Strategies to improve adherence and acceptability of hormonal methods for contraception.
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.


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


METHODS
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.


METHODS
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.


METHODS
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.


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.


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.
Halpern
V
V
Family Health International, Clinical Research Department, 2224 E NC Highway 54, Durham, North Carolina 27713, USA. vhalpern@fhi.org
Grimes
D A
DA
Lopez
L
L
Gallo
M F
MF
D003267:Contraception / Q000523:psychology*; D003271:Contraceptive Agents, Female / Q000008:administration & dosage* / Q000009:adverse effects; D003278:Contraceptives, Oral, Hormonal / Q000008:administration & dosage / Q000009:adverse effects; D003376:Counseling; D005260:Female; D006801:Humans; D017258:Medroxyprogesterone Acetate / Q000008:administration & dosage / Q000009:adverse effects; D010349:Patient Compliance / Q000523:psychology; D016032:Randomized Controlled Trials as Topic; D016312:Treatment Refusal / Q000523:psychology
D003271:Contraceptive Agents, Female; D003278:Contraceptives, Oral, Hormonal; D017258:Medroxyprogesterone Acetate