeting women initiating a method (including structured counselling on side effects) tended to show positive effects on contraceptive continuation. In contrast, the majority of studies of provider training and decision-making tools for method choice did not find evidence of an effect. Additional antenatal or postpartum counselling sessions were associated with increased postpartum contraceptive use, regardless of their timing in pregnancy or postpartum. Dedicated pre-abortion contraceptive counselling was associated with increased use only when accompanied by broader contraceptive method provision. Male partner or couples counselling was effective at increasing contraceptive use in two of five studies targeting non-users, women initiating implants or seeking abortion. High-quality evidence is lacking for the majority of intervention types.

CONCLUSIONS

The evidence base and quality of studies are limited, and further research is needed to determine the effectiveness of many counselling interventions in different settings.

Motivational interviewing to promote long-acting reversible contraception among Rwandan couples wishing to prevent or delay pregnancy

BACKGROUND

Few family-planning programs in Africa base demand creation and service delivery on theoretical models. Motivational interviewing is a counseling modality that facilitates reflection on the benefits and disadvantages of a health outcome to encourage behavior change.

OBJECTIVES

We evaluate a couples-focused joint family-planning and HIV counseling intervention using motivational interviewing to enhance uptake of long-acting reversible contraception (Paragard copper intrauterine device or Jadelle hormonal implant) among Rwandan couples.

STUDY DESIGN

In this experimental study, couples receiving care at 8 government health clinics in Kigali, the capital city, were referred from a parent study of couples who did not want more children or wanted to wait at least 2 years for their next pregnancy. Long-acting reversible contraception methods were offered on site following joint HIV testing and family-planning counseling. At the first follow-up visit 1 month after enrollment in the parent study, couples who had not yet chosen a long-acting reversible contraception method were interviewed separately using motivational interviewing and then brought together and again offered long-acting reversible contraception.

RESULTS

Following motivational interviewing, 78 of 229 couples (34%) requested a long-acting reversible contraception method (68 implant and 10 intrauterine device). Long-acting reversible contraception uptake after motivational interviewing was associated with the woman being Catholic (vs Protestant/Muslim/other, adjusted odds ratio, 2.87, 95% confidence interval, 1.19-6.96, P = .019) or having an income (vs no income, adjusted odds ratio, 2.54, 95% confidence interval, 1.12-5.73, P = .025); the couple having previously discussed long-acting reversible contraception (adjusted odds ratio, 8.38, 95% confidence interval, 2.54-27.59, P = .0005); either partner believing that unplanned pregnancy was likely with their current method (adjusted odds ratio, 6.67, 95% confidence interval, 2.77-16.11, P < .0001); or that they might forget to take or make an appointment for their current method (adjusted odds ratio, 4.04, 95% confidence interval, 1.32-12.34, P = .014). Neither partner mentioning that condoms also prevent HIV/sexually transmitted infection was associated with long-acting reversible contraception uptake (adjusted odds ratio, 2.86, 95% confidence interval, 1.17-7.03, P = .022), as was the woman citing long-term duration of action of the implant as an advantage (adjusted odds ratio, 5.41, 95% confidence interval, 1.86-15.76, P = .002). The woman not listing any side effects or disadvantages of implants was associated with long-acting reversible contraception uptake (adjusted odds ratio, 5.42, 95% confidence interval, 2.33-12.59, P < .0001). Clinic location (rural vs urban), couple HIV status, and concerns about negative economic effects of an unplanned pregnancy were significant in bivariate but not multivariate analysis.

CONCLUSION

Encouraging couples to reflect on the benefits and disadvantages of long-acting reversible contraception methods, the likelihood of unplanned pregnancy with their current contraception, and the impact of an unplanned pregnancy is an effective motivational interviewing technique in family-planning counseling. One third of couples who did not want a pregnancy for at least 2 years but had not chosen a long-acting reversible contraception method when provided with standard family-planning counseling did so after motivational interviewing. Involving the male partner in family-planning discussions facilitates joint decision making about fertility goals and contraceptive choice. Combining family planning and joint HIV testing for couples allows targeted focus on dual-method use with discordant couples, who are advised to use condoms for HIV/sexually transmitted infection prevention along with a more effective contraceptive for added protection against unplanned pregnancy.

The history of tiered-effectiveness contraceptive counseling and the importance of patient-centered family planning care

Public health workers, clinicians, and researchers have tried to increase long-acting reversible contraceptive (LARC) use by changing contraceptive counseling between patients and providers. Several major health organizations now recommend tiered-effectiveness counseling, in which the most effective methods are explained first so that patients can use information about the relative efficacy of contraceptive methods to make an informed choice. Some scholars and practitioners have raised concerns that, given histories of inequitable treatment and coercion in reproductive health care, tiered-effectiveness counseling may undermine patient autonomy and choice. This Clinical Opinion examines the development of tiered-effectiveness contraceptive counseling, how its rise mirrored the focus on promoting LARC to decrease the unintended pregnancy rate, and key considerations and the potential conflicts of a LARC-first model with patient-centered care. Finally, we discuss how reproductive justice and shared decision making can guide efforts to provide patient-centered contraceptive care.

Computer-assisted motivational interviewing for contraceptive use in women leaving prison: A randomized controlled trial

OBJECTIVES

Rates of unintended pregnancies in women with a history of incarceration are high and access to contraception before and after arrest can be limited. Individualized counseling can better prepare women for healthy pregnancy or provide an opportunity for contraceptive education and access within correctional facilities. In this study, we assessed the efficacy of motivational interviewing as an individualized intervention to increase the initiation of contraceptive methods while incarcerated and continuation after release in female inmates who wanted to avoid pregnancy for at least one year after release.

STUDY DESIGN

We performed an RCT in a population of incarcerated women who wanted to avoid pregnancy. Women were randomized to either a computer-assisted motivational interviewing intervention group (n = 119) or an educational video with counseling control group. (n = 113). The primary outcome was initiation of a method of birth control prior to release from the correctional facility.

RESULTS

Initiation of contraception was higher in the intervention group (56% vs. 42%, p = 0.03), but this difference was not significant after controlling for number of male partners within the year prior to incarceration. There was no difference between the groups in the rates of pregnancies or STIs or continuation of contraception after release, which was generally low (21%).

CONCLUSION

Computer-assisted motivational interviewing did not improve uptake or continuation of contraception in this study.

IMPLICATIONS

Periods of incarceration provide an opportunity to offer contraceptive services to women who want to avoid a pregnancy. Motivational interviewing may not be an effective method to affect contraceptive behaviors in this population. Future research should explore the family planning values and preferences of women who become involved with the correctional system.

Collaboratively seeking to improve contraceptive counselling at the time of an abortion: a case study of quality improvement efforts in Sweden

BACKGROUND

Many women find it difficult to choose and initiate a contraceptive method at the time of an abortion. There is a gap between regular clinical practice and existing evidence on motivational and person-centred counselling, as well as on use of long-acting reversible contraception (LARC). This study aims to describe and evaluate a Quality Improvement Collaborative (QIC) designed to enhance contraceptive services, with regard to changes in healthcare professionals' (HCPs') counselling in clinical practice, and in women's subsequent choice of, and access to, contraception.

METHODS

Three multiprofessional teams working in abortion services from three hospitals in Sweden, and two women contributing with user experience, participated in a QIC during the period March-November 2017. Using a case study design, we collected and analysed both quantitative and qualitative data.

RESULTS

Teams agreed on QIC goals, including that ≥50% of women would start LARC within 30 days post-abortion, and tested multiple evidence-based changes, aided by the two women's feedback. During the QIC, participating HCPs reported that they gained new knowledge and developed skills in contraceptive counselling at the time of an abortion. The teams welcomed the development of a performance feedback system regarding women's post-abortion contraception. While the majority of women counselled during the QIC chose LARC, only 20%-40% received it within 30 days post-abortion.

CONCLUSION

The QIC, incorporating user feedback, helped HCPs to develop capability in providing contraceptive services at the time of an abortion. Timely access to LARC remains a challenge in the present setting.

Confidence and readiness to discuss, plan and implement postpartum contraception during prenatal care versus after delivery

No studies exist to determine the optimal timing to counsel women regarding postpartum contraception which means opportunities for immediate postpartum contraception are often missed. Women between the gestational ages of 25^0/7 and 35^6/7 weeks, meeting inclusion criteria and attending an outpatient clinic were offered to participate in the study. Subjects completed surveys querying readiness, capability and confidence in discussing and committing to a postpartum contraceptive plan. Two hundred and forty-three patients were enrolled in the study. Sixty-three percent of patients responded they considered that the best time for contraception discussion was the second or third trimester. More women reported a contraception plan was important or very important postpartum than prenatally (78% vs. 56%; p<.0001). More women reported feeling ready or very ready to discuss (82% vs. 66%; p<.0001), and ready or very ready to choose (84% vs. 64%; p<.007), capable or highly capable of choosing (90% vs. 79%; p=.0009) postpartum than prenatally. Postpartum, more women felt confident or very confident (98% vs. 90%; p=.0006) in their ability to use effective contraception after delivery. Women reported higher levels of readiness and capability to choose and discuss contraception postpartum than prenatally. Most women felt ready and capable to choose a contraceptive option prior to postpartum discharge. IMPACT STATEMENT What is already known on this subject? Short interpregnancy interval is associated with increased maternal and neonatal morbidity and mortality. Effective postpartum contraception can be decided upon and administered, thereby increasing the interval between subsequent pregnancies. What do the results of this study add? The results of this study demonstrate that women report high levels of readiness and capability to choose and discuss contraception before postpartum discharge. What are the implications of these findings for clinical practice and/or further research? These findings imply that further research is needed to determine how to use motivational interviewing to encourage pregnant women to make a postpartum contraception decision prior to the postpartum period to facilitate uptake of their contraceptive choice.

Prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among young women (24 and below) in Nepal: Strategy in the search for improvements

Introduction

Postabortion contraceptive use differs across countries, suggesting the need for country-level research to identify barriers and suggest appropriate interventions. This study aimed to identify the prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among women aged 24 or younger in Nepal.

Methods

This is a cohort study using Health Management Information System (HMIS) data where individual case records of women seeking induced abortion or postabortion care were documented using structured HMIS 3.7 records. Analysis was performed on the individual case records of 20,307 women 24 years or younger who received induced abortion or postabortion care services in the three-year period from July 2014 to June 2017 at 433 public and private health facilities.

Findings

Overall, LARC uptake during the study period was 11% (IUD: 3% and implant: 8%). The odds of LARC acceptance was higher for young women (24 and below) who belonged to Brahmin/Chhetri (AOR = 1.23; 95% CI: 1.02–1.47) and Janajatis (AOR = 1.20; 95% CI: 1.01–1.43) as compared to Dalits; young women who had an induced abortion (AOR = 3.75; 95% CI: 1.75–8.06) compared with postabortion care; and those receiving service from public sector health facilities (AOR = 4.00; 95% CI: 2.06–7.75) compared with private sector health facilities.

Conclusion

The findings from this study indicate the need to focus on barriers to acceptance of LARC among several groups of young women (24 and below) receiving abortion care in Nepal: Dalits, Madhesis and Muslims; nulliparous women; and those receiving services at private sector health facilities.

Shared negative experiences of long-acting reversible contraception and their influence on contraceptive decision-making: a multi-methods study

OBJECTIVES

We explored how negative stories about long-acting reversible contraception (LARC) - defined as a firsthand negative experience with LARC shared directly with the study participant - were involved in participants' decisions about whether to use LARC following abortion, and how counseling affected the influence of negative LARC stories on contraceptive choices.

STUDY DESIGN

We performed a multi-methods study, embedded within a trial examining the impact of a theory-based counseling intervention on LARC uptake post-abortion. Participants completed a baseline survey to determine the influence of negative LARC stories. We subsequently invited respondents who reported having heard negative LARC stories to participate in a semi-structured qualitative interview. We analyzed quantitative data with univariate statistics. We analyzed qualitative data using thematic content analysis.

RESULTS

Among the 60 participants, 16 (27%) reported having heard negative LARC stories. Two of the 16 (13%) planned to initiate LARC prior to counseling, compared to 18 of 44 women (41%) who had not heard negative LARC stories (p=0.06). Prior to counseling, 69% of participants with negative LARC stories reported that these stories made them less likely to use LARC. In qualitative interviews with 9 women, we identified several key themes: (1) negative LARC stories deterred LARC use; (2) friends and family were valued informants; (3) potential side effects were important to LARC decision-making; and (4) positive and negative features of the counseling encounter influenced the effect of negative LARC stories.

CONCLUSIONS

Negative LARC stories are common among women presenting for abortion at our institution and may influence patient uptake of these methods. Implications This study uses a multi-methods approach to examine the influence of negative stories about long-acting reversible contraception (LARC) on decision-making about LARC. These findings can help providers elicit patients' needs in contraception counseling and generate hypotheses for future counseling research.

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.

Correlates of long-acting reversible contraception uptake among rural women in Guatemala

OBJECTIVE

In many low-resource settings around the world utilization of long-acting reversible contraception (LARC) is low, in part due to access barriers. We sought to explore LARC utilization patterns as well as factors associated with LARC initiation by women seeking contraception in rural Guatemala from a program working to reduce contraception access barriers.

STUDY DESIGN

We analyzed data from a program that provides family planning in six remote, primarily indigenous, villages in Guatemala with limited access to alternative health services. Methods are free and delivered directly within villages by culturally competent providers. We conducted a retrospective chart review of all 288 women who initiated a contraceptive method over a 16-month period and conducted a logistic regression to obtain adjusted odds ratios (OR) for predictors of LARC uptake.

RESULTS

Overall 79.2% of women elected a LARC method. More than half of women (49.8%) switched to LARC from short-acting hormonal methods. In the univariate analysis prior use of short-acting method (p = 0.014), number of prior methods (p = 0.049), and current contraceptive use (p<0.01) were significantly associated with choosing a LARC. In the logistic regression model current use of contraception remained significant (OR 3.29, 95% CI 1.67-8.04). Report of abnormal bleeding or other side effects from prior short-acting method use did not predict LARC uptake (p = 0.82 and p = 0.079).

CONCLUSIONS

Most women in this marginalized population opted for a LARC method.

IMPLICATIONS

Low utilization of LARCs may be related to service delivery factors. Further research is needed to validate these conclusions prospectively and in less selected populations.

Adolescent girls and young women living with HIV: preconception counseling strategies

Background

Rates of pregnancy among women living with HIV are similar to those in the general population. Unintended pregnancies are also common, and among adolescents and young women perinatally infected (PHIV+) or behaviorally infected (BHIV+) with HIV, planning for both conception and contraception is an important element of HIV care that may be neglected. This pilot study examined the influence of intervention strategies targeting fertility planning, safer conception practices and patient-provider communication. It was hypothesized that preconception counseling interventions would enhance reproductive knowledge, planning and practices, as well as stimulate discussion with providers regarding conception.

Methods

Adolescent girls and young women (N=34) perinatally (n=21) or behaviorally (n=13) infected with HIV, aged 16–29 years, were recruited from urban South Florida, and completed measures of reproductive knowledge, sexual practices and fertility intentions. Participants were randomized to condition, ie, video presentation plus Motivational Interviewing (MI), MI only, control.

Results

The average age of women was 22 years (SD =3.27), and the majority of them were African American. Levels of depression were higher among BHIV+ compared to PHIV+ at baseline and 6 months. Pregnancy knowledge (pregnancy, safe conception and pregnancy planning) and the proportion of those engaging in birth control planning (condom use, long-term birth control, patient-provider discussions on preventing pregnancy and fertility desires) were similar between conditions at post-intervention and 6 months. Bayes factors indicated that the data were insensitive with regard to differences between conditions, limiting support for both the null and alternative hypotheses.

Conclusion

The impact of interventions used in this study to stimulate pregnancy planning was inconclusive. Results suggest that pregnancy planning interventions may require greater intensity to influence sexual behavior in this population. Despite adequate reproductive knowledge, HIV-infected adolescent girls and young women may fail to engage in planning behavior.

Theory-based interventions for contraception

BACKGROUND

The explicit use of theory in research helps expand the knowledge base. Theories and models have been used extensively in HIV-prevention research and in interventions for preventing sexually transmitted infections (STIs). The health behavior field uses many theories or models of change. However, many educational interventions addressing contraception have no explicit theoretical base.

OBJECTIVES

To review randomized controlled trials (RCTs) that tested a theoretical approach to inform contraceptive choice and encourage or improve contraceptive use.

SEARCH METHODS

To 1 November 2016, we searched for trials that tested a theory-based intervention for improving contraceptive use in PubMed, CENTRAL, POPLINE, Web of Science, ClinicalTrials.gov, and ICTRP. For the initial review, we wrote to investigators to find other trials.

SELECTION CRITERIA

Included trials tested a theory-based intervention for improving contraceptive use. Interventions addressed the use of one or more methods for contraception. The reports provided evidence that the intervention was based on a specific theory or model. The primary outcomes were pregnancy and contraceptive choice or use.

DATA COLLECTION AND ANALYSIS

We assessed titles and abstracts identified during the searches. One author extracted and entered the data into Review Manager; a second author verified accuracy. We examined studies for methodological quality.For unadjusted dichotomous outcomes, we calculated the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI). Cluster randomized trials used various methods of accounting for the clustering, such as multilevel modeling. Most reports did not provide information to calculate the effective sample size. Therefore, we presented the results as reported by the investigators. We did not conduct meta-analysis due to varied interventions and outcome measures.

MAIN RESULTS

We included 10 new trials for a total of 25. Five were conducted outside the USA. Fifteen randomly assigned individuals and 10 randomized clusters. This section focuses on nine trials with high or moderate quality evidence and an intervention effect. Five based on social cognitive theory addressed preventing adolescent pregnancy and were one to two years long. The comparison was usual care or education. Adolescent mothers with a home-based curriculum had fewer second births in two years (OR 0.41, 95% CI 0.17 to 1.00). Twelve months after a school-based curriculum, the intervention group was more likely to report using an effective contraceptive method (adjusted OR 1.76 ± standard error (SE) 0.29) and using condoms during last intercourse (adjusted OR 1.68 ± SE 0.25). In alternative schools, after five months the intervention group reported more condom use during last intercourse (reported adjusted OR 2.12, 95% CI 1.24 to 3.56). After a school-based risk-reduction program, at three months the intervention group was less likely to report no condom use at last intercourse (adjusted OR 0.67, 95% CI 0.47 to 0.96). The risk avoidance group (abstinence-focused) was less likely to do so at 15 months (OR 0.61, 95% CI 0.45 to 0.85). At 24 months after a case management and peer-leadership program, the intervention group reported more consistent use of hormonal contraceptives (adjusted relative risk (RR) 1.30, 95% CI 1.06 to 1.58), condoms (RR 1.57, 95% CI 1.28 to 1.94), and dual methods (RR 1.36, 95% CI 1.01 to 1.85).Four of the nine trials used motivational interviewing (MI). In three studies, the comparison group received handouts. The MI group more often reported effective contraception use at nine months (OR 2.04, 95% CI 1.47 to 2.83). In two studies, the MI group was less likely to report using ineffective contraception at three months (OR 0.31, 95% CI 0.12 to 0.77) and four months (OR 0.56, 95% CI 0.31 to 0.98), respectively. In the fourth trial, the MI group was more likely than a group with non-standard counseling to initiate long-acting reversible contraception (LARC) by one month (OR 3.99, 95% CI 1.36 to 11.68) and to report using LARC at three months (OR 3.38, 95% CI 1.06 to 10.71).

AUTHORS' CONCLUSIONS

The overall quality of evidence was moderate. Trials based on social cognitive theory focused on adolescents and provided multiple sessions. Those using motivational interviewing had a wider age range but specific populations. Sites with low resources need effective interventions adapted for their settings and their typical clients. Reports could be clearer about how the theory was used to design and implement the intervention.