Contraceptive counseling, provision increases use, reduces unintended pregnancy

Counseling patients about contraceptive use and providing contraceptives increases contraceptive use without increasing the risk for sexually transmitted infections (STIs) or reducing condom use compared to usual practice, according to a review and meta-analysis.

Researchers analyzed randomized controlled trials of the effectiveness of contraceptive counseling and provision of interventions to increase use of contraceptives and reduce unintended pregnancy in cisgender women. Trials were included if they compared provision of enhanced contraceptive counseling, contraceptives, or both versus usual care or an active control. The study was funded by the Resources Legacy Fund, a private organization that funds efforts on climate change, social change, and diversity, equity, and inclusion. The study results were published May 24 by Annals of Internal Medicine. A video summary of the review is also available.

The review and meta-analysis included 38 trials involving 43 articles and 25,472 participants. Contraceptive use was higher with various counseling interventions (risk ratio [RR], 1.39 [95% CI, 1.16 to 1.72]; 10 trials), with provision of emergency contraception in advance of use (RR, 2.12 [95% CI, 1.79 to 2.36]; 8 trials), and with provision immediately postpartum (RR, 1.15 [95% CI, 1.01 to 1.52]; 5 trials) or at the time of abortion (RR, 1.19 [95% CI, 1.09 to 1.32]; 5 trials) than with usual care or active controls in multiple clinical settings, the analysis found. Pregnancy rates were generally lower with interventions, although most trials were underpowered and did not determine pregnancy intention. Interventions were not associated with increased risk for STIs (RR, 1.05 [95% CI, 0.87 to 1.25]; 5 trials) or reduced condom use (RR, 1.03 [95% CI, 0.94 to 1.13]; 6 trials).

The researchers noted that results showed consistently higher contraceptive use for adolescents and women during the months after the interventions compared to usual care or controls, such as receiving educational materials without accompanying counseling. None of the trials evaluated potential harms such as anxiety, stigma, and reproductive coercion.

“Clinicians and health systems could improve contraceptive care by providing effective services applicable to their patient populations. These include implementing enhanced contraceptive counseling, provision, and follow-up services; providing emergency contraception in advance; and delivering services immediately postpartum or at the time of abortion,” the authors wrote.

In an accompanying editorial, Christine Laine, MD, FACP, Editor-in-Chief of Annals of Internal Medicine, noted that unintended pregnancy has adverse consequences for physical and mental well-being and that the health consequences of an unintended pregnancy can be particularly great for women with underlying medical conditions. In addition, contraceptive counseling and provision should become a routine part of internal medicine practice as well as a quality metric for clinicians, she said.

“Changes in training, reimbursement, and quality measures are needed to facilitate such integration. However, it is in the power of every physician to begin to make contraceptive counseling a routine part of preventive care by asking women of childbearing age a few key questions and facilitating effective contraception for those who do not desire pregnancy,” the editorial stated. “In addition, if the goal is to reduce unintended pregnancies, we should ask all patients regardless of sex and gender who are sexually active whether pregnancy is possible and desired and, when appropriate, counsel them about effective contraception.”

A cover story in the May ACP Internist addressed long-acting reversible contraceptives and the incorporation of placement procedures and contraceptive counseling into primary care and resident education.