Effectiveness of contraceptive counseling strategies

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Counseling strategies for modern contraception that target women initiating a method, including structured counseling on side effects, tend to have positive effects on contraceptive continuation, according to a systematic review in BMJ Sexual & Reproductive Health. But in most cases, provider training and decision-making tools for method choice did not have an effect.

On the other hand, additional antenatal or postpartum counseling sessions resulted in an increased rate of postpartum contraceptive use, regardless of their timing in pregnancy or postpartum. But dedicated pre-abortion contraceptive counseling was linked to increased use only when accompanied by a broader contraceptive method provision. The review also found that male partner or couples counseling can be effective at increasing contraceptive use among non-users, or in women initiating contraceptive implants or seeking abortion.

Methods
The investigators, who were from several countries, searched six electronic databases for relevant studies of women or couples published in English since 1990: Medline, Embase, Global Health, Popline, the Cumulative Index of Nursing and Allied Health Literature (CINAHL) Plus and Cochrane Library. A total of 61 studies from 63 publications met the inclusion criteria, for which there was substantial heterogeneity in study settings, interventions, and outcome measures. However, high-quality evidence was absent for the majority of intervention types.

Findings
In summarizing the advantages and disadvantages of different counseling intervention methods, a few studies noted the increased cost of  staffing, resources, and contraceptive products when providing additional and longer patient consultations. Conversely, interventions like digital tools during waiting times prior to consultation can potentially save provider time. However, counseling satisfaction with digital tools alone was low, and best used in conjunction with face-to-face counseling.

While telephone-based interventions provide access to many women at low cost, these interventions are unable to reach women without phones and may require multiple attempts to reach participants with phones.

Counseling up to the time of birth or abortion for women who may not access services later allows for a fuller discussion of different contraceptive methods, yet some women may be reluctant to initiate contraception immediately, thus effective follow-up mechanisms are necessary. Routine postpartum counseling at 3 to 6 weeks may help some women after they have resumed sexual activity.

Including male partners in counseling sessions may also be valuable, if they are the main contraceptive decision-maker. But partner availability poses logistical challenges.

Conclusions
“Our focus on comparing counseling strategies is critical to help identify successful interventions to improve contraceptive services,” the authors wrote. “However, preventing unmet need for contraception and unwanted pregnancies (influenced by multiple other factors) is the ultimate objective from a public health standpoint, and counseling process indicators such as client participation and knowledge are also important.”

Three limitations of the review are that study quality was variable; substantial heterogeneity existed in study settings, interventions and outcomes, thereby limiting comparability of studies; and many of the included studies failed to clearly state whether the intervention targeted women initiating, switching, and/or continuing contraception, plus women switching methods were often grouped with initiators.

Nonetheless, the findings underscore that when feasible, repeated counseling throughout pregnancy and postpartum can contribute to maximum access to information and contraceptive uptake. However, interventions seeking to improve contraceptive counseling need to be tailored to patient flow, record flow, and the contraceptive methods available, while embedded within broader quality-of-care improvements, including clinical training.

The authors noted that further research is needed to determine the effectiveness of many contraceptive counseling interventions, including novel efficacious interventions, among various settings.