A motivational interviewing-based counseling intervention to increase postabortion uptake of contraception: A pilot randomized controlled trial.
ABSTRACT: To determine if a counseling intervention using the principles of motivational interviewing (MI) would impact uptake of long-acting reversible contraception (LARC) after abortion.We conducted a pilot randomized controlled trial comparing an MI-based contraception counseling intervention to only non-standardized counseling. Sixty women 15-29 years-old were randomized.uptake of LARC within four weeks of abortion.uptake of any effective contraceptive, contraceptive use three months after abortion and satisfaction with counseling. Bivariate analysis was used to compare outcomes.In the intervention arm, 65.5% of participants received a long-acting method within four weeks compared to 32.3% in the control arm (p=0.01). Three months after the abortion, differences in LARC use endured (60.0% vs. 30.8%, p=0.05). Uptake and use of any effective method were not statistically different. More women in the intervention arm reported satisfaction with their counseling than women in the control arm (92.0% vs. 65.4%, p=0.04).Twice as many women in the MI-based contraception counseling intervention initiated and continued to use LARC compared to women who received only non-standardized counseling.A contraception counseling session using the principles and skills of motivational interviewing has the potential to impact LARC use after abortion.
Project description: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.
Project description:OBJECTIVE:To investigate whether an early 3-week postpartum visit in addition to the standard 6-week visit increases long-acting reversible contraception (LARC) initiation by 8 weeks postpartum compared to the routine 6-week visit alone. STUDY DESIGN:We enrolled pregnant and immediate postpartum women into a prospective randomized, non-blinded trial comparing a single 6-week postpartum visit (routine care) to two visits at 3 and 6 weeks postpartum (intervention), with initiation of contraception at the 3-week visit, if desired. All participants received structured contraceptive counseling. Participants completed surveys in-person at baseline and at the time of each postpartum visit. A sample size of 200 total participants was needed to detect a 2-fold difference in LARC initiation (20% vs. 40%). RESULTS:Between May 2016 and March 2017, 200 participants enrolled; outcome data are available for 188. The majority of LARC initiation occurred immediately postpartum (25% of the intervention arm and 27% of the routine care arm). By 8 weeks postpartum, 34% of participants in the intervention arm initiated LARC, compared to 41% in the routine care arm (p=.35). Overall contraceptive initiation by 8 weeks was 83% and 84% in the intervention and routine care arms, respectively (p=.79). There was no difference between the arms in the proportion of women who attended at least one postpartum visit (70% vs. 74%, p=.56). CONCLUSION:The addition of a 3-week postpartum visit to routine care does not increase LARC initiation by 8 weeks postpartum. The majority of LARC users desired immediate rather than interval postpartum initiation. CLINICAL TRIAL REGISTRATION:Clinicaltrials.govNCT02769676 IMPLICATIONS: The addition of a 3-week postpartum visit to routine care does not increase LARC or overall contraceptive initiation by 8 weeks postpartum when the option of immediate postpartum placement is available. The majority of LARC users desired immediate rather than interval postpartum initiation.
Project description:OBJECTIVE:To compare the proportion of women receiving same-day long-acting reversible contraception (LARC) between two different models of contraceptive provision adapted from the Contraceptive CHOICE Project. STUDY DESIGN:We used a controlled time-trend study design to compare 502 women receiving structured contraceptive counseling in addition to usual care ("Enhanced Care") to 506 women receiving counseling plus healthcare provider education and cost support for LARC ("Complete CHOICE") at three federally qualified health centers. We provided funds to health centers to ensure an "on-the-shelf" supply and no-cost LARC for uninsured women. We recorded the contraceptive method chosen after contraceptive counseling and the healthcare provider appointment as well as the contraceptive method received that day. Among women choosing LARC, we calculated proportions and performed Poisson regression with robust error variance to estimate relative risks for same-day insertion. RESULTS:Participant demographics reflected the health center populations; 69% were black, 66% had a high school diploma or less, 57% were publicly insured, and 75% reported household income less than 101% federal poverty line. There were 153 (30.5%) women in "Enhanced Care" and 273 (54.0%) in "Complete CHOICE" who chose LARC (p<0.01). Among women who chose LARC (n=426), those in "Complete CHOICE" were more likely to receive a same-day insertion, 53.8% vs. 13.7% (RRadj 4.73; 95%CI 3.20-6.98) compared to "Enhanced Care." CONCLUSIONS:A contraceptive care model that included healthcare provider education and cost support for LARC in addition to structured contraceptive counseling resulted in higher rates of same-day LARC insertion compared to contraceptive counseling and usual care alone. IMPLICATIONS:Contraceptive care provision which includes contraceptive counseling, healthcare provider education, and "on-the-shelf", long-acting reversible contraception facilitate same-day initiation of these methods. Interventions that focus solely on contraceptive counseling do not address other structural barriers to same-day contraceptive provision of all methods including cost and provider practice.
Project description:OBJECTIVE:Integration of services is a promising way to improve access to contraception in sub-Saharan Africa, but few studies have evaluated this strategy to increase access to contraception among women requiring anticoagulation. Our objective was to evaluate a model of care integrating contraceptive counseling and provision within an anticoagulation management clinic in Eldoret, Kenya, to determine the impact on long-acting reversible contraception (LARC) use. STUDY DESIGN:We performed a prospective observational study of reproductive-age women referred for integrated services from the anticoagulation management clinic at Moi Teaching and Referral Hospital from March 2015 to March 2016. All participants received disease-specific contraceptive counseling and provision, free reversible methods (excluding hormonal intrauterine devices [IUDs]) and follow-up care. We compared LARC use 3?months postintervention to preintervention using the proportions test. Logistic regression analysis was used to determine factors related to use of contraceptive implants and copper IUDs. RESULTS:Of 190 participants, 171 (90%) completed 3-month follow-up. There was a significant increase in contraceptive implant use from 10% to 19%, p=.02, and injectable contraceptive use from 14% to 24%, p=.013. There was a concomitant decrease in the use of no method/abstinence from 57% to 39% (33% decrease, p<.001). Younger age, having at least one child and discussing family planning with a partner were predictive of LARC use. CONCLUSION:Integrating contraceptive services into an anticoagulation management clinic increases the use of highly effective contraception for women with cardiovascular disease. Implementation of similar models of care should be evaluated within other sites for chronic disease management. IMPLICATIONS:A model of care integrating contraceptive counseling and provision into anticoagulation management services is an effective strategy to improve LARC and overall highly effective contraceptive use among women with cardiovascular disease requiring anticoagulation. This model of care may be utilized to prevent maternal morbidity and mortality among this high-risk population.
Project description:To describe contraceptive use and attitudes towards contraceptive use in Sweden which has the highest abortion rate in Western Europe. Secondary objectives were to investigate knowledge of contraceptive methods and outcomes of unplanned and unwanted pregnancies.Telephone survey.National survey of women living in Sweden.Women between 16 and 49 years.The survey contained 22 questions with free text and multi choice answers on demographics, contraceptive use, knowledge of and attitudes towards contraception, the importance of monthly bleeding and experience of unintended pregnancy.Distribution of use of contraceptive methods and non-use of contraception among Swedish women. Prevalence and outcome of unintended pregnancies.A total of 1001 women participated in the survey. Of all women, 721/1001 (72.1%) currently used contraception whereas 268/1001 (26.8%) women did not. Long acting reversible contraception, (LARC; implant and intra uterine contraception) was used by 24.3% of women. The unmet need of contraception in Sweden was estimated at 8.9% (89/1001 women). A total of 781 (78%) women had never experienced an unintended pregnancy whereas 220 (22%) women had had at least one unintended pregnancy. Users and non-users alike stated that one of the most important characteristics of a contraceptive method is its effectiveness.Sweden has a large unmet need for contraception. Furthermore, a large proportion of women have experienced at least one unintended pregnancy. Increasing contraceptive use and promotion of LARC is a possible way forward in the effort to reduce the rates of unwanted pregnancies.
Project description:OBJECTIVES:To assess the impact of specialist contraceptive support after abortion on effective contraceptive use at six months and subsequent abortions within two years. METHODS:Multicentre randomised controlled trial among women undergoing induced abortion in three London boroughs. Allocation was through electronically concealed stratified randomisation by centre, blinding clinicians and participants to arm allocation until interventions. Control group received standard care, comprising advice to follow up with their general practitioner or contraceptive clinic as needed. Intervention group additionally received specialist contraceptive support via telephone or face-to-face consultation at 2-4 weeks and 3 months post-abortion. Primary outcome was rate of effective contraceptive use at six months post-abortion. Secondary outcomes were subsequent abortions within two years. RESULTS:569 women were recruited between October 2011 and February 2013, randomised to intervention (282) and control (287) groups; 290 (142 intervention, 148 control) were available for primary outcome analysis. Intention-to-treat analysis showed no significant difference between the two groups in effective contraceptive use after abortion (62%, vs 54%, p = 0·172), long-acting contraceptive use (42% versus 32%, p = 0·084), and subsequent abortion (similar rates, at 1 year: 10%, p = 0·895, between 1-2 years: 6%, p = 0·944). Per-protocol analysis showed those who received the complete intervention package were significantly more likely to use effective contraception (67% versus 54%, p = 0·048), in particular long-acting contraception (49% versus 32%, p = 0·010) and showed a non-significant reduction in subsequent abortions within 2 years (at 1 year: 5% versus 10%, p = 0·098; and between 1-2 years: 3% versus 6%, p = 0·164, respectively). CONCLUSIONS:Structured specialist support post-abortion did not result in significant use of effective contraception at six months or reduction in subsequent abortions within two years. Participants engaging with the intervention showed positive effect on effective contraception at six months post-abortion. The potential benefit of such intervention may become evident through further studies with increased patient participation.
Project description:BACKGROUND:Long-acting reversible contraception (LARC) is among the most effective contraceptive methods, but uptake remains low even in high-income settings. In 2009/2010, a target-based pay-for-performance (P4P) scheme in Britain was introduced for primary care physicians (PCPs) to offer advice about LARC methods to a specified proportion of women attending for contraceptive care to improve contraceptive choice. We examined the impact and equity of this scheme on LARC uptake and abortions. METHODS AND FINDINGS:We examined records of 3,281,667 women aged 13 to 54 years registered with a primary care clinic in Britain (England, Wales, and Scotland) using Clinical Practice Research Datalink (CPRD) from 2004/2005 to 2013/2014. We used interrupted time series (ITS) analysis to examine trends in annual LARC and non-LARC hormonal contraception (NLHC) uptake and abortion rates, stratified by age and deprivation groups, before and after the P4P was introduced in 2009/2010. Between 2004/2005 and 2013/2014, crude LARC uptake rates increased by 32.0% from 29.6 per 1,000 women to 39.0 per 1,000 women, compared with 18.0% decrease in NLHC uptake. LARC uptake among women of all ages increased immediately after the P4P with step change of 5.36 per 1,000 women (all values are per 1,000 women unless stated, 95% CI 5.26-5.45, p < 0.001). Women aged 20 to 24 years had the largest step change (8.40, 8.34-8.47, p < 0.001) and sustained trend increase (3.14, 3.08-3.19, p < 0.001) compared with other age groups. NLHC uptake fell in all women with a step change of -22.8 (-24.5 to -21.2, p < 0.001), largely due to fall in combined hormonal contraception (CHC; -15.0, -15.5 to -14.5, p < 0.001). Abortion rates in all women fell immediately after the P4P with a step change of -2.28 (-2.98 to -1.57, p = 0.002) and sustained decrease in trend of -0.88 (-1.12 to -0.63, p < 0.001). The largest falls occurred in women aged 13 to 19 years (step change -5.04, -7.56 to -2.51, p = 0.011), women aged 20 to 24 years (step change -4.52, -7.48 to -1.57, p = 0.030), and women from the most deprived group (step change -4.40, -6.89 to -1.91, p = 0.018). We estimate that by 2013/2014, the P4P scheme resulted in an additional 4.53 LARC prescriptions per 1,000 women (relative increase of 13.4%) more than would have been expected without the scheme. There was a concurrent absolute reduction of -5.31 abortions per 1,000 women, or -38.3% relative reduction. Despite universal coverage of healthcare, some women might have obtained contraception elsewhere or had abortion procedure that was not recorded on CPRD. Other policies aiming to increase LARC use or reduce unplanned pregnancies around the same time could also explain the findings. CONCLUSIONS:In this study, we found that LARC uptake increased and abortions fell in the period after the P4P scheme in British primary care, with additional impact for young women aged 20-24 years and those from deprived backgrounds.
Project description:BACKGROUND:Adoption of modern contraceptive methods after menstrual regulation (MR) is thought to reduce subsequent unwanted pregnancy and abortion. Long-acting reversible contraceptives (LARCs) are highly effective at reducing unintended pregnancy, but uptake in Bangladesh is low. Providing information on the most effective methods of contraception increases uptake of more effective methods. This protocol describes a randomised controlled trial of an intervention delivered by mobile phone designed to support post-MR contraceptive use in Bangladesh. METHODS:This is a multi-site single blind individual randomised controlled trial. At least 960 women undergoing MR procedures at selected facilities will be recruited after their procedure by female research assistants. Women will be randomised into the control or intervention group with a 1:1 ratio. All participants will receive usual clinic care, including contraceptive counselling and the telephone number of a non-toll-free call centre which provides counselling on MR and contraception. During the 4 months after their MR procedure, intervention participants will be sent 11 recorded interactive voice messages to their mobile phone about contraception with a focus on their chosen method and LARCs. Each message allows the participant to connect directly to the call centre. The intervention is free to the user. The control group will receive no messages delivered by mobile phone. All participants will be asked to complete an in-person questionnaire at recruitment and follow-up questionnaires by telephone at 2 weeks, 4 months and 12 months after their MR. The primary outcome for the trial will be self-reported LARC use 4 months post-MR. Secondary outcomes include LARC use at 2 weeks and 12 months post-MR, use of any effective modern contraceptive method at 2 weeks, 4 months and 12 months post-MR, and contraceptive discontinuation, contraceptive method switching, pregnancy, subsequent MR and experience of violence during the 12 month study period. DISCUSSION:Mobile phones offer a low-cost mechanism for providing individualised support to women with contraception outside of the clinic setting. This study will provide information on the effects of such an intervention among MR clients in Bangladesh. TRIAL REGISTRATION:Trial registered with clinicaltrials.gov Registration number: NCT02579785 Date of registration: 16th October 2015.
Project description:The physiological changes that occur during pregnancy can be deleterious to women with a cardiovascular condition. Evidence-based contraceptive counseling and provision is essential in this patient population. Although long-acting reversible contraception (LARCs), which include the intrauterine device (IUD) and the etonogestrel contraceptive implant, have been found to be safe and effective in healthy women, there are inadequate data regarding LARC use in patients with cardiovascular conditions. We conducted a retrospective chart review of women diagnosed with cardiovascular disease who had a copper IUD, levonorgestrel-releasing intrauterine system or contraceptive implant placed at the University of Washington Medical Center from 2007 to 2012. We abstracted and analyzed patient demographic characteristics, medical conditions, indications for LARC placement, and complications. The sample included 470 women with cardiovascular conditions. The mean age was 34.6 years. One hundred twenty-four patients (26.11%) were nulligravid and 169 patients (35.58%) were nulliparous. Four hundred ten chose the levonorgestrel-releasing intrauterine system (87.23%), 33 patients (7.02%) opted for the copper IUD, and 23 patients (4.89%) chose the etonogestrel implant. Eighteen patients (3.83%) had a confirmed IUD expulsion, 2 patients (0.43%) became pregnant, and there were 4 cases of pelvic inflammatory disease (0.85%). There were no cases of perforation. There were no confirmed cases of infective endocarditis associated with LARC insertion. In conclusion, LARC devices appear safe with few complications for women with cardiovascular conditions. Clinicians can be reassured that LARC may be offered as an appropriate option when counseling women with cardiovascular disease on safe contraceptive methods.
Project description:Almost one-half of women having an abortion in the United States have had a previous procedure, which highlights a failure to provide adequate preventive care. Provision of intrauterine devices and implants, which have high upfront costs, can be uniquely challenging in the abortion care setting.We conducted a study of a clinic-wide training intervention on long-acting reversible contraception and examined the effect of the intervention, insurance coverage, and funding policies on the use of long-acting contraceptives after an abortion.This subanalysis of a cluster, randomized trial examines data from the 648 patients who had undergone an abortion who were recruited from 17 reproductive health centers across the United States. The trial followed participants 18-25 years old who did not desire pregnancy for a year. We measured the effect of the intervention, health insurance, and funding policies on contraceptive outcomes, which included intrauterine device and implant counseling and selection at the abortion visit, with the use of logistic regression with generalized estimating equations for clustering. We used survival analysis to model the actual initiation of these methods over 1 year.Women who obtained abortion care at intervention sites were more likely to report intrauterine device and implant counseling (70% vs 41%; adjusted odds ratio, 3.83; 95% confidence interval, 2.37-6.19) and the selection of these methods (36% vs 21%; adjusted odds ratio, 2.11; 95% confidence interval, 1.39-3.21). However, the actual initiation of methods was similar between study arms (22/100 woman-years each; adjusted hazard ratio, 0.88; 95% confidence interval, 0.51-1.51). Health insurance and funding policies were important for the initiation of intrauterine devices and implants. Compared with uninsured women, those women with public health insurance had a far higher initiation rate (adjusted hazard ratio, 2.18; 95% confidence interval, 1.31-3.62). Women at sites that provide state Medicaid enrollees abortion coverage also had a higher initiation rate (adjusted hazard ratio, 1.73; 95% confidence interval, 1.04-2.88), as did those at sites with state mandates for private health insurance to cover contraception (adjusted hazard ratio, 1.80; 95% confidence interval, 1.06-3.07). Few of the women with private insurance used it to pay for the abortion (28%), but those who did initiated long-acting contraceptive methods at almost twice the rate as women who paid for it themselves or with donated funds (adjusted hazard ratio, 1.94; 95% confidence interval, 1.10-3.43).The clinic-wide training increased long-acting reversible contraceptive counseling and selection but did not change initiation for abortion patients. Long-acting method use after abortion was associated strongly with funding. Restrictions on the coverage of abortion and contraceptives in abortion settings prevent the initiation of desired long-acting methods.