Initiating contraception in sexually transmitted disease clinic setting: a randomized trial

doi:10.1067/S0002-9378(03)00493-9

American Journal of Obstetrics and Gynecology

Volume 189, Issue 2, August 2003, Pages 473-481

https://doi.org/10.1067/S0002-9378(03)00493-9 Get rights and content

Abstract

OBJECTIVE: Our purpose was to determine the effectiveness of sexually transmitted disease (STD) clinic–initiated contraceptive care.

STUDY DESIGN: Nonpregnant women (n = 877) attending an urban STD clinic using either no contraception or only condoms were randomly assigned to either an intervention (n = 437) or control group (n = 440). Both groups received condoms with spermicide and a referral list of primary care providers (PCP) for ongoing reproductive health care, and the intervention group also received enhanced contraceptive counseling, initial provision of contraception, and facilitated referral to a PCP. Outcomes measured at 4-, 8-, and 12-month follow-up were transition to a PCP, effective contraceptive use (ECU), interval pregnancy, and STD.

RESULTS: The median time to PCP transition was 79 days for the intervention group versus 115 days for the control group (P = .007). Rates of ECU were higher for the intervention group than for control group at the 4-month visit (50% vs 22%, P<.0001) as well as the 8-month visit, although in the intervention group ECU diminished over the course of the study. During follow-up, pregnancy outcomes were documented for 229 women (26.1%), for an overall pregnancy rate of 38.2 per 100 person-years of follow-up. Of the 159 pregnancies defined by patient self-report, 153 (96.2%) were described as unintended and 32 (20%) resulted in a therapeutic abortion. The pregnancy rate was 15% lower in the intervention (105/437, 24.0%) than the control group (124/440, 28.2%) (P = .16), but this difference was not statistically significant.

CONCLUSION: The intervention helped women transition to a PCP and initiate ECU but did not significantly reduce the pregnancy rate. More intensive interventions are needed to prevent unintended pregnancy in this high-risk population.

Section snippets

Sample selection and design

The study was conducted at the Denver Metro Health Clinic (DMHC), the STD clinic operated by Denver Public Health. The DMHC is a readily accessible and confidential facility offering free comprehensive, walk-in services for diagnosis, treatment, management, and prevention of STD. Services are provided to all interested persons, regardless of county of residency; there are between 15,000 and 18,000 patient visits per year.

Women with a new problem who identified themselves as being residents of

Baseline characteristics

From December 1996 through January 2000, a total of 7305 women were screened for possible enrollment into the study, of whom 1909 (26.1%) were eligible for participation, with 877 (45.9%) agreeing to participate. The demographic and clinical characteristics of the 877 women who enrolled are outlined in Table I. The majority of patients were ≤24 years old (40.1% ≤19 years old, 35.8% 20-24 years old, and 24.1% ≥25 years old) and of nonwhite ethnicity (white 39.5%, African American 26.1%, Hispanic

Comment

In this randomized controlled study among women not using contraceptives attending an STD clinic, we evaluated the effectiveness of clinic-initiated contraceptive care followed by facilitated referral to a PCP for improving the establishment of contact with a PCP, the use of an effective method of contraception, and the rate of overall and unintended pregnancy. Our results indicate an initial benefit to the intervention, with patients in the intervention transitioning to a PCP earlier than

Acknowledgements

We thank Jennifer Garduno, research assistant for the study, and Cathy Cunningham for her administrative assistance. We thank Sherry Wiggins, RN, nurse manager of the DMHC as well as all the STD clinicians for their support of the study and all the patients who participated in the project.

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Contraceptive Counseling in Clinical Settings: An Updated Systematic Review
2018, American Journal of Preventive Medicine
Citation Excerpt :
New components that emerged from the updated evidence that resulted in some statistically significant positive effects include an emphasis on shared decision making,15 asking about the patient's reproductive life plan/pregnancy intentions,13 and discussion of contraceptive methods by level of effectiveness.13,22 Across the cumulative body of evidence, seven of the counseling interventions that had a significant impact on multiple outcomes15,22,24,26,32,35,40 included at least one of these promising components. This body of evidence has several limitations.
The objective of this systematic review was to update a prior review and summarize the evidence (newly identified and cumulative) on the impact of contraceptive counseling provided in clinical settings.
Multiple databases, including PubMed, were searched during 2016–2017 for articles published from March 1, 2011, to November 30, 2016.
The search strategy identified 24,953 articles; ten studies met inclusion criteria. Two of three new studies that examined contraceptive counseling interventions (i.e., enhanced models to standard of care) among adolescents and young adults found a statistically significant positive impact on at least one outcome of interest. Five of seven new studies that examined contraceptive counseling, in general, or specific counseling interventions or aspects of counseling (e.g., personalization) among adults or mixed populations (adults and adolescents) found a statistically significant positive impact on at least one outcome of interest. In combination with the initial review, six of nine studies among adolescents and young adults and 16 of 23 studies among adults or mixed populations found a statistically significant positive impact of counseling on at least one outcome of interest.
Overall, evidence supports the utility of contraceptive counseling, in general, and specific interventions or aspects of counseling. Promising components of contraceptive counseling were identified. The following would strengthen the evidence base: improved documentation of counseling content and processes, increased attention to the relationships between client experiences and behavioral outcomes, and examining the comparative effectiveness of different counseling approaches to identify those that are most effective.
This article is part of a theme issue entitled Updating the Systematic Reviews Used to Develop the U.S. Recommendations for Providing Quality Family Planning Services, which is sponsored by the Office of Population Affairs, U.S. Department of Health and Human Services.
Impact of Contraceptive Counseling in Clinical Settings: A Systematic Review
2015, American Journal of Preventive Medicine
Citation Excerpt :
Promising components that emerged from the studies in this systematic review include an emphasis on the quality of interaction between counselor and client (e.g., developing rapport)15,19,28,31; personalizing discussions to meet clients’ individual needs23,28,32,33,35; and addressing psychosocial determinants of contraceptive use behaviors (e.g., perceived benefits and barriers, outcome expectations).22,23,28,32,36 Other promising components include setting goals; discussing possible difficulties with achieving goals (e.g., side effects, difficulty obtaining the method); developing action plans to deal with potential difficulties15,22,23,27; and multiple contacts with clients.15,17,19,33,36 When examining the number of outcomes positively impacted by a single counseling intervention in studies included in this systematic review (Tables 2 and 3), it is not surprising that all five19,28,33,35,36 interventions for which a significant impact on multiple outcomes was detected included one,35 two,19,33,36 or three28 of the promising components.
This systematic review evaluated the evidence on the impact of contraceptive counseling provided in clinical settings on reproductive health outcomes to provide information to guide national recommendations on quality family planning services.
Multiple databases were searched during 2010–2011 for peer-reviewed articles published in English from January 1985 through February 2011 describing studies that evaluated contraceptive counseling interventions in clinical settings. Studies were excluded if they focused primarily on prevention of HIV or sexually transmitted infections, focused solely on men, or were conducted outside the U.S., Canada, Europe, Australia, or New Zealand.
The initial search identified 12,327 articles, of which 22 studies (from 23 articles) met the inclusion criteria. Six studies examined the impact of contraceptive counseling among adolescents, with four finding a significant positive impact on at least one outcome of interest. Sixteen studies examined the impact of counseling among adults or mixed populations (adults and adolescents), with 11 finding a significant positive impact on at least one outcome of interest.
Promising components of contraceptive counseling were identified despite the diversity of interventions and inability to compare the relative effectiveness of one approach versus another. The evidence base would be strengthened by improved documentation of counseling procedures; assessment of intervention implementation and fidelity to put study findings into context; and development and inclusion of more RCTs, studies conducted among general samples of women, and studies with sample sizes sufficient to detect important behavioral outcomes at least 12 months post-intervention.
Pregnancy After Cardiac Transplantation
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Contraceptive needs of women seeking care from a publicly funded sexually transmitted infection clinic
2010, Contraception
To determine the contraceptive needs [including emergency contraception (EC)] of women seeking care from a publicly funded sexually transmitted infection (STI) clinic and to better understand women's knowledge of and attitudes towards EC.
An anonymous survey was administered to 197 women seeking services at one Chicago Department of Public Health STI clinic.
After excluding women unlikely to become pregnant within the next year because of age, sexual orientation, hysterectomy and those who desired pregnancy (n=47), data from 150 women were available for analysis. Thirteen percent were using “very effective” contraception (intrauterine contraception, implant or sterilization) and 26% were using “effective” contraception (contraceptive pill, patch, ring or injectable). Approximately 23% (95% CI 16.5–30.0%) may have benefited from immediate use of EC as they reported at least one act of unprotected intercourse within the past 5 days.
Many women seeking care from public STI clinics are at high risk of unintended pregnancy. A substantial number of women have an immediate need of EC at the time of their clinical visit. Efforts are needed to improve provision of EC as well as effective ongoing contraception for this population.
Reasons for Unprotected Intercourse in Adult Women: A Qualitative Study
2007, Journal of Midwifery and Women's Health
Citation Excerpt :
However, there is little information in the literature about reasons why adult women have unprotected intercourse that puts them at risk for an unintended pregnancy. As a result, interventions are often based on empirical decisions about reasons for non-use of contraception and have met with indifferent results.6,7 We hypothesized that a better understanding of the reasons for unprotected intercourse could provide a better foundation for interventions.
Despite the focus on adolescents, most unintended pregnancies occur in adults. The objective of this study was to identify reasons why adult women have unprotected intercourse when they do not desire pregnancy. We held 4 focus groups to explore reasons for unprotected intercourse. Participants were adult women aged 18 to 39 who were unmarried, fertile, not currently pregnant, not desiring pregnancy, and who had recently had intercourse without using effective contraception. Sessions were audiotaped and transcripts were analyzed thematically. Women gave 146 reasons for unprotected intercourse. Four major categories emerged: method-related, user-related, partner-related, and cost/access-related reasons. The reasons for unprotected intercourse were numerous, but could be organized into a logical framework. The results suggest that multidimensional interventions may be needed to effectively reduce the rate of unintended pregnancy.
Teen Pregnancy and Sexually Transmitted Diseases: Re-thinking the Bedfellow Question Means that Condoms will Never Be Seatbelts
2006, Journal of Pediatric and Adolescent Gynecology

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^☆: Supported by grant No. R01 HD35037 from the National Institute of Child Health and Human Development, National Institutes of Health.

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Initiating contraception in sexually transmitted disease clinic setting: a randomized trial☆

Abstract

Section snippets

Sample selection and design

Baseline characteristics

Comment

Acknowledgements

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Pediatr Clin North Am

Unintended pregnancy in the United States

Fam Plann Perspect

Sexually transmitted diseases and family planning: strange or natural bedfellows, revisited

Sex Transm Dis

Contraceptive needs and practices among women attending an inner-city STD clinic

Am J Public Health

Prevalence of selected maternal behaviors and experiences, pregnancy risk assessment monitoring system (PRAMS), 1999

MMWR Morb Mortal Wkly Rep

STDs and family planning clinics: a regional program for chlamydia control that works

Am J Gynecol Health

Reproductive health practices in women attending an inner-city STD clinic

Sex Transm Dis

Family planning in genitourinary medicine: an opportunistic service?

Genitourin Med

Analysis of incomplete multivariate data