Contraceptive counseling and use with a focus on migrant women in Sweden

INTRODUCTION: Sweden has a high unmet need of contraception resulting in high rates of induced abortions compared with other Northern European countries. The highest abortion rates are seen among women 25-29 years of age. Findings show that Swedish women use less effective contraceptive methods despite the effectiveness of a method being reported as the most important factor when choosing a method. There are no consistent recommendations on how to provide contraceptive counseling. However, previous international studies have stated a higher uptake of long-acting reversible contraception (LARC) and lower pregnancy rates, after counseling focusing on the effectiveness of different methods. Additionally, earlier research states that migrant women in Sweden have lower contraceptive use and a higher proportion of abortions compared with non-migrants. Reasons for the lower use have been explained by access, language and knowledge barriers. However, not many Swedish studies have explored migrant women’s own perspectives on contraception. AIM: This thesis aims to get a better understanding of migrant women’s contraceptive use and perspectives on contraception, but also to present a new way of providing contraceptive counseling. All with the aim of improving access and quality of contraceptive counseling and use. METHODS: Study I was an observational cross-sectional study conducted at abortion clinics in Stockholm. This study aimed to compare contraceptive use and methods, ever-in life, at conception and future planned, after an induced abortion. The comparisons were conducted between migrants, second-generation migrants and non-migrant women. Study II was a cluster randomized controlled trial conducted at abortion, youth and maternal health clinics in Stockholm. The aim was to evaluate effects of structured contraceptive counseling on LARC uptake and pregnancy rates (Paper II). Further, we evaluated effects of LARC uptake and use, as well as satisfaction with the structured counseling among migrants, second-generation migrants and non-migrant participants (Paper III). Study III was a qualitative study using content analysis with an inductive approach. We performed interviews with foreign-born migrants from Iran, Iraq and Syria. In this study we aimed to explore the migrant women’s perceptions and experiences of contraceptive counseling and use. FINDINGS: Migrants and second-generation migrants had a lower contraceptive use ever-in life compared with non-migrant participants. Further, differences were seen in contraceptive methods ever-in life but also planned to be used after the abortion, between the groups. More migrants and second-generation migrants planned to use a LARC method compared with non-migrants after the abortion. Migrants had received sexuality education and contraceptive counseling to a lower extent compared with second-generation migrants and non-migrants. Additionally, migrants stated to a lower extent that they did not have sufficient knowledge to choose a contraceptive method after the abortion compared with second-generation migrants and non-migrants (Study I). Participants who had received the structured contraceptive counseling had a higher LARC uptake compared with participants who had received routine counseling. Additionally, participants who had received the structured contraceptive counseling had less pregnancies at 12 months post-abortion (Paper II). Further, we found that the structured counseling increased LARC uptake and use at 12 months, when controlled for migration background. Also, all the participants were satisfied with the counseling material. However, migrants and second-generation migrants stated to a higher extent that the effectiveness chart was supportive in contraceptive choice as compared with non-migrants (Paper III) (Study II). The foreign-born migrants shared that taboos, such as having no premarital sex and no sex at a young age, influenced their perceptions and experiences of contraceptive counseling and use. They had developed own strategies to be able to use contraception despite the influence of these taboos. Further, the foreign-born migrants shared specific needs from the healthcare provider during the counseling encounter. These were to discuss myths and misconceptions regarding contraception, to receive counseling free of stress and without judgmental attitudes. Additionally, it was shared that audiovisual material can facilitate the counseling if receiving it in a language other than one’s native language (Study III). CONCLUSION: A lower contraceptive use ever-in life was seen among migrants and second-generation migrants compared with non-migrants. Differences in contraceptive methods were also seen between the groups (Study I). Structured contraceptive counseling can increase LARC uptake and decrease pregnancy rates 12 months post-abortion (Paper II). Structured contraceptive counseling can also increase LARC uptake and use, when controlled for migration background. Additionally, a higher proportion of foreign-born migrants and second-generation migrants found the effectiveness chart to be supportive in contraceptive choice compared with non-migrants (Paper III) (Study II). Taboos influence foreign-born migrants’ perceptions and experiences of contraception, leading to development of own strategies and specific needs from the HCP during the contraceptive counseling (Study III)

Contraceptive uptake and compliance after structured contraceptive counseling - secondary outcomes of the LOWE trial

INTRODUCTION: Highly effective long-acting reversible contraceptive (LARC) methods reduce unintended pregnancy rates; however, these methods are underutilized. The LOWE trial intervention provided structured contraceptive counseling resulting in increased uptake of LARC. This longitudinal follow up of the LOWE study assessed the long-term impact of the intervention by investigating the contraceptive use at 12 months with a focus on continued use of LARC. MATERIAL AND METHODS: In the cluster randomized LOWE trial, abortion, youth, and maternal health clinics were randomized to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of an educational video on contraceptive methods, key questions asked by the health care provider, a tiered effectiveness chart and a box of contraceptive models. Women ≥ age 18, who were sexually active or planned to be in the upcoming 6 months, could participate in the study. We assessed self-reported contraceptive use at three, six and 12 months. Contraceptive choice and switches were analyzed with descriptive statistics. Contraceptive use at 12 months and continued use of LARC were analyzed using mixed logistic regressions, with clinic included as a random effect. Analysis with imputed values were performed for missing data to test the robustness of results. RESULTS: Overall, at 12 months, women in the intervention group were more likely to be using a LARC method (aOR 1.90, 95% CI: 1.31-2.76) and less likely to be using a short-acting reversible contraceptive (SARC) method (aOR 0.66, 95% CI: 0.46-0.93) compared to the control group. Women counseled at abortion (aOR 2.97, 95% CI: 1.36-6.75) and youth clinics (aOR 1.81, 95% CI: 1.08-3.03) were more likely to be using a LARC method, while no significant difference was seen in maternal health clinics (aOR 1.84, 95% CI: 0.96-3.66). Among women initiating LARC, continuation rates at 12 months did not differ between study groups (63.9% vs. 63.7%). The most common reasons for contraceptive discontinuation were wish for pregnancy, followed by irregular bleeding, and mood changes. CONCLUSIONS: The LOWE trial intervention resulted in increased LARC use also at 12 months. Strategies on how to sustain LARC use needs to be further investigated

Evaluation of satisfaction with a model of structured contraceptive counseling : Results from the LOWE trial

Introduction: Intervention trials of structured contraceptive counseling have proved to increase use of long-acting reversible contraceptives (LARCs) and decrease numbers of unintended pregnancies. However, these interventions have not been evaluated from a user perspective. This study aimed to evaluate both healthcare providers’ and participants’ satisfaction with an intervention used in a large trial in Sweden. Material and methods: A cross-sectional study on the intervention group from a cluster randomized trial conducted at 28 clinics in Stockholm, Sweden. Clinics were randomized (1:1 allocation ratio) to provide either structured contraceptive counseling (intervention) or standard contraceptive counseling (control). The intervention consisted of four parts; an educational video to be seen by the participant prior to contraceptive counseling, key questions to be asked by the healthcare provider, an effectiveness chart, and a box of contraceptive models. Eligible participants were 18 years or older, sexually active without a wish to conceive, and with the main purpose of contraceptive use being pregnancy prevention. Healthcare providers completed an electronic semi-structured survey to evaluate the intervention. This study analyses provider and participant satisfaction with the counseling material used in the intervention and if the intervention was found to be supportive in contraceptive counseling and contraceptive choice. Trial registration: ClinicalTrials.gov (NCT03269357). Results: Fourteen intervention clinics enrolled 658 participants from September 2017 to May 2019. Response rate among providers was 88.0% (55/62) and among participants 97.1% (639/658). Providers found the intervention to be supportive in their counseling. Each separate part of the intervention package received high ratings from both providers and participants. Participants found the educational video and the effectiveness chart to be more helpful than the box of contraceptive models in their contraceptive choice. Providers reported the time taken to complete the intervention outside the study to be time-neutral to standard counseling, and most providers wished to continue to use all parts of the intervention package. Conclusions: The intervention of structured contraceptive counseling had high provider and participant satisfaction. The structured counseling package could be used in several clinical settings to improve quality in contraceptive counseling and to enhance informed decision making about use of contraceptive methods. © 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG

IMplementing best practice post-partum contraceptive services through a quality imPROVEment initiative for and with immigrant women in Sweden (IMPROVE it): a protocol for a cluster randomised control trial with a process evaluation

Abstract Background Immigrant women’s challenges in realizing sexual and reproductive health and rights (SRHR) are exacerbated by the lack of knowledge regarding how to tailor post-partum contraceptive services to their needs. Therefore, the overall aim of the IMPROVE-it project is to promote equity in SRHR through improvement of contraceptive services with and for immigrant women, and, thus, to strengthen women’s possibility to choose and initiate effective contraceptive methods post-partum. Methods This Quality Improvement Collaborative (QIC) on contraceptive services and use will combine a cluster randomized controlled trial (cRCT) with a process evaluation. The cRCT will be conducted at 28 maternal health clinics (MHCs) in Sweden, that are the clusters and unit of randomization, and include women attending regular post-partum visits within 16 weeks post birth. Utilizing the Breakthrough Series Collaborative model, the study’s intervention strategies include learning sessions, action periods, and workshops informed by joint learning, co-design, and evidence-based practices. The primary outcome, women’s choice of an effective contraceptive method within 16 weeks after giving birth, will be measured using the Swedish Pregnancy Register (SPR). Secondary outcomes regarding women’s experiences of contraceptive counselling, use and satisfaction of chosen contraceptive method will be evaluated using questionnaires completed by participating women at enrolment, 6 and 12 months post enrolment. The outcomes including readiness, motivation, competence and confidence will be measured through project documentation and questionnaires. The project’s primary outcome involving women’s choice of contraceptive method will be estimated by using a logistic regression analysis. A multivariate analysis will be performed to control for age, sociodemographic characteristics, and reproductive history. The process evaluation will be conducted using recordings from learning sessions, questionnaires aimed at participating midwives, intervention checklists and project documents. Discussion The intervention’s co-design activities will meaningfully include immigrants in implementation research and allow midwives to have a direct, immediate impact on improving patient care. This study will also provide evidence as to what extent, how and why the QIC was effective in post-partum contraceptive services. Trial registration NCT05521646, August 30, 2022