European Journal of Obstetrics & Gynecology and Reproductive Biology
ReviewMotivational interviews to improve contraceptive use in populations at high risk of unintended pregnancy: a systematic review and meta-analysis
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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