Updates in Contraception From The XVI World Congress of the International Federation of Gynecology and Obstetrics

David A. Grimes, MD

Disclosures

September 20, 2000

In This Article

Contraceptive Counseling During Pregnancy: Does It Make a Difference?

The need for evidence-based practice in family planning is as acute as it is in other areas of medicine. Many of our clinical assumptions are just that: hunches that may not hold up to scientific scrutiny. The fallibility of conventional wisdom is well documented, and a recent trial[20] from Nicaragua provided more evidence. Investigators examined the usefulness of several strategies to promote condom use in motels in Managua, Nicaragua, used both for extramarital sex and for prostitution. All the bedrooms were provided with 2 free condoms and a note that they were courtesy of the house. Rooms were then randomized to various educational strategies, such as leaflets and wall charts, on the importance of using condoms to prevent STDs. The outcome measure was collection of used condoms by study staff disguised as housekeeping personnel after the room had been vacated. Paradoxically, couples exposed to the health education messages were less likely to have used the free condoms than those not exposed to the counseling. The counseling messages backfired. Hence, we have an urgent need to test the effect of educational strategies.

Dr. Cheng Linan of the Shanghai Institute of Family Planning, China, and her colleagues[21] conducted a randomized controlled trial of the benefit of anticipatory family planning counseling during pregnancy. Whether providing women with counseling during their prenatal care would increase contraceptive use and pregnancy rates later was unknown. The trial took place at 3 disparate sites: Shanghai, Edinburgh, and Cape Town, South Africa. Five hundred women at 24-36 weeks' gestation were recruited at each site between February and August 1997. Half were randomized to receive formal contraceptive counseling during antenatal care, while the other half got routine advice. The investigators sought to evaluate all participants by questionnaire at 16 and 52 weeks after delivery.

As might be anticipated, the initial contraceptives chosen by women in these 3 cities varied widely. However, at the 1-year evaluation, no significant difference emerged in the proportion still using contraception. More importantly, no significant differences appeared in the pregnancy rates between the experimental and control groups. As Dr. Cheng noted, "Contraceptive counseling during the antenatal period seems sensible but has very little impact on contraceptive use or subsequent pregnancy rates."

Although counseling to prevent unintended pregnancy is a routine activity for clinicians who care for women, the effectiveness of our efforts is unclear. The U.S. Preventive Services Task Force[22] critically examined all the literature in English and concluded that the quality of the evidence was poor and the number of credible studies small. No clear evidence of the benefit of counseling emerged, although they gave counseling a "B" recommendation, meaning fair evidence existed to support the practice. The randomized controlled trial reported by Cheng would rate as level I evidence in the U.S. Preventive Services Task Force taxonomy: a properly done randomized controlled trial. This study provides good evidence that contraceptive counseling during antenatal care is no more effective than standard obstetric care. This study is a prototype for how we should make decisions about family planning counseling.

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