Review
Motivational interviews to improve contraceptive use in populations at high risk of unintended pregnancy: a systematic review and meta-analysis

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Abstract

Objective

Effective contraceptive use has the potential to prevent around 230 million births each year. An estimated 222 million women want to delay pregnancy or cease childbearing, but are not actively using contraception. Lack of education is a known barrier for effective contraceptive use. Motivational interviews are presumed to improve effective contraceptive use, but studies to date report varied findings. Some studies demonstrate an improvement and others report no effect.

Study design

A systematic review of evidence on the impact of motivational interviews on contraceptive use in women of childbearing age was carried out using MEDLINE, EMBASE, BNI, Cochrane library, CINHAL, African Index Medicus, Web of Science, the Reproductive Health Library, and the Science Citation Index (inception-January 2013) without language restriction. Search terms included ‘motivational interview* AND contraception OR family planning OR maternal OR pregnancy’. Randomised controlled trials comparing the effect of motivational interviews with standard practice on effective contraception use in women of reproductive age were included. The outcome measures were use of effective contraception or use of high-level contraception, and subsequent births or pregnancies. The random effects model was used to pool the risk ratios from individual studies.

Results

Eight randomised controlled trials were included in the review with a total of 3424 women at high risk of pregnancy. Meta-analysis showed an increase in effective contraceptive use with motivational interviews when compared with control (RR 1.32 95%CI 1.11, 1.56: P = 0.002) in the period of zero to four months post intervention. No difference in effective contraceptive use was shown at four to eight months (RR 1.10, 95%CI 0.93, 1.32: P = 0.27), and between eight to twelve months (RR 1.18 95%CI 0.96, 1.46: P = 0.12). No evidence of effect in the reduction of subsequent pregnancies or births at twelve to twenty-four months was seen with motivational interviews (RR 0.80 95%CI 0.51, 1.26: P = 0.34).

Conclusion

Motivational interviews significantly increase effective contraceptive use immediately after and up to four months post-intervention. The effect without reinforcement is short lasting as no evidence of effect is seen after four months post-intervention.

Introduction

An estimated 222 million women want to delay pregnancy or cease childbearing, but are not actively using contraception [1]. Known barriers to contraceptive use are inadequate contraceptive education, social constraints or opposition against contraceptive use [1], and the side effects of some contraceptive methods [2]. Consistent and effective use of contraceptives can also be problematic, as good compliance with some methods has been demonstrated to be low in some regions [3]. Research has demonstrated that half of women using oral contraceptives (48.5%) use this method incorrectly, thus resulting in an unintended pregnancy [3].

Effective family-planning can empower women. It can also directly reduce the incidence of maternal deaths by preventing around 230 million potential births each year [4]. The maternal mortality ratio in the USA has increased within the last two decades from 12 maternal deaths per 100,000 live births in 1990, to 21 maternal deaths per 100,000 live births in 2010. Globally, the maternal mortality ratio of industrialised countries has also risen by 2% between 1990 and 2010 [5]. Reducing rates of unintended pregnancies through effective family-planning reduces the need for unsafe abortion, and the morbidity and mortality associated with this procedure. Effective family-planning also has the potential to benefit the wider community, as it can reduce poverty and malnutrition, particularly in regions where poverty and food security problems are present [6].

Despite the barriers the global use of modern contraceptive use has increased with a rise from 54% in 1990 to 57% in 2012 [4]. However, the level of unmet need for contraception (definition in Box 1) remains high [7]. It is estimated that in 2015, 153 million women globally will have an unmet need for contraception, of which 138 million women will be in developing countries [7].

The use of behavioural and theory based interventions to improve contraceptive uptake and contraceptive compliance have recently been addressed [8], [9], [10]. Motivational interviews are a counselling approach that aims to facilitate and engage the participants’ intrinsic motivation to change their behaviour. When compared with non-directive counselling, motivational interviewing is suggested to be more goal-orientated and more participant-centred. Motivational interviewing encourages the participant to think about the changes that could be made, rather than the counsellor offering suggestions. The key concepts of motivational interviews are the participant recognising and accepting the need to make changes in their lives; this approach encourages the participants to consider their readiness to change their behaviour [11], [12]. For this reason motivational interviews are commonly associated with targeting changing addictive behaviours, [13], [14], [15], [16], [17] and they have recently been used with adolescents [18] and pregnant women [19], [20], [21]. However, the evidence of their effectiveness to improve contraceptive use includes conflicting findings, with some studies reporting an improvement and others reporting no effect. This systematic review and meta-analysis were performed to examine the effects of motivational interviews on effective contraceptive use when compared with standard practice.

Section snippets

Materials and methods

Databases were searched for randomised controlled trials investigating the effects of using motivational interview to improve effective contraceptive use. We searched MEDLINE, EMBASE, BNI, Cochrane library, CINHAL, ASSIA, African Index Medicus, the Reproductive Health Library, and the Science Citation Index (from database inception to January 2013). Hand searching complemented electronic searches, and reference lists were checked. The search terms were ‘motivational interview* AND contraception

Results

The processes of literature search and selection are provided in Fig. 1. Eight randomised controlled trials were included in the review with a total of 3424 women at high risk of pregnancy.

Comment

Motivational interviews appear to significantly improve effective contraceptive use between zero to four months, but effects are reduced with time. There appears to be no difference in subsequent pregnancies or births at the two year period as measured at one year and two years post intervention, although only two studies reported this outcome. There was moderate to high statistical heterogeneity in all analyses, as well as clinical heterogeneity within the intervention arms within the trials.

Conflicts of interest

We declare that we have no conflicts of interest.

Authors’ contribution

A. Wilson conceived the systematic review, performed the literature search, and the study selection. AW performed the data extraction, data analysis, data interpretation and discussion. Quality assessment of the studies and risk of bias was also completed by AW.

K. Nirantharakumar performed the study selection, the data extraction, provided critical input and E.G. Truchanowicz, C. MacArthur and A. Coomarasamy provided critical input. R. Surenthirakumaran undertook quality assessment of the

Funding

Ammalife supported the cost of the research fellow AW (www.ammalife.org, UK registered charity number 1120236).

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