Structured Contraceptive Counseling to Improve Women's Knowledge

Introduction and Overview of the Problem

A wide variety of contraceptive methods are available in the United States for women to select in order to prevent or reduce the number of unwanted pregnancies. However, unintended pregnancy rates have remained high, and it is estimated that approximately 49% of pregnancies within a given year are unintended. The rate of unintended pregnancies is highest among women under the age of 25 (Abdel-Tawab & Roter, 2002; Zapata et al., 2015). The high frequency of unintended pregnancy places a significant burden on the women themselves, their families, and the healthcare system. It is also noted that unintended pregnancy is experienced disproportionately among women from ethnic and racial minority groups and women of lower socioeconomic statuses, which may contribute to their cycle of disadvantage. There is evidence that some contraceptive methods are more effective than others, and the choice of method may be a contributing factor to unintended pregnancies (Zapata et al., 2015). A slight reduction in unintended pregnancies was demonstrated in an analysis carried out in 2001 (Abdel-Tawab & Roter, 2002). The number of unintended pregnancies in 2001 was 48% (approximately 1.5 million pregnancies), all occurring in a month when women reported having used contraception — compared to 51% in 1994 (Zapata et al., 2015).

The high frequency of unintended pregnancy is mainly associated with nonuse of contraceptive methods, incorrect and inconsistent use, and reliance on less effective methods. Disparities in unintended pregnancy are further contributed to by racial and ethnic differences in contraceptive use. The lack of knowledge and failure to understand or remember what has been taught regarding contraceptive usage is also a contributing factor. The increase in unintended pregnancy rates has resulted in a corresponding increase in termination rates, which currently stand at 47% at this clinic (Zapata et al., 2015). The number of women presenting to their healthcare providers with unintended pregnancies has continued to be high (Abdel-Tawab & Roter, 2002). A majority of these women state that if they had known more about contraceptives they would have prevented the pregnancy; many indicated they would have used a contraceptive method if they had the necessary information (Dehlendorf, Kimport, Levy, & Steinauer, 2014). However, the information that most women receive from their healthcare providers regarding contraceptives is insufficient and inconsistent. The impact that provider information has on a woman's contraceptive choice is determined by age, preference, and the healthcare provider's recommendation (Culwell & Adams Hillard, 2008). While evidence suggests that most women do listen to their providers, they appear to have difficulty recalling the advice given, leading to usage problems as reported by women who visit the clinic.

At this obstetrics (OB) and gynecology (GYN) clinic, four healthcare providers each deliver their own versions of contraceptive education and counseling. There is no standardized method for delivering education. Without a standardized approach, conflicting information may be confusing the women who visit the clinic. Some providers show a preference for a particular type of contraceptive (Dehlendorf, Kimport, et al., 2014), which they advocate for regardless of the patient's desires. This can result in failure by the women to follow usage guidelines, since they may not feel committed to a method they did not choose. Contraceptive method selection should be a collaborative process after the patient has understood the different methods available. Education should be targeted at instilling knowledge rather than promoting a particular method (Dehlendorf, Levy, Kelley, Grumbach, & Steinauer, 2013). If a standardized method of delivering education were established, all four healthcare providers would be offering the same information, which would increase the retention rate for the material being taught. When diverse and conflicting information is provided, women become confused and often do not understand or remember how and when to use contraceptives.

It is for this reason that we are seeking to implement a structured method for contraceptive education that will help prevent the negative patient outcomes currently being experienced at the clinic. The method to be implemented will provide an effective means of increasing patients' contraceptive knowledge, with the expectation that improved education will increase contraceptive usage (Dehlendorf et al., 2013). With a better approach to contraceptive education, patients will be more comfortable, and interactive sessions will allow them to ask questions (Culwell & Adams Hillard, 2008). This reinforcement is likely to help them remember what they have learned and apply that knowledge to reduce unintended pregnancies.

In 2016, the clinic reported 76 out of 1,000 women experiencing an unintended pregnancy — 30% higher than the national average. Given how high that figure is, there is a clear need for interventions to reduce it. Although the clinic had already adopted some contraceptive counseling, rates have not decreased as expected. Further investigation revealed the need for structured education to ensure that all providers follow the same procedures and educate patients using the same methods. A majority of patients presenting with unintended pregnancies were either unaware of contraceptive options or appeared to have misunderstood the instructions they received. For contraception to be effective, it must be used correctly and consistently; therefore, adopting the strategies proposed here and ensuring identical information is delivered by all providers is essential.

Our PICOT question is: "What methods of contraceptive counseling are shown to improve patients' retention of contraceptive knowledge?" Analyzing what researchers have found to be effective in knowledge retention will enable the development of evidence-based strategies suitable for this setting. The target is to replace the current unstructured practice — in which different providers offer inconsistent education and may not recall what they recommended to a particular patient — with a standardized approach that ensures comprehensive, consistent, and patient-centered information delivery.

Providing women with accurate information regarding contraception will result in positive outcomes for the clinic and will reduce the rate of unintended pregnancies. The lack of knowledge has been identified as the primary driver of high unintended pregnancy rates, and since the clinic already offers educational programs, the focus must shift to ensuring that the information delivered is well understood and adhered to (Dehlendorf, Tharayil, et al., 2014; Moos, Bartholomew, & Lohr, 2003). The project aims to implement a structured education system for contraceptive counseling delivery. Using this structured method will allow healthcare providers to disseminate information consistently, and offering advice backed by evidence will ensure that recommended contraceptive methods align with each patient's individual needs and preferences.

Review and Synthesis of Literature

In order to identify the appropriate literature, we employed numerous search strategies aimed at answering our PICOT question. To maximize the likelihood of obtaining a coherent body of evidence related to structured contraceptive counseling, we included only articles using data collected after 2009. Our searches were conducted using four database engines: Ovid SP, PubMed, CINAHL, and the Cochrane Library. Initial searches focused on contraceptive counseling aimed at increasing knowledge retention among women but returned many irrelevant or redundant results, mostly discussing the prevalence of unintended pregnancies and high abortion rates. We subsequently narrowed the search using the phrase "structured contraceptive counseling," which allowed us to select the required five articles. Not all databases contained the relevant articles independently, but combining results from all four enabled us to identify the most appropriate articles for the project.

Titles and abstracts of initially identified articles were analyzed to determine inclusion or exclusion based on our eligibility criteria. Abstracts suggesting experimental and cohort designs, qualitative methodology, or cross-sectional data were advanced for full article review, after which further screening was necessary to reach our final selection of five articles.

Structured counseling is designed to prevent unintended pregnancy by allowing clients to visualize and understand information as they progress toward making an informed contraceptive choice. According to Farrokh-Eslamlou et al. (2014), structured counseling is standardized such that clients receive tailored, well-organized information on the use, effectiveness, and side effects of contraceptive methods. Dehlendorf, Krajewski, and Borrero (2014) corroborate this, noting that structured counseling has been shown to be more effective than routine contraceptive counseling. Informing clients of potential side effects ensures they understand the risks and know what to expect. Dehlendorf, Krajewski, et al. (2014) found that 37% of women who chose to use a hormonal IUD were unaware that irregular bleeding was a likely side effect — a clear indicator of inadequate education. Had these women undergone structured counseling, they would have been aware of side effects and might have selected a method they were more comfortable with (Dehlendorf, Tharayil, et al., 2014).

Structured counseling within a clinical setting also offers clients the opportunity to interact with their healthcare provider. Permitting clients to ask questions ensures they understand what they are learning and can seek clarification — a practice shown to increase knowledge retention (Secura, Allsworth, Madden, Mullersman, & Peipert, 2010). The benefits extend to providers as well: those who follow a structured process are more likely to provide complete information, promote compliance, and improve their performance by reducing guesswork (Farrokh-Eslamlou et al., 2014).

Madden, Mullersman, Omvig, Secura, and Peipert (2013) also employed structured contraceptive counseling. Notably, a majority of the research team members in that study had no formal healthcare training, yet the study demonstrated that even non-healthcare providers can effectively deliver contraceptive education when a structured method is in place. Participants were able to select from different contraceptive methods with a clear understanding of each option. This supports Farrokh-Eslamlou et al.'s (2014) position that structured counseling is more effective in ensuring adherence and knowledge retention than other approaches. Both studies achieved a success rate of 89% when providers used structured counseling.

Visual aids have been the most widely used educational tools in contraceptive counseling sessions. Langston, Rosario, and Westhoff (2010) established that the use of audio-visual methods was associated with increased contraceptive use and continuation of effective methods. Making use of audio-visual training allows the client to both see and hear the information being presented (Hersh et al., 2017), combining modalities to deepen understanding and retention. Langston et al. (2010) found that 54% of women in their study were able to select an effective contraceptive method following audio-visual education. Visual aids also allow healthcare providers to communicate the efficacy and side effects of contraceptive methods in a meaningful, accessible way. As Yee and Simon (2010) note, communicating about contraceptive effectiveness in an informative and meaningful manner is critical. Following audio-visual instruction, knowledge assessment showed that a majority of clients demonstrated improved understanding of contraceptive methods; on their next clinic visit, they recalled significantly more information. There was a 78% increase in information retention, and pre-test and post-test scores indicated that 85% of women had a better understanding of contraceptive methods than when they first enrolled in the class (Secura et al., 2010).

The World Health Organization developed a structured counseling intervention called the Decision-Making Tool (DMT) for use by family planning providers and clients. The DMT is designed to improve quality of care by enhancing client-provider interactions, providing accurate information, and increasing informed choice. Essentially, the DMT is a two-sided flip chart: one side assists the client in decision-making and the other guides the provider through the counseling process (Langston et al., 2010; Farrokh-Eslamlou et al., 2014). This tool has been shown to improve communication with clients. The overall decision-making score for clients increased from 22.5 to 27.6 (p < 0.001), and provider decision-making scores rose from 28.6 to 36.8 (p < 0.001) (Kim, Davila, Tellez, & Kols, 2007). Clients using the DMT reported better understanding of provider explanations and greater comfort in asking questions during consultations (Kim et al., 2005). The number of clients seeking clarification increased by 69% and asking questions by 62% (Kim et al., 2005) — a significant improvement given that these clients had rarely asked questions previously. Because the flip chart is interactive and two-sided, it transforms the counseling session from a one-directional provider lecture into a collaborative exchange. Although the studies reviewed did not directly measure reductions in unintended pregnancy rates attributable to the DMT, implementing this method in the current clinic setting could still yield meaningful improvements in structured education delivery.

The concept of shared decision-making has received increasing attention in health communication. Shared decision-making occupies a position between directive counseling and fully autonomous informed choice: each party is recognized as having relevant expertise, with the patient as the expert on her own values and preferences and the healthcare provider possessing superior medical knowledge (Dehlendorf, Krajewski, et al., 2014). Using this model has been shown to increase women's contraceptive knowledge by approximately 79%. Despite its effectiveness, this approach remains underused — one study found it was employed in fewer than a quarter of visits, with most providers preferring an informed-choice or foreclosed approach. According to Dehlendorf, Kimport, et al. (2014), women in a qualitative study reported that receiving counseling with elements of shared decision-making was consistent with their personal preferences for family planning. Other studies have also reported positive effects, particularly regarding increased use of effective contraception and enhanced knowledge acquisition.

Critical appraisal involves systematically assessing the outcomes of scientific research to judge its trustworthiness, relevance, and value in a specific context. It examines internal validity, relevance, and generalizability, and it enables clinicians to use research evidence reliably and efficiently.

RAPID Critical Appraisal of Langston et al. (2010): This randomized controlled trial enrolled 222 women seeking a first-trimester procedure for a spontaneous or induced abortion. Results indicated that 54% of all participants chose a very effective contraceptive method; however, women in the intervention group were no more likely to choose a very effective method (OR 0.74, 95% CI 0.44–1.26) or to initiate their method (OR 0.65, 95% CI 0.31–1.34) compared to the usual care group. In multivariate models, structured counseling was not associated with use of a very effective method at three months (AOR 1.06, 95% CI 0.53–2.14), indicating little to no significant difference. Although the study population is similar to our clinic's, the limited outcomes make direct implementation in this setting inadvisable. Counseling remains important but should be individualized; the study's limited scope makes it difficult to extrapolate findings to our patients, who prefer affordable and easy-to-use methods.

RAPID Critical Appraisal of Madden et al. (2013): This prospective cohort study enrolled 10,000 women aged 14–45 who wished to avoid pregnancy for at least one year and were initiating a new form of reversible contraception. Of these, 6,530 (86%) enrolled at the primary university site and 1,107 (14%) at partner clinics. Uptake of long-acting reversible contraception was high at both sites (72% and 78%, respectively; p < .0001). After adjusting for confounders, no significant difference in long-acting reversible contraception uptake was found between sites (adjusted relative risk = 0.98, 95% CI [0.94–1.02]). While the study demonstrates that structured counseling can be delivered effectively by staff without prior clinical training, its outcomes are not directly linked to structured contraceptive counseling, limiting its direct applicability to the current setting.

RAPID Critical Appraisal of Dehlendorf, Krajewski, et al. (2014): This review article does not provide an explicit search strategy or validity assessment for the studies reviewed; however, results are consistent across studies, making this review feasible for implementation. The authors conclude that contraceptive counseling has significant potential to empower women to choose a birth control method they can use correctly and consistently, thereby reducing individual risk of unintended pregnancy. A shared decision-making approach that elicits and responds to patient preferences is highlighted as particularly valuable. The population described is similar to our own, and the recommended treatment approach aligns with our patients' preferences for understood and easily recalled methods.

RAPID Critical Appraisal of Kim et al. (2007): This longitudinal study was conducted from 2003 to 2005 at 49 government health facilities in three districts of Nicaragua. It evaluated whether training on and use of the DMT would improve family planning counseling and decision-making. Results showed that decision-making scores for continuing clients rose substantially more among less educated clients (from 18.1 to 29.7, p < 0.05) than more educated clients (from 18.1 to 20.3, p < 0.05). Provider decision-making scores increased from 28.6 to 36.8 (p < 0.001). Implementation of study results in our setting is feasible because the patient population is comparable to ours, and allowing patients to select a method that suits them is vital for ensuring contraceptive continuation and knowledge retention.

RAPID Critical Appraisal of Farrokh-Eslamlou et al. (2014): This systematic review included all RCTs — cluster-randomized trials, quasi-randomized trials, and pre-post intervention studies — and constitutes a Cochrane review of intensive counseling techniques including group motivation, structured counseling, peer counseling, and multi-component counseling, assessed for their impact on contraception adherence. The search strategy and inclusion criteria are clearly stated. Effects of interventions were calculated using risk ratio (RR) or Mantel-Haenszel odds ratio (OR) with 95% confidence intervals using a fixed-effect model for dichotomous variables and mean difference (MD) with 95% CI for continuous variables. Sensitivity analysis was applied for studies with more than 20% loss to follow-up. While the patient population is comparable to our clinic's, direct implementation is limited because the study's recommendations may not align with our patients' preference for affordable, easy-to-use methods.

Overall, the reviewed studies focused primarily on using structured contraceptive counseling as an educational method. Most studies did not adequately address knowledge retention outcomes (De Cetina, Canto, & Luna, 2001), indicating a need for further research in this area. What is clear is that structured counseling enables healthcare providers to offer comprehensive and consistent education to all patients. Structured counseling also ensures that patients are involved in decision-making for their preferred contraceptive (George, DeCristofaro, Dumas, & Murphy, 2015), and the current clinical setting will benefit from improved information flow and provider consistency.