Ways to improve use of hormonal birth control

Hormonal types of birth control are used by many women worldwide. The most common hormonal methods are birth control pills and injections. These methods often do not work as well as they could. Women may have problems using the birth control as planned. They may miss taking some pills. Other women may stop using a method due to bleeding changes. This review looked at whether more counseling or reminders helped women use these types of birth control.

Through August 2013, we did computer searches for randomized trials comparing special counseling with usual counseling. In addition, we looked at reference lists to find trials. We also wrote to researchers to find more studies.

We found nine trials. Five studies counseled women about the method and its side effects. Four trials focused on reminders for appointments or pill-taking, but two also provided health information. Three trials showed some positive results. One study gave structured counseling about an injected type of birth control. More women who got the structured counseling kept using the birth control than women who had the usual counseling. Also, fewer women who had the structured counseling stopped using the birth control due to bleeding changes. Another study gave special counseling with or without follow-up calls. In the short-term, more women with counseling and phone calls said they took the birth control pills regularly than those without phone calls or those with usual care. The third study sent text-message reminders to cell phones about birth control pills plus health information. More women in the text-message group were still taking their pills at six months than women with standard care.

Only three studies showed better results with the special counseling or reminders. Four trials had few women in them and six lost many women during the study. The studies had moderate quality data. To prevent pregnancy, women should use birth control as planned and should keep using it. More trials of good quality are needed to learn how to help women use their birth control method.

Authors' conclusions: 

Only three trials showed some benefit of strategies to improve adherence and continuation. However, several had small sample sizes and six had high losses to follow up. The overall quality of evidence was considered moderate. The intervention type and intensity varied greatly across the studies. A combination of intensive counseling and multiple contacts and reminders may be needed to improve adherence and acceptability of contraceptive use. High-quality RCTs with adequate power and well-designed interventions could help identify ways to improve adherence to, and continuation of, hormonal contraceptive methods.

Read the full abstract...

Worldwide, hormonal contraceptives are among the most popular reversible contraceptives. Despite their high theoretical effectiveness, typical use results in much lower effectiveness. In large part, this disparity reflects difficulties in adherence to the contraceptive regimen and low rates for long-term continuation.


The intent was to determine the effectiveness of ancillary counseling techniques to improve adherence to, and continuation of, hormonal methods of contraception.

Search strategy: 

Through August 2013, we searched computerized databases for randomized controlled trials (RCTs) comparing client-provider interventions with standard family planning counseling. Sources included CENTRAL, MEDLINE, EMBASE, POPLINE, ClinicalTrials.gov and ICTRP. Earlier searches also included LILACS, PsycINFO, Dissertation Abstracts, African Index Medicus, and IMEMR.

Selection criteria: 

We included RCTs of an intensive counseling technique or other client-provider intervention compared to routine family planning counseling. Interventions included group motivation; structured, peer, or multi-component counseling; and intensive reminders of appointments or next dosing. Outcome measures were discontinuation, reasons for discontinuation, number of missed pills or on-time injections, and pregnancy.

Data collection and analysis: 

One author evaluated the titles and abstracts from the searches to determine eligibility. Two authors extracted data from the included studies. We calculated the Mantel-Haenszel odds ratio (OR) for dichotomous outcomes. For continuous variables, the mean difference (MD) was computed; RevMan uses the inverse variance approach. For all analyses, 95% confidence intervals (CI) were also computed. Since the studies identified differed in both interventions and outcome measures, we did not conduct a meta-analysis.

Main results: 

Nine RCTs met our inclusion criteria. Five involved direct counseling; of those, two also provided multiple contacts by telephone. Four other trials provided intensive reminders, two of which also provided health education information. Three trials showed some benefit of the experimental intervention. In a counseling intervention, women who received repeated structured information about the injectable depot medroxyprogesterone acetate (DMPA) were less likely to discontinue the method by 12 months (OR 0.27; 95% CI 0.16 to 0.44) than women who had routine counseling. The intervention group was also less likely to discontinue due to menstrual disturbances (OR 0.20; 95% CI 0.11 to 0.37). Another trial showed a group with special counseling plus phone calls was more likely than the special-counseling group to report consistent use of oral contraceptives (OC) at 3 months (OR 1.41; 95% CI 1.06 to 1.87), though not at 12 months. The group with only special counseling did not differ significantly from those with standard care for any outcome. The third trial compared daily text-message reminders about OCs plus health information versus standard care. Women in the text-message group were more likely than the standard-care group to continue OC use by six months (OR 1.54; 95% CI 1.14 to 2.10). The text-message group was also more likely to avoid an interruption in OC use longer than seven days (OR 1.53; 95% CI 1.13 to 2.07).

Health topics: