Effectiveness of Contraceptive Counseling - Prime Practices to Ensure Quality communication and Enable Effective Contraceptive Use

Effectiveness of Contraceptive Counseling - Prime Practices to Ensure Quality communication and Enable Effective Contraceptive Use

Dr. Sunita Chandra, Dr. Suhani Chandra, Dr. Sangeeta Jain

Background: Contraceptive effectiveness is the leading characteristic for most women when choosing a method, but they often are not well informed about effectiveness of methods. Because of the serious consequences of misinformed choice, Counseling should proactively discuss the most effective methods long-acting reversible contraceptives and permanent methods -using the WHO tiered-effectiveness model.

Objective: The purpose of this study was to evaluate the effectiveness of contraceptive counselling to ensure quality communication and enable effective contraceptive use

Material and methods: One hundred twenty - six postpartum women in the age group of 16 - 35 years, requesting contraception, were enrolled in the study at Rajendra Nagar Hospital & IVF Centre, Lucknow from February 2018 to December 2019.Meticulated contraception Counseling was administered using a definitive protocol with comprehensive education material on the available contraceptive methods. Questions were explored about the information on the women’s pre- and post-Counseling choice of contraceptive method, her perceptions, and the reasons behind her post-Counseling decision were filled by the participating women.

Results: Maximum women enrolled for the study were in the age group of 22- 29 years. In pre-Counseling, 40% postpartum women selected a contraceptive method, 20% a non hormonal method, and 12% a hormonal method. After Meticulated contraception Counseling, 95% of women chose a contraceptive method. There were significant differences between the women’s choices of contraceptive methods in the pre- and post-Counseling sessions.

Conclusion: This study showed that POPs are the most frequently preferred contraceptive method among postpartum women followed by inj-DMPA and then IUD. Using standardized protocol, proper and Meticulated counseling resulted in a significant increase in selection of contraceptive methods by postpartum women.

Keywords: Postpartum women/ contraception Counseling/ IUD/ progesterone-only pills

Corresponding address

1 Chairperson & Director, Rajendra Nagar Hospital & IVF Centre, Lucknow drschandra50@gmail.com, 9415405091
2Consultant , Rajendra Nagar Hospital & IVF Centre, Lucknow
3Consultant, 4, Pushpanjali Enclave, Delhi


Family planning in India is based on efforts largely sponsored by the Indian government. From 1965 to 2009, contraceptive usage has more than tripled (from 13% of married women in 1970 to 48% in 2009) and the fertility rate has more than halved (from 5.7 in 1966 to 2.4 in 2012), but the national fertility rate remains high, causing concern for long-term population growth. India adds up to 1,000,000 people to its population every 20 days.1-5 Extensive family planning has become a priority in an effort to curb the projected
population of two billion by the end of the twenty-first century.

In 2015, the total fertility rate of India was 2.40 births per women 6 and 15.6 million abortions performed, with an abortion rate of 47.0 abortions per 1000 women aged between 15 - 49 years,With high abortions rates follows a high number of unintended pregnancies, with a rate of 70.1 unintended pregnancies per 1000 women aged 15–49 years 7. Overall, the abortions occurring in India make up for one third of pregnancies and out of all pregnancies occurring, almost half were not planned.8 On the Demographic Transition Model, India falls in the third stage due to decreased birth rates and death rates.9 In 2026, it is projected to be in stage 4 once the Total Fertility Rate reaches 2.1.

Material and Methods

One hundred twenty six postpartum women in the age group of 16–35 years, requesting contraception, were enrolled in the study at Rajendra Nagar Hospital and IVF Centre, Lucknow from February 2018 to December 2019, within 8 weeks of delivery all were counselled for the hormonal and nonhormonal methods of contraception. The sample size with 80% power was calculated based on the assumption that the survey will detect at least a 25% increase in the proportion of women choosing a method {the more reliable contraceptive methods: progesterone-only pill [POP], injectable contraceptive, intrauterine system [IUS], intrauterine device [IUD]/condoms/lactation amenorrhea) after Counseling compared to that before.

Counseling. Underlying assumption was that 25% of women switch from less-reliable contraceptive methods (e.g., withdrawal, fertility-based awareness techniques, improper lactation amenorrhea method) or contraception choice to more-reliable contraceptive methods (e.g., POP, injectable contraceptive, IUD, IUS, condoms/proper lactation amenorrhea) after Counseling. The Type 1 error probability associated with this test of this null hypothesis is 0.05. The uncorrected Chi- squared statistic to evaluate this null hypothesis was used.

Inclusion Criteria

• Postpartum women within 8 weeks of delivery.
• Women who agree to sign an informed consent form.

Exclusion Criteria

• Postpartum women choosing permanent method of contraception (sterilization).
• Postpartum women more than 8 weeks post delivery.


The study was reviewed and approved by the ethical committee of Rajendra Nagar Hospital and IVF Centre.Couples were informed about this study . During these meetings all couples received written information.


Counseling was provided using a standardized protocol with balanced and comprehensive education material on the available contraceptive methods. Counseling card for nonhormonal methods was developed specifically for the study. In addition, a questionnaire was prepared to record information on the women’s pre- and post-Counseling contraceptive choice, and the reasons behind her post-Counseling decision. The demographic variables (age, highest educational level, employment status, breast feeding and number of children) were also included in the questionnaire.

Statistical Methods
The contraceptive methods opted by women pre- and post Counseling program was represented as a shift table and was analyzed using Mc Nemar’s Chi - square test. Pre- and post-Counseling, proportions of women opting for any one of contraceptive methods were recorded and compared.


One hundred thirty- five women were screened for the eligibility criteria of the study. Of these, 9 were excluded. Major reasons for exclusions were not meeting the study eligibility criteria and not filing the study questionnaire completely. This resulted in a total of 126 eligible women who were included in the final analysis and counselled using hormonal and non-hormonal contraceptive cards (Table 1.)


A large number of pregnancies in India are unintended and associated with inadequate birth spacing. The postpartum period is an important, yet underutilized, time to initiate contraception. Evidence shows that closely spaced pregnancies pose health risks to mothers and newborns. An analysis of data from the Demographic and Health Survey (DHS) for various years shows that babies born less than 2 years after the next oldest sibling were more than twice as likely to die in the first year compared with babies born after an interval of 3 years 10. Also, women with short inter-pregnancy intervals (less than 6 months) were at higher risk of maternal death odds ratio [OR] = 2.54), third trimester bleeding (OR = 1.73), premature rupture of membranes (OR = 1.72) and anemia (OR = 1.30) 11. Adequate spacing -24 months from delivery to the next pregnancy - could save the lives of mothers and newborns. Family planning could prevent up to one- third of all maternal deaths by allowing women to delay motherhood, space births, avoid unintended pregnancies and unsafe abortions, and stop childbearing when they have reached their desired family after size 12. National-level surveys show that the adoption of contraceptive methods for spacing has remained low in India, despite the fact that many women (50 %) desire at least a 3-year gap between two births. National Family Health Survey (NFHS-3) data (2005 - 2006) show that among the married women aged 15-34 years, only 20% were using any contraceptive method for spacing. Therefore, postpartum contraception is vital to the reduction of short interval pregnancies, which is a significant source of neonatal morbidity and medical care costs 13. The variety of contraceptive methods available for postpartum women includes hormonal contraception (POP, inj-DMPA), IUD, lactational amenorrhea, barrier contraception, natural family planning and sterilization. The present study was designed to explore the impact of a balanced and comprehensive structured Counseling session on increasing contraceptive acceptability among postpartum
women. Several studies have reported the need and utilization of contraceptives in India. However, there is a lack of studies evaluating the impact of contraceptive Counseling on the selection of contraceptive methods among postpartum women. A study conducted by Goel et al. 14 shows that women who received advice on family planning were more likely to adopt postpartum contraception (unadjusted OR = 1.63 p˂0.001) than those who were not advised at all. The hormonal contraceptive methods were found to be the preferred
contraceptive method selected by postpartum women in India. This is in conformity with the results for India in the world contraceptive use pattern survey.Contraceptive choices were found to be significantly influenced by the time-bound Counseling sessions, as evident by the change in proportions of postpartum women choosing a particular method pre- versus post-Counseling 15. In the present study, structured contraception Counseling of an average duration of 30 minutes about various available hormonal and non hormonal contraceptive methods helped most women (92.8 %) to choose a contraceptive method. Although not conducted among postpartum women, similar observations regarding
contraceptive Counseling selection were reported in studies conducted in different countries. The effect of Counseling on the selection of combined hormonal contraceptive methods in 11 countries was reported by others 16.

The poor usage of contraceptives as observed in the present study may be linked to the low education status of the postpartum women. This may partly explain the poor accessibility and information among these women regarding the various available contraceptive methods. Therefore, through Counseling, the knowledge imparted to these postpartum women, regarding the advantages as well as disadvantages of each contraceptive method helped them make well-informed contraceptive choices catering to their specifications and requirements. The results of the present study emphasize the importance of communication (Counseling) interventions in educating the postpartum women.

Meticulated contraceptive Counseling has big potential as a strategy to empower women who do not want pregnancy to choose a method of birth control that she can use correctly and consistently over time, thereby reducing her individual risk of unintended pregnancy. This study showed that POPs are the most frequently preferred contraceptive method among postpartum women followed by inj-DMPA and then IUD. For societies to reap the many rewards of family planning, both at the individual and macro levels, all methods of family planning, reversible and permanent, should be widely available. Provision of these methods must include free choice, discontinuation on demand, and comprehensive Counseling that proactively focuses on the WHO tiers of effectiveness. Until then, we are failing to accurately inform women with rights-based family planning programs.

Compliance with Ethical Standards and Conflict of interest:

The authors would like to thank all the women for their participation in this study. We would also like to thank the personnel of the Rajendra Nagar Hospital and IVF Centre.
The study was approved by Hospital ethical committee.
This study was funded by the Revolving Fund of the Rajendra Nagar Hospital and IVF Centre, Lucknow, India.


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