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Strategies to improve adherence and acceptability of hormonal methods for contraception

RHL Commentary by Goonewardene M

1. INTRODUCTION

It is estimated that over 100 million women in the world use the combined oral contraceptive (COC) pills and more than 50 million women use injectables such as depot-medroxyprogesterone acetate (DMPA) (1). The use of progestogen-only pills, the contraceptive patch, the vaginal ring and the levonorgestrel-releasing intrauterine device is much less and confined to well-resourced settings. Although steroid hormonal contraceptives have high efficacy, their actual effectiveness is reduced owing to poor adherence to the regimens as well as to high discontinuation of the methods, mainly because of side-effects.

During the period 2001–2005, the prevalence of use of COCs varied from approximately 1% in Rwanda to 40% in Morocco, and that of injectables (such as DMPA) varied from approximately 0.1% in Armenia to 27.8% in Indonesia (2). Discontinuation rates for contraceptives were the highest in sub-Saharan Africa, with Mali having an estimated discontinuation rate of 66% in 2001. Viet Nam had the lowest estimated discontinuation rate of 13% in 2002. Up to 50% of women discontinue contraceptives use for method-related reasons, mainly side-effects and health concerns, and in up to 5% discontinuation is due to spousal disapproval (2). In Brazil, 11.8% and 27.4% users, respectively, discontinued COCs and DMPA within one year because of side-effects and health-related reasons (3). During 2001–2005, due to side-effects and health-related reasons, 26.4% and 40.1% discontinued COC and DMPA, respectively, in Sri Lanka (4). In a study carried out in 19 countries, 28% of women discontinued COCs within 12 months because of dissatisfaction with the method, but only 35 % of them switched to another modern method within three months (5). Up to 47 % and 22 % of women may miss one or more COC pills, and two or more pills, respectively (6).

The low effectiveness of contraceptives can result in unintended pregnancies which could lead to unsafe abortion, especially in under-resourced settings. It has been estimated that over one million unintended pregnancies are related to COC use, misuse or discontinuation and 20% of the 3.5 million annual unintended pregnancies in the USA occur in women who had discontinued COCs (7). Globally, it is estimated that approximately 47 000 maternal deaths are as a result of unsafe abortion and this accounts for approximately 13% of all maternal deaths (8). A common reason given by abortion seekers for not using or discontinuing contraception is fear of side-effects and dislike of contraception (9). Therefore, adoption of appropriate counselling strategies to improve adherence, acceptability and long-term continuation of hormonal contraceptives is important from a public health perspective. This Cochrane review sought to determine the effectiveness of techniques aimed at improving adherence to, and continuation rates of, hormonal methods of contraception (10).

2. METHODS OF THE REVIEW

A comprehensive search appears to have been carried out and eligible randomized controlled trials (RCT) have been identified and reviewed. The 2011 updated Cochrane review includes two new RCTs that studied the effectiveness of follow-up of women with telephone calls and daily text-message reminders. The method of grading the quality of evidence is summarized and explained in the review appropriately. The methods of contraception used by the women as well as the type of intervention varied from study to study and therefore the authors could not perform a meta analysis of the data.

3. RESULTS OF THE REVIEW

Eight RCTs involving 2807 women were included in the review. Three of the studies had very small sample sizes (less than 100). Two of these small studies and one other study had very high rates of loss to follow-up. In all the studies there was a possibility of ‘contamination’ of the control group by participants in the intervention group sharing information about the intervention with those in the control group. This would decrease the likelihood of a difference being detected between the groups.

Moderate-quality evidence was available from three studies involving 1462 women. The first study involving 1030 women with no reported loss to follow-up showed that group motivation counselling by specially trained medical nurses using audio visual aids could reduce discontinuation due to dissatisfaction with the selected contraceptive [odds ratio (OR) 0.61, 95% confidence interval (CI) 0.38–0.98]. However, both hormonal and nonhormonal methods were included in this trial. The second study involving 350 women selecting DMPA for contraception, with loss to follow up of 3%, showed that structured, pretreatment, and follow-up intensive counselling could reduce discontinuation by 6 months (OR 0.36, 95% CI 0.20–0.64) and 12 months (OR 0.27, 95% CI 0.16–0.44); discontinuation due to menstrual disturbances was also reduced significantly (OR 0.20, 95% CI 0.11–0.37). The third study, involving 82 women with a loss to follow-up of 22% showed that daily text messages did not reduce the mean number of missed COC pills either in the first or the third cycle.

Another study involving 57 adolescents attending an adolescent gynaecological clinic and wishing to use COCs showed a drop out rate of only 23% at 4 months among those who were counselled by a peer compared with 42% among those who had been counselled by a nurse (OR 0.42, 95 % CI 0.13–1.32).

Interventions that appeared to be ineffective were multi-contact peer counselling for women requesting elective abortion, antenatal counselling with the use of audio visuals, written material for women who had unintended pregnancies, and mail and telephone reminders for the next injection for women using DMPA, patch or COCs.

4. DISCUSSION

4.1 APPLICABILITY OF THE RESULTS

Repeated structured counselling was found to be effective and group motivation counselling by specially trained medical nurses using audiovisual aids was found to be somewhat effective in reducing discontinuation due to dissatisfaction with the selected contraceptive. However, strategies such as routine counselling and multi-contact peer counselling appeared not be beneficial. The studies that showed a modest benefit were carried out in relatively under-resourced settings. Therefore, these strategies could be implemented in under-resourced settings, although it should be noted that the overall quality of the available studies was moderate to low.

Motivation and reinforcement of knowledge by repetition of input are known to improve knowledge and attitudes of the recipients. Group motivation, carried out by trained health-care workers using audio visual aids and structured intensive counselling prior to commencement of the hormonal contraceptive as well as during the regular follow-up visits, could also be a feasible option. Peer counselling could be adopted in clinics and services aimed at adolescents.

4.2 IMPLEMENTATION OF THE INTERVETNION

At the initiation of use of a contraceptive, the clients should be educated regarding the non-contraceptive health benefits of the method, management of the possible side-effects and the possibility of changing over to another effective method if the need arises. In such sessions, the client's fears should be allayed and myths and false beliefs dispelled. Repeated structured intensive counselling could be easily implemented by timing the follow-up visits to coincide with the three-monthly repeat injection time of DMPA. Three packs of COCs could be prescribed at a time to enable the same strategy to be applied as for DMPA. Whenever possible, women's partners should be encouraged to accompany the women to the service provider, who should be adequately trained to motivate and counsel both the women and their partners. Information leaflets could be given to the women to take home and they should be encouraged to read them again, especially in case of any side-effects. The information leaflets should contain details of how to contact a service provider, if required. In addition to medical officers, even nurses and family health workers could be trained for this purpose. Adolescents who request contraception, especially those who require contraception following an unintended pregnancy, should be motivated to participate in counselling their peers attending adolescent clinics.

4.3 IMPLICATIONS FOR RESEARCH

Further research is needed to strengthen the evidence that group motivation and use of peers for counselling adolescents can increase adherence, acceptability and continuation of hormonal contraceptives. Ideally, there is a need to identify cost–effective and feasible intervention strategies through well-designed multicentre cluster randomized controlled community trials that randomize clusters of clinics and not individual clients requesting contraception. To avoid the risk of contamination, the cluster receiving the intervention should be geographically a significant distance away from the cluster not receiving the intervention. The role of the male partners in this context should also be studied and appropriate interventions instituted to increase their involvement in decision-making as well as adherence to and continuation of the method chosen by the women.

References

• Population Reference Bureau. Family Planning Worldwide 2008 Data Sheet. Washington DC: PRB 2008. Available at: http://www.prb.org/pdf08/fpds08.pdf (accessed on 25.05.2011)
• Khan S, Missra V, Arnold F, Abderrahim N. Contraceptive trends in developing countries. DHS Comparative Report No. 16: 2007, Calverton Maryland USA, Macro International Inc. Available at http://www.measuredhs.com/pubs/pdf/CR16/CR16.pdf (accessed on 25.05.2011)
• Leite IC, Gupta N. Assessing regional differences in contraceptive discontinuation, failure and switching in Brazil. Reproductive Health 2007;4: 6.available at http://www.reproductive-health-journal.com/content/4/1/6. ( accessed on 25.05.2011)
• Department of Census and Statistics, and Ministry of Health Care and Nutrition, Sri Lanka Demographic Health Survey 2006/7, Colombo Sri Lanka 2008. Department of Census and Statistics Sri Lanka. Available at http://www.statistics.gov.lk/social/DHS Sri Lanka Preliminary Report.pdf. (accessed on 25.05.2011)
• Ali M, Cleland J. Oral contraceptive discontinuation and its aftermath in 19 developing countries. Contraception 2010; 81(1): 22-29.
• Rosenberg MJ, Waugh MS, Burnhill MS. Compliance counselling and satisfaction with oral contraceptives: a prospective evaluation. Family Planning Perspectives 1998; 30(2): 89-92.
• Rosenberg MJ, Waugh MS, Long S. Unintended pregnancies and use, misuse and discontinuation of oral contraceptives. Reproductive Medicine 1995; 40(5): 355-360.
• World Health Organization. Unsafe abortion: Global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. 6th Edition.2011, Geneva World Health Organization. (WQ 440).
• Senanayake L, Wilathgamuwa S. Reducing the burden of unsafe abortion in Sri Lanka. 2009; Colombo, The Family Planning Association of Sri Lanka.
• Halpern V, Lopez LM, Grimes DA, Gallo MF. Strategies to improve adherence and acceptability of hormonal methods of contraception. Cochrane Database of Systematic Reviews 2011;Issue 4. Art. No.: CD 004317; DOI:10.1002/14651858.CD004317.pub3.

This document should be cited as: Goonewardene M. Strategies to improve adherence and acceptability of hormonal methods for contraception: RHL commentary (last revised: 1 August 2011). The WHO Reproductive Health Library; Geneva: World Health Organization.