Using contraception counseling to further improve adherence

Dear editor

As medical students recently having done our Obstetrics and Gynecology placements, we feel the paper written by Rodriguez et al¹ addresses a major issue within Gynecology. As mentioned by the authors, approximately half of the pregnancies are unintentional, either due to no contraception being used, poor compliance, or method failure.^2,3

Rodriguez et al had reviewed the different modalities that could be used in counseling patients on contraception and how this has an impact on contraception uptake and adherence. We agree with their conclusion that a combination of modalities, such as including visual aids and utilizing social media, in addition to the clinician consultation is most effective. Using a combination of modalities allows patients to see the information multiple times, and as people have different learning styles, it increases the chances of their understanding and remembering the information. This enables clinicians to adopt a more patient-centered approach, working with patients to select contraception that is best suited to them, and thus most likely to be adhered to.

As well as using a patient-centered approach and utilizing multiple modalities to present information, we believe that a key issue not mentioned in this paper is emphasizing the importance of adherence to the patient through describing the differences in efficacy between “typical” and “perfect” use. It can be very reassuring for a patient to learn that their method of contraception is >99% effective.⁴ However, this statistic is based on “perfect” use, and “typical” adherence is often much lower, with one study reporting that in oral contraception, 47% of users missed at least one pill per cycle and 22% missed two or more pills per cycle.⁵ As highlighted in the paper, there is a significant difference between “perfect” and “typical” use, with the efficacy of the combined oral contraceptive pill falling from >99% to 91%.⁴ Presenting this difference to the patient during contraception counseling may be an effective way of highlighting the importance of and motivating patients to achieve “perfect” adherence.

Currently, information on the efficacy of different types of contraception is presented to patients and may be taken into account in their decision making. There is up to 6% difference in efficacy between the most common methods of contraception.⁴ However, when comparing the rate of efficacy between “perfect” and “typical” use for each method, there is more than 8% difference for oral contraception and 18% difference for male condoms.⁴ The more relevant information to take into account when trying to maximize efficacy may, therefore, be the difference in efficacy between “perfect” and “typical” use and the importance of aiming to achieve “perfect” use.

We believe that educating patients on the difference between “perfect” and “typical” use in contraception counseling may help to improve adherence, consequently reducing the rate of unintentional pregnancies.