Increasing uptake of long-acting reversible contraception with structured contraceptive counselling: cluster randomised controlled trial (the LOWE trial)

Non-daily contraception: Reinforcing the choice of users and addressing unmet needs of reproductive health

Despite great societal efforts promoting female autonomy, Sweden still faces unmet contraceptive needs, with abortion rates being the highest in the Nordic countries. In this commentary, we discuss using non-daily contraception options to combat these unmet needs. Non-daily methods include transdermal (i.e., patch), ring, injectables, and long-acting reversible contraception (LARC). Numerous studies have revealed that users prefer non-daily methods, and studies implementing structured counseling have revealed an increase in non-daily methods. Relative to LARC, the patch and the ring are non-daily parenteral methods that offer the possibility for self-management. Ultimately, client-centered counseling and shared decision-making are crucial for increasing awareness of all methods and enhancing method utilization and adherence. Finally, dispelling myths surrounding reversible hormonal contraception is essential for empowering women to make informed choices and improving overall reproductive health outcomes.

Evaluating the effectiveness of a tailored online educational video on the contraceptive knowledge and decision making of young women from culturally and linguistically diverse backgrounds: findings from the EXTEND-PREFER study

BACKGROUND

Young Australian women from culturally and linguistically diverse (CALD) backgrounds are vulnerable to unwanted pregnancy. We aimed to assess whether an online educational video, co-designed with young CALD women, can increase their contraceptive knowledge, preference for and uptake of long-acting reversible contraception (LARC).

METHODS

Online advertising was used to recruit young CALD women aged 16-25 years. Participants completed the pre-video survey (S1), watched the 13-min co-designed video, then completed a survey immediately afterwards (S2) and 6 months later (S3). Outcomes were analysed using McNemar tests and multivariate logistic regression.

RESULTS

A total of 160 participants watched the video, completed S1 and S2, and 57% of those completed S3. At S1 only 14% rated their knowledge about every contraceptive method as high. Knowledge improved at S2 for all methods (aOR 3.2, 95% CI 2.0 to 5.0) and LARC (aOR 4.7, 95% CI 2.9 to 7.5). Overall method preference for LARC increased from 2.5% (n=4) at S1 to 51% (n=82) at S2. Likelihood of using a LARC increased at S2 (aOR 3.8, 95% CI 2.6 to 5.6). The overall proportion of participants using a LARC increased from 8% at S1 to 11% at S3; however, this increase was not significant (p=0.7).

CONCLUSIONS

The significant increase in knowledge, likelihood of use, and preference for LARC underscores the potential of online video-based contraceptive education to address contraceptive knowledge gaps and challenge misconceptions about LARC held by young women. Combining contraceptive education with supports to LARC access is crucial for empowering young CALD women to make informed contraceptive decisions.

Effects of structured contraceptive counseling in young women: Secondary analyses of a cluster randomized controlled trial (the LOWE trial)

INTRODUCTION

Unwanted pregnancy constitutes a huge health issue. Long-acting reversible contraception (LARC) are the most effective methods for preventing unwanted pregnancy, especially among young women. This study evaluates the intervention effect of structured contraceptive counseling on the choice, initiation, and use of LARC in young women.

MATERIAL AND METHODS

This is a secondary analysis of women aged 18-25, enrolled in a multicenter cluster randomized controlled trial performed in abortion, youth, and maternal health clinics across the Stockholm County in Sweden. Clinics were randomized (1:1) to provide structured contraceptive counseling (intervention) or standard counseling (control). Surveys were administered at the clinic visit and follow-ups at 3, 6, and 12 months. Primary outcome focused on the choice of LARC among women 18-25 years of age. Secondary outcomes included initiation, and use of LARC at 3 and 12 months, satisfaction with the counseling received and information on extended use of combined hormonal contraceptives. The study was registered at Clinicaltrials.gov (NCT03269357).

RESULTS

From September 2017 to May 2019, 770 women aged 18-25 years from 28 clinics/clusters were recruited. There was a significant intervention effect on LARC choice (aOR 5.96, 95% CI 3.25-10.94), initiation (aOR 4.43, 95% CI 2.32-8.46), and use at 12 months (aOR 2.21, 95% CI 1.31-3.73). The odds of LARC choice at pre-booked visits were higher and more women received information about extended-use regimen for short-acting reversible contraception in the intervention group compared to the control group. The intervention package was well received, but with higher satisfaction at pre-booked compared to drop-in visits.

CONCLUSIONS

Our study demonstrates that comprehensive structured contraceptive counseling significantly increases LARC choice, initiation and use, with high satisfaction among young participants, especially at pre-booked visits. The results highlight an approach that merits implementation to increase quality of care in contraceptive services, to enhance reproductive health for adolescents and young adults.

Demographic and pregnancy-related predictors of postnatal contraception uptake: A cross-sectional study

OBJECTIVE

To examine the uptake of postnatal contraception (PNC) and experiences of PNC care across a geographical region of England.

DESIGN

Cross-sectional online survey.

SETTING

The North East and North Cumbria Integrated Care System (ICS).

POPULATION

Women who had completed a pregnancy in the previous 3 years.

METHODS

The uptake of PNC by accessed method(s) and the availability of preferred method(s) is described, and adjusted odds ratios are reported for group differences in uptake by characteristics of interest.

MAIN OUTCOME MEASURES

Uptake of medically prescribed/administered contraception and uptake of long-acting reversible contraception (LARC) during the postnatal period, and access to preferred PNC methods.

RESULTS

Although almost half of respondents (47.1%; n = 1178) reinitiated some form of sexual activity during the postnatal period, only 38.7% (n = 969) of respondents accessed a medically prescribed/administered contraceptive method postnatally, and only 15.5% (n = 389) of respondents accessed a LARC. It is a matter of concern that 18.8% (n = 451) of respondents indicated that they were unable to access their preferred PNC. In multivariate analysis, younger age, lower household income, higher multiparity, operative delivery, unplanned pregnancy and not breastfeeding were significant predictors of higher PNC uptake.

CONCLUSIONS

The uptake of PNC in this cohort was low, with almost a fifth of women unable to access their preferred method. However, there was some evidence that women belonging to groups perceived to be at risk of rapid repeat pregnancy were more likely to access reliable PNC methods.

Contraceptive uptake and compliance after structured contraceptive counseling - secondary outcomes of the LOWE trial

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.

Women's experiences of postpartum contraceptive services when elective caesarean section is the method of birth: a qualitative study

BACKGROUND

The unmet need for postpartum contraception is a global challenge. Postpartum placement of an intrauterine device (IUD) within 48 hours of vaginal delivery is available in many settings worldwide, but is not routinely practised in Sweden. To improve contraceptive services and facilitate the informed choice of IUD placement at the time of a caesarean section (CS), we performed this study to identify and describe women's experiences of contraceptive services before, during and after an elective CS.

METHODS

A qualitative design and methodology was used. We interviewed 20 women aged 28-42 years who underwent elective CS in Sweden. Interviews were analysed using reflexive thematic analysis.

RESULTS

The three main themes found were (1) receptivity to contraceptive counselling in the context of CS, (2) communication and decision-making about postpartum contraception before CS and (3) lack of support and guidance to receive contraceptive services before and after CS. The participants described readiness and interest regarding postpartum contraception. They prefered counselling from around 25 weeks of gestation. Despite this finding, antenatal communication and contraceptive decision-making seemed rare. Participants reported a lack of support and guidance which necessitated a need by women to navigate the contraceptive services themselves in order to receive information about contraception before CS and to receive postpartum support.

CONCLUSIONS

Antenatal contraceptive counselling including information about IUD placement during CS was appreciated and welcomed by women with elective CS as their birth method. Most of the women whom we interviewed would prefer to receive contraception counselling on postpartum use during the second half of their pregnancy.

Impact of a post-partum family planning intervention on contraception and fertility in Tanzania: two-year follow-up of a cluster-randomised controlled trial

PURPOSE

We evaluate contraceptive use and pregnancy two years following an intervention in Tanzania, which provided antenatal post-partum family planning counselling and post-partum intrauterine device (PPIUD) services following delivery.

METHODS

We analyse data from five hospitals in Tanzania using a difference-in-difference cluster randomised design, with randomisation at the hospital level. We use women-level data collected at the index birth and a follow-up survey two years later among 6,410 women. Outcomes (overall modern contraceptive use, contraceptive type, pregnancy) are modelled with an intent-to-treat (ITT) approach using linear regression. We compare with the complier average causal effect (CACE) of the intervention among those counselled.

RESULTS

The intervention increased long-term PPIUD use by 5.8 percentage points (95% CI: 0.7-11.2%) through substitution away from other modern methods. There was no impact on overall modern contraceptive prevalence or pregnancy. Only 29% of women reported receiving PPIUD counselling. When accounting for this in the CACE analysis we saw a larger impact with 25.7% percentage point increase in PPIUD use (95% CI: 22.7-28.6%).

CONCLUSION

The intervention provided women an additional contraceptive choice, resulting in higher use of PPIUD over two years. Increase in PPIUD use was brought about by shifting methods, not creating new modern contraceptive users.

Contraceptive use among women seeking an early induced abortion in Sweden

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.

The use and access to contraception in Sweden during the COVID-19 pandemic period

PURPOSE

Explore perceived access to, the need for, use of, and satisfaction with telemedicine services for contraceptive counselling and prescription-renewal-only during the COVID-19 pandemic, and the impact of the COVID-19 pandemic period on the choice and use of contraceptives.

MATERIALS AND METHODS

Internet-based e-survey of Swedish women of fertile age, 16-49 years.

RESULTS

In total, 1016 participants completed the survey. Most participants (69.7%) rated their access to contraceptive services 'as usual'. Among the remaining participants, a higher proportion rated their access as deteriorated (73.4%) compared to improved (26.6%; p < 0.001). In total, 38.0% reported a need for contraceptive counselling, whereof 14.0% had used telemedicine for counselling and reported high satisfaction. Telemedicine for prescription-renewal-only was used by 15.1% of the total population. Two per cent reported use of another contraceptive than their intended, whereof long-acting reversible contraceptives were the most common intended method. The proportion of current contraceptive users was lower than in 2017 (62.4% vs 71.1%, p < 0.001), and current users of long-acting reversible contraception decreased from 30.6% to 19.3% (p < 0.001).

CONCLUSIONS

During the COVID-19 pandemic period, most women found their access to contraceptive services unaffected, but more women felt that it had deteriorated than improved. The use of telemedicine was low, and the use of contraception overall fell. Efforts are needed to raise awareness of available services, and TM-provided interventions for maintained quality of care and informed decision-making remain to be evaluated.SHORT CONDENSATIONThe COVID-19 period imposed a change in contraceptive service provision, and efforts are needed to raise awareness of available services, including telemedicine. Access to all contraceptives, including LARCs, is crucial and telemedicine-provided interventions need evaluation.

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

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.

Recap of the sixth international symposium on intrauterine devices and systems for women's health

Due to the COVID-19 pandemic, the Sixth International Symposium on Intrauterine Devices and Systems for Women's Health was held as a series of seven 2-hour webinars between May 28, 2020, and June 22, 2021. This Symposium featured 48 different presenters and moderators covering a wide range of topics to highlight new IUD issues and update general IUD knowledge, just as it was done in previous symposia dating back to 1962 [1-5]. A total of 1346 people attended remotely to observe the events live. In this article, we share summaries of the presentations from the sixth symposium. These summaries, provided by the presenters, are meant to archive the symposium. This article gives the reader an overview of the topics and identifies the sessions' moderators and speakers charged with providing the content. Those interested in further detail, references, and information about the speakers can find more information on the conference website: www.iud2020.com. After the summaries, we share ideas for future IUD research and programmatic needs, as provided by Symposium's presenters and organizers. The authors' summaries are personal opinions and do not necessarily reflect the perspectives of the Symposium's organizers or the medical community at large. The Symposium was recorded and the sessions are available for viewing free of charge at the website, www.iud2020.comor on YouTube. As of July 2022, approximately 1700 visitors have viewed the recordings.

An educational video on long-acting reversible contraception as a counseling tool for postpartum adolescents

Objective

To assess the effects of using an animated local language educational video to counsel postpartum adolescents on the benefits and use of long-acting reversible contraception (LARC).

Materials and methods

A two-stage, single group, experimental study was conducted. A total of 124 female adolescents aged < 20 years who had given birth within the last six weeks participated in the study. An educational video and a questionnaire were developed and validated. Participants were asked to fill out a questionnaire on basic demographic data, contraception preferences, and 10 true/false statements to test general contraceptive knowledge, after which they were shown an educational video in a private room. Following this, participants completed the second part of the questionnaire that assessed their knowledge using the same true/false statements and contraception preferences administered earlier.

Results

The mean age (standard deviation) of participants was 18.1 (1.5) years. Participants’ mean age (SD) at the time of their first sexual intercourse was 16.2 (1.6) years. Among the 124 participants, 31 (25%) indicated that they would use LARC before viewing the educational video. After viewing the educational video, this number increased to 48 (38.7%). The participants’ knowledge score was independently associated with their preference to select LARC (adjusted odds ratio 1.46, 95% confidence interval 1.09- 1.97).

Conclusion

This study demonstrated that counseling tools such as animated local language educational video might effectively improve contraceptive knowledge and the preference for LARC in postpartum adolescents. An educational video regarding LARC could be used as a counseling tool for postpartum adolescents.

Can an online educational video broaden young women's contraceptive choice? Outcomes of the PREFER pre-post intervention study

INTRODUCTION

Contraceptive knowledge mediates access and use. We aimed to assess whether an online educational video describing all methods and their benefits, side effects and mode of action increased young women's contraceptive knowledge and their long-acting reversible contraception (LARC) preference and uptake.

METHOD

We used Facebook advertising to recruit young women aged 16-25 years. Participants completed the pre-video survey (S1), watched the 11-min video, then completed surveys immediately after (S2) and 6 months later (S3). Outcomes were analysed using McNemar tests and multivariate logistic regression (generalised estimating equations).

RESULTS

A total of 322 participants watched the video, completed S1 and S2, and 88% of those completed S3. At S1 only 6% rated their knowledge about every method as high. Knowledge improved at S2 for all methods (OR 10.0, 95% CI 5.9 to 17.1) and LARC (OR 4.2, 95% CI 3.1 to 5.7). LARC preference increased at S2 (OR 1.7, 95% CI 1.4 to 2.1) and S3 (OR 1.4, 95% CI 1.2 to 1.7), as did LARC uptake at S3 (OR 1.3, 95% CI 1.11 to 1.5). LARC uptake was driven by a 4.3% (n=12) absolute increase in intrauterine device (IUD) use, but there was no change in contraceptive implant use (p=0.8). The use of non-prescription methods such as condoms and withdrawal did not change (OR 0.92, 95% CI 0.76 to 1.11).

CONCLUSIONS

Many young women in Australia do not feel well informed about their contraceptive options. The contraceptive education video, delivered via social media, increased their self-reported contraceptive knowledge and IUD preference immediately after viewing, and their IUD uptake 6 months later. Focus should be given to how young women navigate contraceptive access after internet-based education, and strategies to increase access to preferred methods.

Use of contraception and attitudes towards contraceptive use in Swedish women: an internet-based nationwide survey

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.

Attitudes Toward the Copper IUD in Sweden: A Survey Study

Background

While the efficacy and safety of the contraceptive copper intrauterine device (IUD) have been affirmed, alongside its importance for the prevention of unintended pregnancies, some studies have pointed to negative attitudes toward the device. In recent years, social media communication about it has included claims about systemic side effects, unsubstantiated by medical authorities. Research from the Swedish context is sparse. This study investigates attitudes toward the copper IUD and any correlations between negative attitudes toward or experiences of the device, and (1) sociodemographic characteristics, (2) the evaluation of the reliability of different sources of information, and (3) trust in healthcare and other societal institutions.

Methods

A survey was distributed online to adult women in Sweden (n = 2,000). Aside from descriptive statistics, associations between negative attitudes toward or experiences of the copper IUD and sociodemographic and other variables were calculated using logistic regressions and expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). Open survey responses (n = 650) were analyzed thematically.

Results

While many reported positive attitudes toward and experiences of the IUD, 34.7% of all respondents reported negative attitudes and 45.4% of users reported negative experiences. Negative attitudes were strongly correlated with negative experiences. Negative attitudes and experiences were associated with low income, but no conclusive associations were identified with other socioeconomic variables. Negative attitudes and experiences were associated with lower levels of confidence in and satisfaction with healthcare, as well as lower self-assessed access and ability to assess the origin and reliability of information about the IUD. In open responses, negative comments were prevalent and included references to both common and unestablished perceived side-effects. Respondents pointed to problematic aspects of information and knowledge about the copper IUD and called for improved healthcare communication and updated research.

Conclusion

Healthcare provider communication about the copper IUD should promote reproductive autonomy and trust by providing clear information about potential side effects and being open to discuss women's experiences and concerns. Further research on copper IUD dissatisfaction and ways in which health professionals do and may best respond to it is needed.

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).

Knowledge, challenges, and standard of care of young women with ADHD at Swedish youth clinics

OBJECTIVES

Sexual risk-taking and its consequences for young women with ADHD(attention deficit hyperactivity disorder) including sexually transmitted diseases, teenage pregnancies and underage parenthood constitute substantial challenges for individuals and midwives. The aim was to investigate current knowledge and specific challenges in reproductive health and contraceptive counselling for women with ADHD at Swedish youth clinics.

METHOD

Inductive qualitative interview study of ten midwives at six youth health clinics in Stockholm and Uppsala County. We used a semi-structured interview guide. The interviews were transcribed verbatim and analyzed with the NVivo 12 qualitative data analysis software.

RESULTS

Three main categories were identified: (1) challenges in provision of care of young women with ADHD, (2) standard of care and active adaptations towards women with ADHD and (3) organizational readiness for change;. Several challenges and frustrations, such as difficulties with attention with or without concomitant impulsivity and overactivity, in provision of reproductive health and contraceptive counselling for young women with ADHD were identified. Midwives reported high organizational readiness for improvement of standard of care.

CONCLUSIONS

Inadequate contraceptive counseling or lack of knowledge on specific challenges in the sexual and reproductive health of young women with ADHD may contribute to this group failing to access, inadequately respond to, or act upon counseling at youth clinics. Support for midwives with evidence-based interventions specifically developed for these women are imperative. Development of such tools should be a priority for research.

Educational Multimedia Tool Compared With Routine Care for the Uptake of Postpartum Long-Acting Reversible Contraception in Individuals With High-Risk Pregnancies: A Randomized Controlled Trial

OBJECTIVE

To assess whether an intervention with a multimedia educational tool, compared with routine care, would increase the use of long-acting reversible contraceptives (LARC) at 12 weeks postpartum in individuals with high-risk pregnancies.

METHODS

In this single-center randomized trial, we assigned individuals aged 13-50 years with high-risk pregnancies to either a multimedia educational tool or routine care. Participants were included during pregnancy through postpartum day 1. Those randomized to the multimedia educational tool (MET) group were provided a tablet with the preloaded 3-5-minute multimedia presentation (https://prezi.com/view/jpFrXaPnnxuqRkcI3A4a/), which was viewed without the presence of research staff and resent by secure email every 4 weeks if undelivered. The primary outcome was uptake of LARC (implant or intrauterine device) within 12 weeks of delivery. The secondary outcomes included overall use of any method of contraception and composite maternal and neonatal adverse outcomes. A priori estimates indicated that 380 participants were needed to detect a 40% difference in use of LARC (baseline 40%; alpha=0.05, power=0.8, assumed loss to follow-up 20%). Relative risk (RR) and number needed to treat (NNT), along with 95% CIs, were calculated.

RESULTS

From July 2020 through December 2020, 536 persons were screened and 380 randomized as follows: 190 for the multimedia educational tool and 190 for routine care. Demographic characteristics were similar between groups. The primary outcome-available for more than 90% of participants-was higher in the MET group (32.4%) than in the routine care (RC) group (20.9%) (RR 1.55; 95% CI 1.09-2.21; NNT nine, with 95% CI 5-42). Overall use of contraception was also higher in the MET group than in the RC group (RR 1.16; 95% CI 1.03-1.32).

CONCLUSION

Among individuals with high-risk pregnancies, compared with routine care, use of a multimedia-based educational tool increased the uptake of postpartum LARC by 55%.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT04291040.

FUNDING SOURCE

Funded in part by Investigator-Initiated studies of Organon.

Long-acting reversible contraception and satisfaction with structured contraceptive counselling among non-migrant, foreign-born migrant and second-generation migrant women: evidence from a cluster randomised controlled trial (the LOWE trial) in Sweden

OBJECTIVE

This trial aimed to evaluate effects of structured contraceptive counselling among non-migrants, foreign-born migrants and second-generation migrants.

METHODS

A cluster randomised controlled trial was conducted in 2017-2019 at abortion, youth and maternal health clinics in Stockholm, Sweden (the LOWE trial). Patients were eligible if they were 18 years or older, could understand Swedish or English (or if assisted by an interpreter), were sexually active or planning to be, and were seeking contraception for pregnancy prevention. We randomised clinics at a 1:1 allocation ratio to give either structured contraceptive counselling (intervention) or to maintain standard contraceptive counselling (control). Blinding was not deemed feasibile. A study-specific package for structured contraceptive counselling was used and comprised an educational video, an effectiveness chart, four key questions and a box with contraceptive models. Outcomes were effects of the intervention on long-acting reversible contraception (LARC) choice, initiation and use, and satisfaction with the intervention material among the participants.

RESULTS

We involved 14 clinics in each of the intervention and control groups, respectively. A total of 1295 participants were included: 1010 non-migrants, 169 foreign-born migrants and 116 second-generation migrants. Participants in the intervention group chose LARC to a higher extent than the control group (adjusted OR (aOR) 2.85, 95% CI 2.04-3.99), had higher LARC initiation rates (aOR 2.90, 95% CI 1.97 to 4.27) and higher LARC use within the 12-month follow-up period (aOR 2.09, 95% CI 1.47 to 2.96). The majority of the participants who received the intervention package found all the different parts to be supportive in contraceptive choice. The effectiveness chart was the only part of the package that a higher proportion of foreign-born migrants (58/84, 69%) and second-generation migrants (40/54, 74.1%) found supportive in contraceptive choice compared to non-migrants (259/434, 59.7%) (p = 0.048).

CONCLUSIONS

Structured contraceptive counselling increased LARC choice, initiation and use, controlled for participants' migration background. The effectiveness chart was found to be significantly more supportive among foreign-born migrants and second-generation migrants compared to non-migrants when choosing contraceptive methods.

TRIAL REGISTRATION NUMBER

NCT03269357.

Provision of long-acting reversible contraception at surgical abortion-A cross-sectional nationwide register study

INTRODUCTION

Provision of long-acting reversible contraception (LARC) at surgical abortion is safe, practical, and leads to higher user rates than does delayed provision. The aim of this study was to explore whether provision of LARC at surgical abortion is associated with known risk factors for subsequent abortions and inconsistent use of contraception, including sociodemographic factors and psychiatric disorders.

MATERIAL AND METHODS

This was a register-based cross-sectional study of 6251 women having a surgical abortion in Sweden. Data were collected from National health and population registers. Women with procedure codes for surgical abortion were identified in the National Patient Register from October 2016 to December 2018. Information from Statistics Sweden, the National Patient Register, and the Swedish prescribed drug register on sociodemographic factors, psychiatric disorders, and dispensed LARC was added and linked on an individual level. Associations of sociodemographic factors and psychiatric disorders with LARC provision were explored with generalized logit mixed models and presented as crude and adjusted odds ratios with 95% confidence intervals (CIs).

RESULTS

The overall rate of LARC provision at the time of the abortion was 2515/6251 (40.2%). Younger age and lower level of education were associated with an increased likelihood of LARC provision. In the study population, 2624/6251 (42.0%) patients had a pre- or post-abortion psychiatric disorder, a factor associated with an increased likelihood of LARC provision compared with women with no such disorders (adjusted odds ratio 1.21; 95% CI 1.08-1.34). The highest rates and odds were seen among women with personality, substance use, and/or neurodevelopmental disorders and among women with multiple psychiatric disorders.

CONCLUSIONS

Sociodemographic risk factors and psychiatric disorders were associated with increased LARC provision at surgical abortion, indicating that women at high risk of unwanted pregnancies are provided with effective contraception. Still, less than half of all women undergoing surgical abortion were provided with LARC, suggesting that contraceptive access and counseling prior to a surgical abortion can be improved.

Pillenmüdigkeit? Fakten und Auswirkungen

Hintergrund

In den letzten Jahren scheint sich ein Trend zu Alternativen für die „Pille“ abzuzeichnen.

Fragestellung

Es stellt sich die Frage, was es mit der postulierten „Pillenmüdigkeit“ auf sich hat, ob tatsächlich eine Abkehr von der hormonellen Kontrazeption stattfindet, was mögliche Gründe dafür sein könnten und ob sich Auswirkungen feststellen lassen.

Material und Methoden

Es wurde eine Literaturrecherche zu folgenden Punkten durchgeführt: 1. Hinweise auf Veränderungen im Verhütungsverhalten in Deutschland, Österreich und der Schweiz, 2. Evidenz in Bezug auf die zurzeit viel diskutierten Auswirkungen hormoneller Kontrazeptiva auf Psyche und Sexualität und 3. Hinweise auf eine Zunahme der Schwangerschaftsabbrüche.

Ergebnisse

Die Verwendung der Pille zeigt eine rückläufige Tendenz. Zurzeit lässt sich keine Aussage machen, ob es zu einer signifikant häufigeren Anwendung der Kupferspirale gekommen ist. Die Sorge vor Nebenwirkungen ist für einen beträchtlichen Prozentsatz der befragten Frauen ein wesentlicher Grund, hormonelle Verhütungsmittel zu vermeiden. Gemäß aktuellen Übersichtsbeiträgen verzeichnen die meisten Frauen, die kombinierte orale Kontrazeptiva verwenden, keine oder eine positive Wirkung auf die Stimmung, die Inzidenz einer depressiven Symptomatik ist gering und nur in Untergruppen relevant. Die Auswirkungen hormoneller Kontrazeptiva auf die Sexualität der Frau sind nicht ausreichend untersucht und die verfügbaren Daten deuten darauf hin, dass nur eine Minderheit eine positive oder negative Veränderung wahrnimmt. Eine Zunahme der Schwangerschaftsabbrüche zeichnet sich nicht ab.

Schlussfolgerung

In Anbetracht des Stellenwerts, den unter anderem die Nebenwirkungen bezüglich Zufriedenheit mit und Adhärenz zur Verhütungsmethode haben, ist eine individuell zugeschnittene Kontrazeptionsberatung essenziell.

Evaluation of satisfaction with a model of structured contraceptive counseling: Results from the LOWE trial

INTRODUCTION

Intervention trials of structured contraceptive counseling have proved to increase use of long-acting reversible contraceptives (LARCs) and decrease numbers of unintended pregnancies. However, these interventions have not been evaluated from a user perspective. This study aimed to evaluate both healthcare providers' and participants' satisfaction with an intervention used in a large trial in Sweden.

MATERIAL AND METHODS

A cross-sectional study on the intervention group from a cluster randomized trial conducted at 28 clinics in Stockholm, Sweden. Clinics were randomized (1:1 allocation ratio) to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of four parts; an educational video to be seen by the participant prior to contraceptive counseling, key questions to be asked by the healthcare provider, an effectiveness chart, and a box of contraceptive models. Eligible participants were 18 years or older, sexually active without a wish to conceive, and with the main purpose of contraceptive use being pregnancy prevention. Healthcare providers completed an electronic semi-structured survey to evaluate the intervention. This study analyses provider and participant satisfaction with the counseling material used in the intervention and if the intervention was found to be supportive in contraceptive counseling and contraceptive choice.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03269357).

RESULTS

Fourteen intervention clinics enrolled 658 participants from September 2017 to May 2019. Response rate among providers was 88.0% (55/62) and among participants 97.1% (639/658). Providers found the intervention to be supportive in their counseling. Each separate part of the intervention package received high ratings from both providers and participants. Participants found the educational video and the effectiveness chart to be more helpful than the box of contraceptive models in their contraceptive choice. Providers reported the time taken to complete the intervention outside the study to be time-neutral to standard counseling, and most providers wished to continue to use all parts of the intervention package.

CONCLUSIONS

The intervention of structured contraceptive counseling had high provider and participant satisfaction. The structured counseling package could be used in several clinical settings to improve quality in contraceptive counseling and to enhance informed decision making about use of contraceptive methods.