Counselling may increase uptake of LARCs and decrease unintended pregnancy rate- Study
There are no consistent recommendations or models on how to provide effective contraceptive counselling involving informed decision-making that results in fewer unintended pregnancies. Information from providers may be affected by provider bias and evidence shows that some women may experience contraceptive coercion. On the other hand leaving the patient without any guidance is far from ideal. Rather, informed choice should be an essential guiding principle.
Evidence shows that the minor differences between the perfect and typical use effectiveness of long-acting reversible contraceptives (LARCs: subdermal implants and intrauterine devices) reduce unintended pregnancy and improves reproductive health. In the European TANCO study, it was shown that 73% of the participants would consider LARCs if they were given comprehensive information about these methods.
Removal of costs and access barriers in the contraceptive CHOICE project in the USA, led to 75% of participants choosing LARCs. This resulted in lower unintended pregnancy rates and high acceptability rates for the methods chosen. Advertisement and recruitment in the community could have led to enrolment in the study to obtain a LARC method. Furthermore, a standard script about LARC was read to all participants at the outset of counselling which likely increased LARC initiation rates at all sites. Notably, no difference was seen in LARC initiation rates at sites where a structured counselling protocol was used, compared to sites with "standard" counselling.
Karin Emtell Iwarsson and team performed a cluster randomised controlled trial of structured contraceptive counselling on LARC uptake, i.e. choice and initiation of LARCs, and pregnancy rates in abortion, youth, and maternal health clinics. They explicitly evaluated the effect of a structured counselling protocol while all other services remained unchanged in order to provide a true real-life setting.
The researchers conducted a cluster randomised controlled trial, the LARC fOrWard counsElling (LOWE) trial in the Stockholm Region. An open invitation was sent to abortion, youth, and maternal health clinics. Clinics were assessed for eligibility regardless of their baseline LARC prescription rates.
Study population included sexually active women ≥18 years without a wish for pregnancy seeking abortion and/or contraceptive counselling. For participants in clinics randomised to intervention, trained health care providers implemented a study-specific intervention package designed for structured contraceptive counselling. Participants in the control clinics received routine counselling.
Primary outcome was choice of LARCs at first visit. Secondary outcomes were LARC initiation at three months and pregnancy rates at three and 12 months.
In the clinics randomised to intervention, participants received structured contraceptive counselling with an intervention package specifically designed for this study (Supplementary materials). The package presented all different reversible contraceptive methods including their effectiveness, advantages, and disadvantages aiming to enable the participant to make an informed decision.
The package consisted of:
- i)a seven-minutes-long educational video about contraceptive methods,
- ii)four key-questions,
- iii)a modified tiered effectiveness chart for contraceptive methods in typical use, and
- iv)a demonstration box with contraceptive models.
The four key-questions, developed by the investigators, were intended to make patients
- I)reflect on how to deal with a pregnancy if it were to occur at the moment
- II)specify for how long contraception planned to be used and to
- III)describe menstrual bleeding patterns and
- IV)menstrual pain.
The video, available in Swedish or with English subtitles, were to be seen by participants before counselling in the waiting room either on a private smartphone or on a computer screen provided at the clinic. The other parts of the intervention package were to be used by the health care provider during counselling.
The control clinics maintained their routine contraceptive counselling. This did not follow a given structure and could include inconsistent use of various effectiveness charts and contraceptive models.
Recruitment of participants was conducted from 1st of September 2017 until 16th of May 2019.
A total of 28 clinics were included in the analysis, 14 clinics were randomly assigned to intervention group and 14 to control group.
A total of 1364 participants were enrolled, of which 1338 were included in the analysis of the primary outcome. For the secondary outcome pregnancy rate, data from 1297 participants were included at three months follow-up and 1289 at 12 months follow-up. For the analysis of the contraceptive initiation rate, data from 1059 were included. Two participants included from abortion clinics in the intervention group chose to keep their ongoing pregnancy and were excluded after enrolment.
Baseline LARC use did not differ between study groups with 50.8% of participants using contraception at the first visit, whereof a LARC method was used by 30/325 (9.2%) in the intervention group, and 41/351 (11.7%) in the control group.
However, clinic types differed with respect to intended LARC use with maternal health clinics having fewer participants in the intervention group with intended LARC use (32/264, 12.1%) compared to the control group (57/266, 21.4%). No other baseline characteristics differed between groups.
The mixed model analysis showed that significantly more participants in the intervention group chose LARCs after counselling compared to the control group. While most of the participants intending to use LARCs also chose LARCs, a significant effect was seen for participants who did not intend to use LARCs before counselling. In this group, the proportion of participants choosing LARCs after counselling was higher in the intervention group (145/523, 27.7%) compared to the control group (66/513, 12.9%).
At the three months follow-up, a higher proportion of participants in the intervention group had initiated LARC use (213/528, 40.3%) than in the control group (153/531, 28.8%). Within the three months follow-up, 8/639 (1.3%) and 16/658 (2.4%) participants had experienced a pregnancy in the intervention and control group, respectively.
At 12 months follow-up, 39/634 (6.2%) in the intervention group compared to 56/655 (8.5%) in the control group had experienced a pregnancy. Within 12 months, four of these participants in each group had experienced two pregnancies, resulting in a total number of 103 pregnancies. A significantly lower rate of pregnancies at 12 months follow-up was seen at abortion clinics in the intervention versus the control group.
In this cluster randomised controlled trial, the researchers found that structured contraceptive counselling focusing on contraceptive effectiveness resulted in a higher proportion of participants choosing LARCs. The intervention effect was significant in all clinic types: abortion, youth, and maternal health clinics, which shows the robustness of the intervention for different kinds of clinical settings and participants of all age groups with varying contraceptive needs. Initiation of LARCs at three months follow-up was also significantly higher in the intervention group. The effect of the intervention was most pronounced post abortion with significantly less repeat pregnancy experienced within 12 months.
"In conclusion, the study has shown that an intervention package of structured counselling, focusing on the effectiveness of contraceptive methods, resulted in a higher uptake of LARCs in all clinics, and fewer pregnancies at abortion clinics at 12 months follow-up compared with routine counselling. The intervention could be of particular importance as during the current COVID19 pandemic the advantages of effective contraception, and especially LARC methods, have been further recognised."
Source: doi: 10.1111/1471-0528.16754
