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Introduction
According to the Report on the Records of Voluntary Termination of Pregnancy (VTP), the total number of pregnancy terminations by the woman's choice in the first 10 weeks was 14 899, corresponding to 96.2% of all abortions performed in Portugal in 2018, with a downward trend since 2012 (DGS, 2019).
In 2007, Law no. 6/84 of 11th May, revoked by Law no. 16/2007 of 17th April, decriminalized VTP in Portugal, when carried out by the woman’s choice in the first 10 complete weeks of pregnancy. The VTP takes place in three stages: the first, prior to consultation where medical proof is found showing the pregnancy does not exceed 10 weeks, followed by a minimum period of three days of reflection, after which, the pregnant woman’s free and informed consent to carry out the procedure is obtained from her or her legal representative; the second stage is the surgical or drug intervention that effectively ends the pregnancy; the final stage consists of a family planning consultation held up to fifteen days after the VTP and the prescription of a contraceptive method (Lei 16/2007).
In Portugal there is easy access to information on contraception and free contraceptives. Contraceptive methods serve to protect women from unplanned and unwanted pregnancies. Health professionals are the most reliable sources of information; however, this is not synonymous with reliability, correct use or even the use of a contraceptive method on the part of women (Águas et. al., 2016). Unwanted pregnancies that culminate in VTP threaten the lives of women with consequences for their health and the opportunity to have a more economically favourable life. Regardless of the reasons given for a VTP, we found the problem stems from method failure, incorrect use and non-adherence to contraception (Palma & Presado, 2019).
The aim of this literature review is to carry out a preliminary analysis of the size and scope of the research literature that allows us to know the impact of contraceptive counselling on the choice of a method of contraception by women experiencing a VTP.
1. Literature review
Abortion is a public health indicator that reflects not only the fertility of the population, but also its accessibility to health services. Although the VTP rate in Portugal is lower than the European average (DGS, 2019), it appears that the accessibility to health services and contraceptive methods is unequal and there is low literacy in sexual and reproductive health among the Portuguese population (Presado et. al., 2018). Despite access to information about contraceptive methods, we continue to see a significant number of unplanned and unwanted pregnancies related to non-adherence, discontinuation and incorrect use of contraceptive methods, as well as unmet needs for family planning (Presado et. al., 2018).
VTP is understood as the termination of an unplanned and unwanted pregnancy, of a normal embryo or foetus, at the woman’s behest without health risks (Sousa, 2016).
The most prevalent age group is 25-29 years (22.6%) and 20-24 years (22.4%), with the average age being 29.03 years, demonstrating an increase in the average age of women who have a VTP (DGS, 2019).
Contraceptive methods allow the woman/couple to control their reproductive process, that is, to have children if and when they wish; however, it is necessary to use them regularly and correctly (OMS, 2016). Oral and injectable hormonal contraceptives are the methods used by 37.7% of women (DGS, 2019) and are also the most widely known in Portugal (Bayer, 2017). Nevertheless, they are the ones that present the biggest problems of irregularity, discontinuation and failures in their use (Bayer, 2017). Of women using contraceptive pills, 84% acknowledge that they have already forgotten the dose and 47% intend to change their method to long-term reversible contraception (Bayer, 2017). Long-acting reversible contraceptives (LARC, which include the intrauterine system (IUS), intrauterine device (IUD) and subcutaneous implant) are considered the most effective contraceptives in reducing the incidence of unplanned pregnancies, have fewer side effects and increase user satisfaction and continuity (Secura et. al., 2014), although they are not the most commonly used contraceptive methods (37.4%) in Portugal (DGS, 2019).
When cost, access and knowledge barriers are overcome, women choose the most effective and least user-dependent methods, as is the case with LARC. They not only choose them, but continue to use them satisfactorily, avoiding unintended pregnancy (Secura et al, 2014).
Encouraging the use of LARC may imply the reduction of unwanted pregnancy and VTP rates, translating into better economic, financial, educational and social conditions for women and families (Secura et. al., 2014).
The experience of a VTP promotes awareness of the imminent return of fertility and the concern to look into effective contraceptive alternatives, which is why it is an opportune time for contraceptive counselling. In the post-VTP period, the method’s receptivity, adherence, continuity and satisfaction rate is high, increasing the likelihood of continuity of use (Schunmann & Glasier, 2016; Temmerman, 2019).
Health professionals play a decisive role in health education in family planning after a VTP (Pereira et. al., 2018), promoting the empowerment of women and partners in the informed and conscious choice of the contraceptive method suitable for their needs, expectations and life choices.
We consider contraceptive counselling when guidance on contraception is provided by a health professional in order to empower the woman to make a conscious decision and adhere to a contraceptive (Palma & Presado, 2019).
The aim of this systematic review is to understand the impact of contraceptive counselling on women’s choice of contraceptives during their experience of VTP.
2. Methods
A systematic literature review was performed according to the recommendations of the Joanna Briggs Institute (JBI) Reviewer’s Manual, 1 to 31 January (Palma et. al., 2020), and repeated from 2 to 5 October, 2020, with the aim of gathering the available evidence, according to the pre-specified eligibility criteria and to answer a specific question: “What is the impact of contraceptive counselling given to women undergoing VTP on the choice of method?” The following was considered in the research: P (Patients) = Women in the process of Voluntary Termination of Pregnancy, I (Intervention) = Advice on contraceptive methods; C (Comparison) = Between “Advice” versus “Non-advice”, O (Outcome) = Rate of use of contraceptives and adherence to contraceptives.
The stages followed in this systematic review were: defining the research question and inclusion criteria, research and selection of studies, data collection, assessment of the methodological quality of the studies included, data analysis, identification of biases, summarization and presentation of results, their interpretation and presentation of the conclusions.
2.1 Inclusion and Exclusion Criteria
Thus, the following inclusion and exclusion criteria were defined:
2.2 Research Methods and Strategy
The research strategy was developed according to the three stages defined by the JBI for the systematic review of the literature: a) initial research in databases relevant to the topic; b) search with keywords and terms indexed in selected databases; c) analysis of the references of selected articles to select additional sources.
The initial search was carried out on the ESBCO platform, in the CINAHL, MedLine, MedicLatina and Cochrane Central Register of Controlled Trials databases. The research was carried out by analysing the keywords contained in the titles, abstracts and indexed terms used to describe the articles.
According to the objective, the following descriptors were used: MH “Women”; MH “Contraceptive Devices”; MH “Contraceptive Agents”; MH “Family Planning Services”; MH “Abortion Induced”; “Post Abortion Contraception”; “Family Planning counselling”; “Contraceptive counselling”.
A second search was carried out with all the terms of the question (natural and indexed) in the databases mentioned. In the last stage, the terms found and the Boolean operators “OR” and “AND” were used. The database search strategy was as follows: (MH “Contraceptive Devices” OR MH “Contraceptive Agents” OR MH “Family Planning Services” OR “Post Abortion Contraception”) AND (MH “Women”) AND (MH “Abortion Induced”) AND (“Family Planning counselling” OR “Contraceptive counselling”).
In the third stage, we searched and analysed the bibliographic references of eligible articles in order to identify additional studies.
The methodological quality of the studies was assessed using the instruments recommended by the JBI (2015), namely: “Meta-Analysis of Statistics Assessment and Review Instrument (MAStARI) critical appraisal tools Comparable Cohort/Case Control Studies” and “MAStARI critical appraisal tools Descriptive/Case Series Studies”. The “MAStARI critical appraisal tools Randomized Control/Pseudo-randomized Trial” was also used. Only studies with a high level of quality, a score greater than or equal to 7, were included.
3. Results
In the survey conducted in October, no more articles were included for the selected eligibility criteria. There was a focus on studies related to the impact of the COVID-19 pandemic on access to contraceptive services. Sixty-nine articles emerged in the study selection process, six of which were excluded for being in duplicate, thirty-four after reading the title and abstract, and eighteen articles for not meeting the inclusion criteria. Eleven articles were considered eligible for analysis, after evaluating the inclusion and exclusion criteria described. Titles and abstracts identified from the search were independently reviewed by reviewers. After the selection of the articles, a continuous record was kept and coordinated by the authors with the main information of the studies/articles found. A summary of relevant data collected from each article was written taking into consideration the JBI guidelines. It consisted of the following items: identification of the article, purpose of the study, characterization of the counselling intervention, characterization of the target population, and intervention results.
The eleven articles are primary studies written between 2014 and 2020. They were all in English and conducted in the United States (four), Asia (three), Africa (two), Europe (one) and Australia (one). Sample sizes ranged from 29 to 319,385 women. The studies included had a high level of quality (Table 1), with a score greater than or equal to 7 (six scoring 10, two scoring 9, one scoring 8 and two scoring 7), and those with a low level of quality were excluded (Palma et. al., 2020).
Figure 1 Flow Diagram Summary of Research Performed. Adapted from PRISMA Flow Diagramfor Systematic Review process of Literature in JBI (2015)
After selecting the articles, a continuous record was kept and coordinated by the reviewers with the main information of the studies/articles found. In table 2, it is possible to find a summary of the relevant data collected from each article considering the guidelines of the Joanna Briggs Institute.
According to the Joanna Briggs Institute (2015) methodology, the extracted data should reflect the objectives and research question. They will be presented in narrative form and in Portuguese.
Of the articles eligible for analysis (Palma et. al, 2020), the studies were found to be intended: to describe the characteristics of the population (Tomnay et. al., 2018); to obtain the outcomes of post-abortion contraceptive counselling interventions (Benson et. al., 2018; Tomnay et. al., 2018; Wendot et. al., 2018) and compare them with rates of unwanted pregnancies (Madden et. al., 2019); to report strategies for better contraceptive counselling (Mugore et. al., 2016; Che et. al., 2017); to determine what type of counselling is provided by health professionals regarding contraception and contraceptive methods (Merki-Feld et. al., 2018) and evaluate them post-VTP (Tang et. al., 2017); to describe the rate of adherence to contraception after abortion and the factors that influence this adherence (Pearson et. al., 2017); to present the relationship between provision of contraceptives after VTP and adherence (Laursen et. al., 2017); to find the differences in contraceptive counselling and choices in contraceptive method post-VTP (Rocca et. al., 2018).
4. Discussion
Evidence tells us that the contraceptive profile of women before undergoing VTP is that the vast majority do not use contraception, followed by those who use the contraceptive pill, with a residual percentage of those who use emergency contraception, condoms, injectable hormone and implant (Tomnay et. al., 2018). Studies tell us that most women choose a contraceptive after VTP (Tomnay et. al., 2018; Wendot, et. al., 2018; Merki-Feld et. al., 2018).
In a sample of 152 women, 21 (10.8%) did not start any type of contraception after VTP, 66 (33.8%) opted for the contraceptive pill, 27 (13.8%) for the contraceptive implant, 18 (9, 2%) for the IUD, 17 (8.7%) for the injectable hormone, 3 (1.5%) chose the contraceptive ring, the partner of 8 (4.1%) underwent vasectomy, 7 (3.6%) resorted to condoms and 1 (0.5%) opted for natural methods (Tomnay et. al., 2018).
Other studies corroborate that 73% of women adopted a contraceptive after VTP, divided among injectable hormone (30%), contraceptive pill (29%), condom (14%) and a residual number chose the IUD (9%) (Benson et. al., 2018). Wendot et. al. (2018) added that 6.4% did not use contraception after VTP, 76% chose the contraceptive pill and 16.2% chose more effective methods such as LARC.
It appears that the proportion of choice and adherence to IUDs increases with age (Tomnay et. al., 2018) and marital status (married) (Che et. al., 2017), being low in women below the age of 25 (Benson et. al., 2018). It was also found that there are differences in the choice of LARC in different countries with their use varying between 7% in Portugal and 38% in France (Merki-Feld et. al., 2018).
It is recognized that contraceptive counselling leads to increased adherence to contraceptive methods from 37% to 60%, with contraceptive pills (32%) and contraceptive implants (27%) being the most commonly selected. The IUD was selected by 9% of women and this percentage may be associated with the fact that not all counselling centres have this contraceptive (Mugore et. al., 2016). Evidence shows us that contraceptive counselling should be centred on the needs of women undergoing VTP (Pearson et. al., 2017) and that adherence to contraceptive methods is related to the quality of information transmitted in counselling consultations (Che et. al., 2017). Contraceptive counselling on effective and modern methods such as LARC (Madden et. al., 2019), accessibility to family planning consultations, health education by trained professionals (Che et. al., 2017) and support for contraceptive costs were strategies able to reduce the likelihood of women being exposed to an unplanned pregnancy by up to 40% (Madden et al., 2019). Most women (60%) showed an interest in receiving more information about contraception, with 73% admitting to considering the application of a LARC (Merki-Feld et. al., 2018) and 76.2% adopted a contraceptive after VTP (Pearson et. al., 2017).
Women who underwent surgical VTP showed greater adherence to contraception than those who underwent medical VTP (83% versus 64.6%). The same happened with the choice of a LARC (41.9% versus 23.3%) (Laursen et. al., 2017). Nevertheless, it is believed that this fact was due to the accessibility of health services (Rocca et. al., 2018).
The health professionals who make up the VTP teams are receptive to promoting contraceptive counselling (92%), but only 57% spend more than ten minutes on this. Professionals with more training spend more time in counselling, influencing the quality of counselling provided (Tang et. al., 2017). The authors argue that training health professionals in family planning as an integral part of the VTP process is essential to provide quality contraceptive counselling.
Conclusion
With this Systematic Literature Review, we intend to gather information that will allow us to show the available literature on post-abortion contraception counselling, in order to launch action strategies based on the problem.
In the available literature on post-abortion contraceptive counselling, eleven studies published between 2014 and 2020, published in the United States (four), Asia (three), Africa (two), Europe (one) and in Oceania (one) were identified. No articles on this topic in Portuguese were found, which shows that there is a dearth of Portuguese studies that address this issue and, therefore, a lack of investment in it.
Guidelines in contraceptive counselling tend to be less objective from a social/behavioural point of view. There are guidelines focused on the clinical criteria of counselling, but guidelines related to the social and psychological dimensions of women are lacking.
In the evidence found, we demarcated the main conclusions into two large groups: counselling and the choice and adherence to a contraceptive. Regarding counselling, it is worth noting that counselling favours adherence to contraceptive methods in general; counselling favours the prescription of LARC in particular; counselling is not always provided and when it exists it is very heterogeneous; available resources influence response quality; it is often not adapted to the individual; the quality of counselling depends on the qualification of the professional and counselling must be centred on women’s needs.
In the choice and adherence to contraceptives, financing contraceptives favours choosing them and adherence; accessibility to health services influences the choice of methods; surgical VTP favours adherence to contraception and to LARC in particular; the moment of introduction of a contraceptive influences adherence to it, and post-VTP is the ideal time to adhere to a contraceptive.
To sum up, we can infer that LARCs can be considered the first-line choice for women, regardless of age, given the evidence demonstrated in their satisfaction, continuity, economic benefits and superiority in terms of effectiveness over other contraceptives. The period of time experiencing a VTP seems to be an ideal time for counselling, guidance and choice of contraceptive method and should occur from the woman’s first contact with the health services. Health professionals play a paramount role in education for sexual and reproductive health.
We recognize the limitations of this review where we realized that the epidemiological contexts were very different, with highly variable samples, distinct clinical contexts, cultural and social differences and the absence of Portuguese or Portuguese language studies for these eligibility criteria. The psychosocial aspects of women such as the relationship with their partner, the influence of domestic violence, cultural or religious beliefs and emotional experience are hardly discussed in the literature. Likewise, health professionals, in exercising their practice, are subject to the psychosocial context and face challenges that go beyond clinical guidelines.
The authors believe that qualitative research, in the form of verbal or written reports, by both women and professionals, can represent a way to assess the impact of psychosocial issues. In addition, the authors argue that future lines of research should analyse epidemiological contexts of interest (Portugal), with a greater number of VTPs, in order to develop interventions in the field of contraceptive counselling centred on the person and that can serve as a basis for good care practices for these women.
Funding
Bayer supported the development of this manuscript through funding for Medical Writing, provided by an external partner.
