A systematic review of the effectiveness of counselling strategies for modern contraceptive methods: what works and what doesn’t?

Aim The aim of this systematic review was to synthesise the evidence on the comparative effectiveness of different counselling strategies for modern contraception on contraceptive behaviour and satisfaction, and to examine their advantages and disadvantages. Methods Six electronic databases (Medline, Embase, Global Health, Popline, CINAHL Plus, and Cochrane Library) were searched to identify publications comparing two or more contraceptive counselling strategies and reporting quantitative results on contraceptive use, uptake, continuation or switching, or client satisfaction. Studies of women or couples from any country, published in English since 1990 were considered. Results A total of 63 publications corresponding to 61 studies met the inclusion criteria. There was substantial heterogeneity in study settings, interventions and outcome measures. Interventions targeting women initiating a method (including structured counselling on side effects) tended to show positive effects on contraceptive continuation. In contrast, the majority of studies of provider training and decision-making tools for method choice did not find evidence of an effect. Additional antenatal or postpartum counselling sessions were associated with increased postpartum contraceptive use, regardless of their timing in pregnancy or postpartum. Dedicated pre-abortion contraceptive counselling was associated with increased use only when accompanied by broader contraceptive method provision. Male partner or couples counselling was effective at increasing contraceptive use in two of five studies targeting non-users, women initiating implants or seeking abortion. High-quality evidence is lacking for the majority of intervention types. Conclusions The evidence base and quality of studies are limited, and further research is needed to determine the effectiveness of many counselling interventions in different settings.

Counselling content, format and interactions between client and provider can be amenable to interventions. The majority of interventions have targeted women, although some have targeted couples or men. A wide range of contraceptive counselling strategies have been tried, including structured (method-specific) counselling, comprehensive counselling (using extensive clinical algorithms), group counselling, and patient-centred approaches. A multitude of tools have been used such as visual Decision-Making Tools and recent computer-based counselling aids. The evidence on the effectiveness of these different approaches has not been synthesised.
Key components of quality contraceptive counselling have been proposed. The Bruce framework, proposed in 1990, identifies six dimensions for quality family planning services, including three which relate to contraceptive counselling: choice of methods, information given to clients, and interpersonal relations. 7 It is important that clients are given a choice of methods, sufficient information to make an informed choice, and are treated with respect by providers. Holt and colleagues define quality contraceptive counselling as consisting in three dimensions: needs assessment, decision-making support, and method choice and followup. 8 They argue that a patient-centred approach should be used by assessing needs and tailoring communication based on these responses. Similarly, Dehlendorf et al. suggest that best practices for contraceptive counselling include building a trusting relationship with the client and using a shared decision-making approach, based on eliciting and responding to patient preferences. 9 They further suggest that counselling on side effects and using specific strategies to promote adherence can help improve contraceptive use. Attention has been called to the specific needs of and barriers faced by adolescents, including a need for dual protection (against pregnancy and STIs) and respect for adolescents' autonomy. 10 Despite these diverse frameworks on quality of contraceptive services, no clear consensus exists on how to deliver contraceptive counselling in such a way as to meet contraceptive needs and patient satisfaction. The WHO 2016 Selected practice recommendations for contraceptive use highlights counselling content that should be provided to women, primarily concerning method-specific side effects and prevention and treatment of STIs. 11 The WHO 2018 Global Handbook for Family Planning Providers includes recommendations on content as well as interpersonal qualities (such as showing every client respect, encouraging clients to express concerns, and assuring them of confidentiality). 12 Guidance on the best format for delivering the information during counselling is limited.
The limited evidence available shows that the quality of contraceptive counselling is poor in low-resource settings: 13 in Senegal, only 18% of providers counselled their clients on all three examined items (how to use their methods, possible side effects, and when to return to the clinic). 14 High-quality contraceptive counselling has the potential to ensure that women and couples choose the method best suited to their needs and preferences, are aware of potential side effects and return to the provider as needed, thereby addressing concerns related to health and side effects and ensuring continuation among women who want to use contraception

Why it is important to do this review
Several reviews have examined counselling strategies to improve contraceptive use. A meta-analysis of three RCTs found no evidence that expert individualised contraceptive counselling was associated with contraceptive continuation after abortion. 15 Another systematic review found mixed evidence that brief educational strategies in clinic settings for adolescents and young people reduced pregnancy rates and increased contraceptive use. 16 Postpartum interventions for contraceptive use showed only limited evidence of a reduction in subsequent repeat pregnancies, compared to routine care or no intervention. 17 These reviews have focused on subgroups of women, with often a limited description of the contraceptive counselling received by the control group. Another Cochrane review also showed limited evidence that mobile phone interventions increased uptake or adherence to contraception outside of clinic settings. 18 In this review we examine the effectiveness of counselling strategies to increase contraceptive uptake and continuation among women of reproductive age, including postpartum and post-abortion women. The intervention should involve provision of contraceptive counselling to women (through the provision of information and assistance in decisionmaking), and the control group should include an alternative counselling strategy. Contraceptive counselling may occur within health facilities, or outside of health facilities (such as through outreach strategies or remotely using digital communication tools).
WHO is in the process of developing guidelines for the provision of quality contraceptive services, and this systematic review intends to provide relevant information on what works and what doesn't work in contraceptive counselling to support this process.

OBJECTIVES
The aim of this systematic review is to synthesise the evidence on the comparative effectiveness of different techniques for contraceptive counselling, and examine their advantages and disadvantages.

Criteria for considering studies for this review
Types of studies In this review, we will consider randomised controlled trials (RCTs) and non-randomised studies. RCTs can include both individual and cluster-randomised trials, such as for health facilities. Non-randomised studies will need to be prospective intervention studies and compare at least two contraceptive counselling techniques. There may be limited evidence from RCTs on techniques for contraceptive counselling, due to funding limitations and clinical logistics, and therefore it is important to consider the evidence base from nonrandomised studies.
Only studies reporting quantitative findings will be considered. a

Types of participants
We will include studies with participants who are women of reproductive age or couples, who may be seeking to initiate contraceptive use, switching contraceptive methods or continuing to use the same method. Participants may include women who are post-abortion or postpartum (including breastfeeding women), but will exclude women with specific medical conditions (such as breast cancer, or heart disease). We will consider evidence from all countries.
a Relevant qualitative studies on contraception and counselling identified during the search will be compiled into a bibliographical appendix for reference BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)

Types of interventions
Contraceptive counselling interventions which include provision of information and decisionmaking support for contraceptive methods will be included. We will consider counselling techniques for contraception in health facilities, in the community or remotely via digital communication, delivered by health providers, lay persons or electronically. Counselling methods may include direct oral communication or the use of digital technologies (such as computer-assisted algorithms), or a combination of both. The comparison intervention must include a type of contraceptive counselling, including usual care where it is clear that usual care includes contraceptive counselling (rather than no intervention).
Contraceptive counselling strategies will be considered for modern family planning methods, as defined by Festin et al. 19 However, counselling interventions focusing solely on male condoms will be excluded.

Example of types of interventions (some combine multiple facets)
- Measures of contraceptive continuation will exclude condom use at last sex, and consider only condom use when included as part of a range of modern contraceptive methods. Studies may not ask clients for their satisfaction with the counselling specifically, we will consider studies reporting general satisfaction with contraceptive services received.

Secondary outcomes
We will also synthesise any reported qualitative data on advantages and disadvantages of different counselling techniques in the included studies.
Advantages and disadvantages reported by contraceptive providers and users will be reported.

Electronic searches
We will search for eligible studies in Medline, Embase, Global Health, Popline, CINAHL and Cochrane Database of Systematic Reviews electronic databases, using keywords related to contraception, counselling and outcomes of interest. Searches will focus after the publication of the Bruce framework, 7 from 1 st January 1990 to present (end October 2018). We will restrict to studies published in English. We will review the reference lists of included studies to identify any publications not identified by the search strategy. The proposed search strategies are shown in Appendix 1.

Searching other resources
We will perform a preliminary manual search of a key journal (Contraception) to identify key words to capture relevant studies.

Data collection and analysis
Selection of studies All unique studies retrieved by the search strategy will be assessed for inclusion based on title and abstract by one author. For studies which appear eligible for the review, we will obtain and assess full-text articles. A second reviewer will assess 10-20% of references excluded during title and abstract screen, and any differences will be reconciled by discussion between co-authors.

Data extraction and management
The extracted data will be entered into an Excel spreadsheet. Information extracted will include: -General information: first author, title, year of publication, country -Study characteristics: study design, aim of study, participant recruitment, sampling, method of allocation, inclusion/exclusion criteria -Participants: description, geographic location, sample size -Intervention: type of intervention (initiation, re-supply, switching, all/unspecified), description, aim of intervention, providers delivering intervention, medium/format of intervention, content of intervention, duration, frequency, co-interventions -Comparison: description of control intervention -Outcomes: outcomes evaluated (among outcomes included within the review scope), length of follow-up, methods of assessing outcomes, completeness of outcome data, results for each outcome, type of analysis (intention to treat or treatment received analysis) 10-20% of included full-text articles will be extracted in duplicate by two reviewers and any differences will be reconciled by discussion.

Assessment of quality of evidence
We will not systematically grade the quality of evidence for each study.

Assessment of heterogeneity
Due to the variability in contraceptive counselling techniques and outcomes reported, we anticipate there will be limited scope to conduct a meta-analysis. We will report any differences across studies by measure of contraceptive use (uptake, continuation, switching) and participant populations (such as adolescents and young people, post-partum or postabortion women). If appropriate, we will synthesise results by the type of intervention (such as in-person or digital counselling), and whether the contraceptives were provided to participants at no or reduced cost as part of the intervention.

Data synthesis
We will present a narrative overview of the findings together with tables summarising the extracted data. Summary and descriptive statistics will be presented.

ACKNOWLEDGMENTS
We based this protocol on the prior work of Lopez and colleagues 16  AND TI (counselling OR counseling OR "decision tool" OR "decision-making tool" OR "decision making tool" OR "decision support" ) NOT HIV AND BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Cochrane library of systematic reviews contracepti* or "family planning" AND counselling or counseling or "educational strategies" or "educational interventions" or tool* or "family planning quality" or "quality of family planning" or "patient-provider interaction" or "patient provider interaction" or "client-provider interaction" or "client provider interaction" or "client-provider communication" or "client provider communication" or "patient-provider communication" or "patient provider communication" AND continu* or discontinu* or uptake or initiat* or switch* or satisf* or 'use' or 'using' or 'used' BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)