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Bizjak I, Envall N, Emtell Iwarsson K, Kopp Kallner H, Gemzell‐Danielsson K. Contraceptive uptake and compliance after structured contraceptive counseling - secondary outcomes of the LOWE trial. Acta Obstet Gynecol Scand 2024; 103:873-883. [PMID: 38351571 PMCID: PMC11019526 DOI: 10.1111/aogs.14792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/18/2023] [Accepted: 01/12/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Highly effective long-acting reversible contraceptive (LARC) methods reduce unintended pregnancy rates; however, these methods are underutilized. The LOWE trial intervention provided structured contraceptive counseling resulting in increased uptake of LARC. This longitudinal follow up of the LOWE study assessed the long-term impact of the intervention by investigating the contraceptive use at 12 months with a focus on continued use of LARC. MATERIAL AND METHODS In the cluster randomized LOWE trial, abortion, youth, and maternal health clinics were randomized to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of an educational video on contraceptive methods, key questions asked by the health care provider, a tiered effectiveness chart and a box of contraceptive models. Women ≥ age 18, who were sexually active or planned to be in the upcoming 6 months, could participate in the study. We assessed self-reported contraceptive use at three, six and 12 months. Contraceptive choice and switches were analyzed with descriptive statistics. Contraceptive use at 12 months and continued use of LARC were analyzed using mixed logistic regressions, with clinic included as a random effect. Analysis with imputed values were performed for missing data to test the robustness of results. RESULTS Overall, at 12 months, women in the intervention group were more likely to be using a LARC method (aOR 1.90, 95% CI: 1.31-2.76) and less likely to be using a short-acting reversible contraceptive (SARC) method (aOR 0.66, 95% CI: 0.46-0.93) compared to the control group. Women counseled at abortion (aOR 2.97, 95% CI: 1.36-6.75) and youth clinics (aOR 1.81, 95% CI: 1.08-3.03) were more likely to be using a LARC method, while no significant difference was seen in maternal health clinics (aOR 1.84, 95% CI: 0.96-3.66). Among women initiating LARC, continuation rates at 12 months did not differ between study groups (63.9% vs. 63.7%). The most common reasons for contraceptive discontinuation were wish for pregnancy, followed by irregular bleeding, and mood changes. CONCLUSIONS The LOWE trial intervention resulted in increased LARC use also at 12 months. Strategies on how to sustain LARC use needs to be further investigated.
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Affiliation(s)
- Isabella Bizjak
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Division of Gynecology and Reproductive MedicineKarolinska University HospitalStockholmSweden
| | - Niklas Envall
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Clinical Sciences at Danderyd Hospital, Division of Obstetrics and GynecologyKarolinska InstitutetStockholmSweden
- School of Health and WelfareDalarna UniversityFalunSweden
| | - Karin Emtell Iwarsson
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Division of Gynecology and Reproductive MedicineKarolinska University HospitalStockholmSweden
| | - Helena Kopp Kallner
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Department of Clinical Sciences at Danderyd Hospital, Division of Obstetrics and GynecologyKarolinska InstitutetStockholmSweden
- Division of Obstetrics and GynecologyDanderyd HospitalStockholmSweden
| | - Kristina Gemzell‐Danielsson
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- Division of Gynecology and Reproductive MedicineKarolinska University HospitalStockholmSweden
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Niemeyer Hultstrand J, Törnroos E, Tydén T, Larsson M, Makenzius M, Gemzell‐Danielsson K, Sundström‐Poromaa I, Ekstrand Ragnar M. Contraceptive use among women seeking an early induced abortion in Sweden. Acta Obstet Gynecol Scand 2023; 102:1496-1504. [PMID: 37493190 PMCID: PMC10577618 DOI: 10.1111/aogs.14630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/23/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION In spite of societal efforts to strengthen women's sexual and reproductive health in Sweden, many women have unmet contraceptive needs and the abortion rate remains high. The aim of this study was to investigate contraceptive use among abortion-seeking women. MATERIAL AND METHODS Swedish-speaking women seeking an induced abortion up to the end of gestational week 12 at seven hospitals filled out an anonymous paper questionnaire between January and June 2021. Data were analyzed using frequencies and cross-tabulations, and the Chi-square test was used to compare age-groups. Valid percentages are presented. RESULTS In total, 623 women participated. Median age was 29 years and 13% were born outside the Nordic countries. In the year preceding the abortion, condoms (37%, n = 228) were the most commonly used contraceptive method, followed by short-acting reversible contraception (SARC) (35%, n = 213) and withdrawal (25%, n = 152). Around one in five (n = 113) had not used any method in the year preceding the abortion. Sixteen percent (n = 96) had changed contraceptive method in the last year. At the time around conception, 15% (n = 90) reported use of SARC and 2% (n = 12) of long-acting reversible contraception (LARC). Four out of 10 women (n = 268) reported non-use of contraception at the time around conception, with a higher proportion among adolescents (70%, n = 30, P = 0.001). Among the women who responded to why they had not used any method (n = 387), the main reasons were that they did not believe they could become pregnant at that time (37%, n = 144) or had negative experiences from using contraceptives (32%, n = 123). A majority (88%, n = 527) planned to use contraception after the abortion. Of the women who had decided on method, 55% (n = 271) planned to use LARC, and 38% (n = 188) planned to use SARC. CONCLUSION The unmet need for contraception appears to be high among abortion-seeking women in Sweden. Many had discontinued contraception use during the last year, and the main reasons for avoidance were beliefs that one could not become pregnant and negative experiences of contraceptives. The underestimation of pregnancy risk indicates limited fertility awareness, thus our recommendation would be to strengthen the sexual and reproductive knowledge among this group.
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Affiliation(s)
| | - Elin Törnroos
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - Tanja Tydén
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - Margareta Larsson
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
| | - Marlene Makenzius
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
- Department of Health SciencesMid Sweden UniversityÖstersundSweden
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
| | - Kristina Gemzell‐Danielsson
- Department of Women's and Children's HealthKarolinska InstitutetStockholmSweden
- WHO CenterKarolinska University HospitalStockholmSweden
| | | | - Maria Ekstrand Ragnar
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
- Department of Health SciencesLund UniversityLundSweden
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Kilander H, Sorcher R, Berglundh S, Petersson K, Wängborg A, Danielsson KG, Iwarsson KE, Brandén G, Thor J, Larsson EC. IMplementing best practice post-partum contraceptive services through a quality imPROVEment initiative for and with immigrant women in Sweden (IMPROVE it): a protocol for a cluster randomised control trial with a process evaluation. BMC Public Health 2023; 23:806. [PMID: 37138268 PMCID: PMC10154759 DOI: 10.1186/s12889-023-15776-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/27/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Immigrant women's challenges in realizing sexual and reproductive health and rights (SRHR) are exacerbated by the lack of knowledge regarding how to tailor post-partum contraceptive services to their needs. Therefore, the overall aim of the IMPROVE-it project is to promote equity in SRHR through improvement of contraceptive services with and for immigrant women, and, thus, to strengthen women's possibility to choose and initiate effective contraceptive methods post-partum. METHODS This Quality Improvement Collaborative (QIC) on contraceptive services and use will combine a cluster randomized controlled trial (cRCT) with a process evaluation. The cRCT will be conducted at 28 maternal health clinics (MHCs) in Sweden, that are the clusters and unit of randomization, and include women attending regular post-partum visits within 16 weeks post birth. Utilizing the Breakthrough Series Collaborative model, the study's intervention strategies include learning sessions, action periods, and workshops informed by joint learning, co-design, and evidence-based practices. The primary outcome, women's choice of an effective contraceptive method within 16 weeks after giving birth, will be measured using the Swedish Pregnancy Register (SPR). Secondary outcomes regarding women's experiences of contraceptive counselling, use and satisfaction of chosen contraceptive method will be evaluated using questionnaires completed by participating women at enrolment, 6 and 12 months post enrolment. The outcomes including readiness, motivation, competence and confidence will be measured through project documentation and questionnaires. The project's primary outcome involving women's choice of contraceptive method will be estimated by using a logistic regression analysis. A multivariate analysis will be performed to control for age, sociodemographic characteristics, and reproductive history. The process evaluation will be conducted using recordings from learning sessions, questionnaires aimed at participating midwives, intervention checklists and project documents. DISCUSSION The intervention's co-design activities will meaningfully include immigrants in implementation research and allow midwives to have a direct, immediate impact on improving patient care. This study will also provide evidence as to what extent, how and why the QIC was effective in post-partum contraceptive services. TRIAL REGISTRATION NCT05521646, August 30, 2022.
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Affiliation(s)
- Helena Kilander
- Department of Women's and Children's Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden.
- Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden.
| | - Rachael Sorcher
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - Sofia Berglundh
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - Kerstin Petersson
- Department of Clinical Sciences, Obstetrics and Gynaecology, Umeå University, Umeå, Sweden
| | - Anna Wängborg
- Department of Women's and Children's Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden
| | - Kristina Gemzell- Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden
| | - Karin Emtell Iwarsson
- Department of Women's and Children's Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Brandén
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Center for Epidemiology and Social Medicine, Region Stockholm, Sweden
| | - Johan Thor
- Jönköping Academy for Improvement of Health and Welfare, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Elin C Larsson
- Department of Women's and Children's Health, Karolinska Institutet, and the WHO Collaborating Centre, Karolinska University Hospital, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
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Envall N, Wallström T, Gemzell Danielsson K, Kopp Kallner H. Use of contraception and attitudes towards contraceptive use in Swedish women: an internet-based nationwide survey. EUR J CONTRACEP REPR 2022; 27:409-417. [PMID: 36004625 DOI: 10.1080/13625187.2022.2094911] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE Explore contraceptive use, unmet need of and attitudes towards contraceptive use in Sweden. Secondly, to investigate knowledge of contraceptives, prevalence and outcomes of unintended pregnancies. MATERIALS AND METHODS Internet based e-survey of Swedish women aged 16-49. The e-survey contained 49 questions with both spontaneous and multi-choice character on demographics, contraceptive use, knowledge of and attitudes towards contraception, importance of monthly bleeding, and experience of unintended pregnancy. The e-survey was closed when reaching the estimated sample size of 1000 respondents. RESULTS A total of 1016 women participated, whereof 62.4% used contraception, 31.8% did not and 5.8% had stopped in the last 12 months. Unmet need for contraception was estimated at 17.2%. At least one unintended pregnancy was experienced by 19.9%. All women rated effectiveness as the most important characteristic of a contraceptive method. CONCLUSIONS Use of contraception in Swedish women remains low, 62.4%, and the unmet need for contraception has increased to 17.2%. Method effectiveness and health benefits of hormonal contraception should be emphasised during contraceptive counselling, and actions are needed to target groups with low use of effective contraception as well as to reach those who never seek contraception.KEY MESSAGEClose to one third of Swedish women do not use contraception and one fifth have experienced at least one unintended pregnancy. Unmet need for contraception is high despite easy access and subsidies for young women.
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Affiliation(s)
- Niklas Envall
- School of Health and Welfare, Dalarna University, Falun, Sweden.,Department of Clinical Sciences Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Tove Wallström
- Department of Clinical Science and Education, South General Hospital Stockholm, Stockholm, Sweden.,Department of Obstetrics and Gynecology, South General Hospital Stockholm, Stockholm, Sweden
| | - Kristina Gemzell Danielsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,WHO Collaborating Centre, Division of Gynecology and Reproduction, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Kopp Kallner
- Department of Clinical Sciences Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden.,Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden
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Leon-Larios F, Gutiérrez Ales J, Puente Martínez MJ, Correa Rancel M, Lahoz Pascual I, Silva Reus I, Quílez Conde JC. Results of the National Contraception Survey Conducted by Sociedad Española de Contracepción (2020). J Clin Med 2022; 11:jcm11133777. [PMID: 35807063 PMCID: PMC9267860 DOI: 10.3390/jcm11133777] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 11/21/2022] Open
Abstract
Background: The National Contraception Survey conducted by Sociedad Española de Contracepción intends to know the sexual and contraceptive habits of Spanish women of reproductive age. Methods: A descriptive and cross-sectional study with random sample selection was conducted with women aged from 14 to 49 years old in July and August 2020. Results: A total of 1801 women participated in the study, of which 78.7% used some contraception method during their sexual relationships. The most frequently used methods were condoms (31.3%) and combined oral contraceptives (18.5%) at their last sexual encounter. A total of 25.7% used both condoms and pills, especially younger women and those who had no steady partners (p < 0.001). Use of Long-acting Reversible Contraceptives continues to be low, although a slight increase in their use is observed, and they are recommended for 50% of the users who need contraception. Counselling on contraception was provided to 64.3% of the women, mainly by their gynaecologists. Regarding the decision to use a contraceptive method, the one suggested by health professionals was more influential, although this was not the case for women aged less than 20 years old (p < 0.001). A total of 38.4% of the women have used emergency oral contraception at least once and 66.8% of those who do not make continuous use of contraception methods do so out of personal choice. Conclusions: It is necessary to deepen work on counselling and awareness among the population towards the use of efficient contraceptive methods that prevent unplanned pregnancies.
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Affiliation(s)
| | | | | | - Marta Correa Rancel
- Hospital Universitario de Canarias, 38320 Tenerife, Spain;
- Departamento de Obstetricia-Ginecología, Pediatría, Preventiva, Medicina Legal y Forense, Microbiología, Parasitología, Universidad de la Laguna, 38200 Santa Cruz de Tenerife, Spain
| | | | - Isabel Silva Reus
- Centro de Salud Sexual y Reproductiva de Villena, 03400 Alicante, Spain;
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