Strategies to improve adherence and acceptability of hormonal methods of contraception

  • Review
  • Intervention

Authors


Abstract

Background

Worldwide, hormonal contraceptives are among the most popular reversible contraceptives in current use. Despite their high theoretical effectiveness, typical use results in much lower effectiveness. In large part, this disparity reflects difficulties in adherence to the contraceptive regimen and low rates for long-term continuation.

Objectives

To determine the effectiveness of ancillary techniques to improve adherence to, and continuation rates of, hormonal methods of contraception.

Search strategy

We searched computerized databases for randomized controlled trials (RCTs) comparing client-provider interventions with standard family planning counseling. Sources included CENTRAL, MEDLINE, EMBASE, POPLINE, LILACS, and PsycINFO.

Selection criteria

Randomized controlled trials (RCTs) of an intensive counseling technique or client-provider intervention versus routine family planning counseling. Interventions included group motivation; structured, peer, or multi-component counseling; and intensive reminders of appointments. Outcome measures were discontinuation, reasons for discontinuation, number of missed pills and on-time injections, and pregnancy.

Data collection and analysis

The primary author evaluated all titles and abstracts from the searches to determine eligibility. Two authors independently extracted data from the included studies. With RevMan 4.2, we calculated the odds ratio for all dichotomous outcomes and the weighted mean difference for continuous data. The studies were so different that we could not conduct a meta-analysis.

Main results

We found six RCTs; only one showed a statistically significant benefit of the experimental intervention. In that trial, women who received repeated, structured information about the injectable contraceptive depo-medroxyprogesterone acetate (DMPA) were less likely to have discontinued the method by 12 months (OR 0.27; 95% CI 0.16 to 0.44) than were women who had routine counseling. The intervention group was also less likely to discontinue due to menstrual disturbances. In another study, the intervention group was less likely to discontinue due to dissatisfaction with the contraceptive method, but overall continuation was not affected.

Authors' conclusions

Most studies to date have shown no benefit of strategies to improve adherence and continuation. These trials have important limitations, however. Two had small sample sizes, several had high losses to follow up, and the intervention and its intensity varied across the studies. High-quality research is a priority, since adherence and continuation are fundamentally important to the successful use of hormonal contraceptives.

Plain language summary

Ways to improve use of hormonal birth control

Hormonal types of birth control are used by many women worldwide. The most common hormonal methods are birth control pills and injections. These methods often do not work as well as they could. Women may have problems using the birth control as planned. They may miss taking some pills. Other women may stop using a method due to bleeding changes. This review looked at whether more counseling helped women use these types of birth control.

We did computer searches for randomized trials comparing special counseling with usual counseling. In addition, we looked at reference lists to find trials. We also wrote to researchers to find more studies.

We found six trials that varied in quality. Some trials had few women in them and others lost many women during the study. Only one trial found an important result. That study gave repeated, structured facts about an injected type of birth control. More of the women who got the structured facts kept using the birth control than the women who had the usual counseling. Also, fewer women who had the structured facts stopped using the birth control due to bleeding changes.

To prevent pregnancy, it is important to use the birth control as planned and to keep using it. More trials of good quality are needed to see if more counseling helps women use their birth control method.

Ancillary