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Improving contraceptive compliance through an evidence-based educational program

Lee, Amy S.D.

Journal of Evidence-Based Women’s Health Journal Society: February 2014 - Volume 4 - Issue 1 - p 40–46
doi: 10.1097/01.EBX.0000440887.46582.6b
Original articles

Objective Over 50% of pregnancies in the USA are unintended. A comprehensive contraceptive education program that promotes the patient-provider relationship can promote contraceptive compliance and potentially decrease unintended pregnancies.

Study design This evidence-based contraceptive educational program was accomplished through the use of an educational demonstration board that displayed and explained the various birth control methods available. The healthcare provider educated the patient on each option, allowing the patient to touch the methods and ask questions. The patient was sent home with a pamphlet about the information presented.

Patients and methods The Obstetrics and Gynecology outpatient clinics at a large suburban teaching hospital served as the setting for this project. Fertile women aged 12–50 years who were deemed at risk of unintended pregnancy were the considered candidates for the educational intervention. The participants were selected and asked to participate by the clinical provider.

The clinical provider conducted the education session with individual patients. Once the education session was complete, the participant was asked to complete the six-item ‘Satisfaction With Decision Scale’. A higher score on the scale has been shown to directly correlate with increased levels of compliance with the decision made.

Results Approximately 70% of women who do not desire pregnancy are usually compliant with a contraceptive method. After the contraceptive educational program, the Satisfaction With Decision Scale scores demonstrated a predicted 96.66% percent rate of contraceptive compliance.

Conclusion This educational intervention resulted in a significant increase in predicted contraceptive compliance. Improved contraceptive compliance correlates with fewer unintended pregnancies.

Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, Maryland, USA

Correspondence to Amy S.D. Lee, DNP, ARNP, WHNP-BC, Department of Gynecology and Obstetrics, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287, USA Tel: +1 410 283 7502; fax: +1 410 502 1142; e-mail:

Received October 30, 2013

Accepted November 20, 2013

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Over 50% of pregnancies in the USA today are unintended. An unintended pregnancy is one that is unplanned, mistimed, or undesired. This was true in 2001 when the USA set a goal for 2010 of decreasing unintended pregnancies to 30% 1. Despite this endeavor, the rate continues to be almost half of all pregnancies 2. Unintended pregnancy numbers in 1995 were around three million pregnancies annually 3. Unfortunately, that number remains mostly stagnant at around 3.2 million annually. Unintended pregnancy in the USA is significantly higher than that of many other equally developed nations 4. The average American woman may spend decades avoiding pregnancy. Yet data suggest that women who do not desire to be pregnant still practice contraception poorly or may not use contraception at all 5. Nearly 11% of women who do not desire to be pregnant do not utilize any form of contraception. These women account for nearly 50% of the unintended pregnancies. Another 19% of women who do not desire to be pregnant will use contraception inconsistently or incorrectly 4. A wide range of explanations exists for this contradiction including personal belief systems, past experiences, fears of side effects, partner influences, cultural influences, and problems with access to methods 5. Only 5% of unintended pregnancies are due to true contraceptive failure 4.

Forty-eight percent of all women between the ages of 15 and 44 years have had at least one unintended pregnancy 3. Unintended pregnancy births often result in negative maternal and child health outcomes including delayed prenatal care, premature birth, and negative mental and physical effects. Sixty-four percent of publicly funded births are unintended, whereas nearly half of the unintended pregnancies are terminated 4. Those that continue are at risk of seeking late prenatal care, low birth weight of neonates, child abuse and neglect, children with behavioral problems, and lower educational and economic status for the mothers 3. Teen mothers are less likely to complete their education and more likely to live in poverty 1. The medical, emotional, social, and financial costs of unintended pregnancies to women and the society are appreciable 3.

A literature review of the evidence regarding prevention of unintended pregnancy through contraceptive education and compliance revealed two central themes. These two themes were the need for contraceptive education and the influence of the relationship between the healthcare professional and the patient. The literature revealed a central influence by these factors over contraceptive compliance.

The first theme, the need for contraceptive education, was apparent in eight of the studies reviewed. Gemzell-Danielsson et al.6 concluded that structured educational counseling did indeed facilitate the choice of method for most women, whereas Frost et al.5 found that many methods may be undertaken to improve contraceptive use that would require simple changes in educational practices. The study by Raine et al.7 highlighted the need for educational interventions regarding contraceptive methods, and Schrager and Hoffman 8 found that more effective education should be developed. Little et al. 9 concluded that educational interventions are as important as sociodemographic factors in knowledge determination, whereas Harper et al. 10 discovered that more extensive patient education is necessary for successful integration of new contraceptive methods. Oringanje et al.11 concluded that a combination of educational and contraceptive interventions does indeed reduce unintended adolescent pregnancy rates. Finally, Lopez et al. 12 found that postpartum contraceptive education results in increased contraceptive use and fewer unplanned pregnancies.

The second central theme, the influence of the healthcare professional on the patient, was found in several more studies. Harper et al.10 cross over to the second central theme of provider influence by concluding that the provider could exhibit influence over the patient’s choice through the type of educational counseling provided. Lamvu et al. 13 found that the influence of the healthcare provider was the only factor associated with the consistency between contraceptive choice and the reasons for starting contraception. Dehlendorf et al. 14 concluded that a lack of consistent and accurate contraceptive knowledge by the provider could diminish the care received by the patient significantly and impact the provider’s ability to prevent unintended pregnancy inversely. Hayter 15 determined that contraceptive education requires a skilled practitioner who is flexible and understanding, whereas Akers et al. 16 found that there is a need for improved integration and efficient delivery of contraceptive education at all levels of healthcare. Finally, Frost et al. 17 concluded that providers could assist women in avoiding unintended pregnancy through regular assessments of the method use, better method choice and pregnancy risk counseling, and identification of higher risk women.

A review of the literature on contraceptive education and compliance presents two common themes affecting compliance. These are contraceptive education and provider influence. Nola Pender developed the health promotion model as a way to help nurses understand the major causes of health behaviors, which forms a basis for counseling to promote healthy life choices 18. These two themes with the support of the health promotion model can be utilized as a basis for an interactive educational intervention to answer the question, ‘Does education promote contraceptive compliance in fertile women?’

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Patients and methods

This contraceptive educational program was accomplished through the use of an educational demonstration board that displayed the various birth control methods available and provided information about each. The healthcare provider actively educated the patient on each option, allowing the patient to touch the methods and consider the choice that was best for their situation while answering any questions the patient may have had. The patient was sent home with a pamphlet designed to be reflective of the information presented on the board to refer to later (see Fig. 1). Once the education session was complete, the patient was asked to complete the six-item ‘Satisfaction With Decision Scale’ (SWD).

Patients aged 12–50 years who were deemed at risk of unintended pregnancy in the Obstetrics and Gynecology clinics of a large urban nonprofit teaching hospital were the considered candidates for the educational program offering. The hospital’s primary service area includes the city and surrounding counties. This area accounts for 63.4% of the patient population geographically. The primary service area statistics for education and income are similar to the national average, but the area immediately surrounding the hospital presents dismal statistics related to poverty. Whereas 92% of the population is African-American, 40% is unemployed, and 70% have household incomes below $25 000. More than 19% of the city residents live below the federal poverty line 19. Ninety patients were selected to participate in the project.

Six months before implementation of the contraceptive education program, the Institutional Review Board (IRB) process at the large urban hospital clinical site was initiated. As this is an educational program, the project was appropriate for an expedited review. Under the guidelines of the IRB at the clinical site, verbal consent may be obtained for the project if the project presents minimal risk to the participant and the activity would otherwise not normally require consent. Given these requirements, a request for verbal consent was part of the IRB proposal. Approval from the IRB for an expedited review was obtained and was requested to extend for 1 year, which was well beyond the anticipated project completion.

This contraceptive educational program was accomplished through the use of an educational demonstration board that displayed a sample of each type of the ‘major’ contraceptive headings available to the patients at the clinic: progesterone implant (Nexplanon, Merck, Whitehouse Station, New Jersey, USA), intrauterine devices (IUD’s) (Mirena, Bayer, Whippany, New Jersey, USA and Paragard, Teva Women’s Health, North Wales, Pennsylvania, USA), Essure (Bayer, Whippany, New Jersey, USA), bilateral tubal ligation (Fallope ring), medroxyprogesterone (Depo Provera, Pfizer, New York, New York, USA), combined pills, transdermal patch, vaginal ring, progesterone-only pills, barrier methods, and emergency contraception. The samples were arranged in order of most effective to least effective and attached to the large board. Next to each one there was a blurb that read ‘Typically effective ___ %’, ‘How you use it: ___’, ‘What your friends (or your Mom) might say:___’, ‘What’s the truth:___’, ‘What are the most common side effects:___’. All of this information was found to be important factors to patient compliance in the literature reviewed 20.

During the first week of project implementation, the project was presented to the clinical site and the team of healthcare providers was inserviced on its use. The healthcare providers were considered to be any provider of healthcare to the patient who was responsible for contraceptive education. In this setting, contraceptive education is carried out by nurses, social workers, resident physicians, attending physicians, and advance practice nurses. Inservices on the use of the teaching board were conducted one on one with the nurses, social workers, advance practice nurses, and attending physicians. Resident physicians were instructed and supervised in this setting by attending physicians and advance practice nurses. Therefore, resident physicians received instructions on the board use from previously educated advance practice nurses or attending physicians. The use of the program began immediately after the instruction on its use.

Before using the project resources, the patient was asked to participate in this type of contraceptive education by the provider. If they agreed, a consent script was read to them by the healthcare provider. The teaching board was then presented and reviewed with the patient by the provider. The patient was able to touch each method and ask questions. This interaction helped to facilitate the patient-provider relationship, while allowing the patient to make an informed choice.

There was also a take-home pamphlet that reflected the information on the board (Fig. 1). This pamphlet was a trifold paper that detailed each contraceptive heading in the order of effectiveness. The pamphlet information mirrored the information provided through the educational board. The patient was given this pamphlet to take-home for reinforcement of the face-to-face counseling session.

Figure 1

Figure 1

Once the education session was complete, the patient was asked to complete the six-item SWD. After each patient completed the scale, the scale was collected in an envelope and kept in a secure locked clinic setting with the project board. No patient identification was associated with the scales. Use of the educational board continued for 8–10 weeks. A sample size of 90 women was recruited and all participated.

At the end of 8 weeks, the SWDs were scored. The SWD scale consisted of six questions regarding the patient’s satisfaction with the healthcare choice they made. Answers were given on a scale of 1–5, with 1 being strongly disagree, 2 disagree, 3 neither agree nor disagree, 4 agree, and 5 strongly agree. A higher score on the scale reflected less conflict regarding the decision made 21. Higher satisfaction with the decision made was reflected through higher scores on the scale. This has been shown to directly correlate with increased levels of compliance with the decision 22.

The SWD was developed in the mid-1990s to address the developing patient involvement in their healthcare decisions and as a way to suggest compliance with the healthcare decision made. The six-question scale has undergone extensive reliability and validity testing and will prove a valuable tool in measuring compliance in today’s patient involved healthcare decisions 22. Discriminant validity was determined through a comparison with the SWD and O’Connor’s Decisional Conflict Scale and the Health Status Restriction measure. To establish reliability, 120 women were recruited from the Michigan State faculty for a pilot study. A Cronbach’s α score of 0.88 confirmed reliability. O’Connor 23 and Wills and Holmes-Rovner 24 also confirmed reliability with Cronbach’s α scores of 0.81 and 0.85, respectively. O’Connor 23 verified the discriminant validity by demonstrating its ability to discriminate those desiring a flu shot, whereas Wills and Holmes-Rovner 24 demonstrated the construct validity through a pattern of relationships with other identified measures. Studies by Parhiscar and Rosenfeld 25 and Pipe et al. 26 used the scale to demonstrate that patient satisfaction with their healthcare decision was related to compliance with their treatment regimen. This scale directly correlates with patient compliance 22.

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The survey data were easily converted to give each patient an additive score. If all questions were answered, the lowest score a patient could receive was 6 and the highest possible score was 30. Scores of 22 or higher were in the top third of scoring and were considered more predictive of compliance (Fig. 2). The individual scores were evaluated cumulatively to evaluate the overall promotion of compliance. In the regular population, nearly 11% of women who do not desire to be pregnant do not utilize any form of contraception. Another 19% of women who do not desire to be pregnant will use contraception inconsistently or incorrectly 4. If compliance with a contraceptive method can be improved to greater than 70% of the at-risk population, then this should reflect an improvement in compliance over the national average of contraceptive compliance for women at risk of unintended pregnancy. Predicted contraceptive compliance rates were 96.66%. Given that the average national contraceptive compliance rates are 70%, this reflected an improvement in compliance over national reported compliance levels (Fig. 3). On the basis of this information, the educational intervention appeared to have a positive effect on contraceptive compliance. With improved compliance, the rate of unintended pregnancies will be reduced 1. The significance of the project data came from an improvement in compliance rates of the project population over national reported compliance levels (Fig. 3).

Figure 2

Figure 2

Figure 3

Figure 3

An unanticipated recognition of trends in particular survey responses allowed for further evaluation of individual survey questions to identify possible trends related to contraceptive compliance. With the lowest mean score found in the category related to personal values (a mean of 4.48) and 30% of participants giving this question a score of 4 or lower, it could be suggested that many women experience personal value conflict when making decisions regarding contraception. Addressing this concern with patients may be more important than often realized. The highest mean scores were found in the categories of feeling completely informed (mean of 4.77, 16.7% scoring 4 or lower) and feeling that the decision was theirs to make (mean of 4.74, 19% scoring four or lower). This suggests that the project was successful in comprehensive education of the participants and support of patient choice.

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The purpose of this evidence-based change project was to improve contraceptive compliance through an interactive contraceptive education project as predicted by the SWD. Healthcare providers significantly improve contraceptive compliance through patient education 20. There is a strong influence over contraceptive compliance in women who have had contact and counseling with their healthcare provider 13. Improved contraceptive compliance reduces unintended pregnancy rates 1.

The outcomes of this evidence-based contraceptive education program were evaluated against the national average contraceptive compliance rate of 70% to determine the effectiveness of the program. The SWD was utilized to predict contraceptive compliance rates. Analysis of data received from the SWDs revealed a cumulative project contraceptive compliance rate of 96.66%. This would indicate that the project was effective in improving contraceptive compliance rates in the project participant population.

Further evaluation of SWD results also provided the suggestion that women experience more personal value conflict regarding contraception than perhaps is fully appreciated. This information allows consideration of this aspect when providing effective contraceptive education. Higher average category scores in the area of feeling completely informed and feeling confident of personal choice indicate that the project was successful in adequately educating participants regarding available contraceptive methods and in supporting their choice. Effective contraceptive education promotes contraceptive compliance and ultimately reduces the rate of unintended pregnancies 27.

A higher score on the SWD has been shown to directly correlate with increased levels of compliance with the decision made 22. Although a woman may initially be compliant with her decision, it does not predict as to how long she will be compliant. As contraceptive compliance must be maintained for as long as pregnancy is undesired, there is a potential that compliance may wane over time. It is necessary to reinforce the teaching session at regular intervals to maintain compliance and satisfaction with a chosen contraceptive method. Patients may even choose to change contraceptive methods as their needs change throughout life.

Predicted contraceptive compliance rates after the educational intervention of 96.66% were expected based on the literature support. The increased predicted compliance over the national average of 70% further supports the use of a comprehensive contraceptive interactive education program for all women at risk of unintended pregnancy. Although personal values are known to be a factor affecting contraceptive compliance, it is worth noting that this indication was the lowest mean scoring category, with 30% of the participants scoring 4 or lower, and could represent a significant effect on contraceptive compliance that should be appreciated. The highest mean scores of individual question categories on the SWD were with regard to how informed the patient felt of the information, with only 16.7% scoring a 4 or lower, and, how much they felt the choice was theirs to make, with only 19% scoring a 4 or lower. This supports the validity of the educational aspect of the project and the concept of supported patient choice. This very low cost intervention is easily integrated into routine practice. Involving support staff to further reinforce the teaching message would further create a positive relationship for patients, which would promote increased compliance.

This comprehensive contraceptive education program resulted in improved contraceptive compliance. There were no medical, legal, or financial risks to the participants. Benefits included improved compliance with contraceptive use, resulting in a probable reduction in unintended pregnancies for the participants. A decrease in the unintended pregnancy rate benefits women and society the medically, emotionally, socially, and financially 3.

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Many women who do not desire to be pregnant still practice contraception poorly or may not practice contraception at all 5. With an unintended pregnancy rate in this country around 50%, only 5% of unintended pregnancies are due to true contraceptive failure 4. Decreasing the unintended pregnancy rate requires improved contraceptive compliance 1. Healthcare providers can play a critical role in a patient’s contraceptive education, contraceptive choice, and ultimate contraceptive compliance 20.

A review of the literature provided clear guidance for the development and implementation of a comprehensive contraceptive educational program to improve contraceptive compliance 8. The literature also defined the significance of provider influence over contraceptive choice and compliance. The literature review called for a contraceptive education program that required a knowledgeable skilled clinician who is responsive to patient needs and concerns 15.

The data obtained from the evidence-based change intervention calls for implementation of this type of education for all patients in the clinic at risk of unintended pregnancy. A potential future project to further validate this proposition will be to measure unintended pregnancy rates among the clinic population in the year after implementation of the educational intervention. With improved contraceptive compliance, the rate of unintended pregnancies will be reduced 1.

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Conflicts of interest

There are no conflicts of interest.

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contraceptive compliance; contraceptive education; contraceptive methods; unintended pregnancy

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