Halpern Vera, Lopez Laureen M, Grimes David A, Gallo Maria F
Clinical Sciences, FHI, P.O. Box 13950, Research Triangle Park, North Carolina, USA, 27709.
Cochrane Database Syst Rev. 2011 Apr 13(4):CD004317. doi: 10.1002/14651858.CD004317.pub3.
Worldwide, hormonal contraceptives are among the most popular reversible contraceptives in current use. 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.
To determine the effectiveness of ancillary techniques to improve adherence to, and continuation rates of, hormonal methods of contraception.
We searched computerized databases for randomized controlled trials (RCTs) comparing client-provider interventions with standard family planning counseling. Sources included CENTRAL, MEDLINE, EMBASE, POPLINE, LILACS, PsycINFO, ClinicalTrials.gov and ICTRP.
We included randomized controlled trials (RCTs) of an intensive counseling technique or client-provider intervention versus 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 and on-time injections, and pregnancy.
The primary author evaluated all titles and abstracts from the searches to determine eligibility. Two authors independently extracted data from the included studies. With RevMan, we calculated the odds ratio for all dichotomous outcomes and the mean difference for continuous data. The studies were so different that we did not conduct a meta-analysis.
We found eight RCTs; only one showed a statistically significant benefit of the experimental intervention. In that trial, women who received repeated, structured information about the injectable contraceptive depo-medroxyprogesterone acetate (DMPA) were less likely to have discontinued the method by 12 months (OR 0.27; 95% CI 0.16 to 0.44) than were 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). In another study, the intervention group was less likely to discontinue due to dissatisfaction with the contraceptive method (OR 0.61; 95% CI 0.38 to 0.98), but overall continuation was not affected.
AUTHORS' CONCLUSIONS: Most studies to date have shown no benefit of strategies to improve adherence and continuation. These trials have important limitations, however. Three had small sample sizes, four had high losses to follow up, and the intervention and its intensity varied across the studies. High-quality research is a priority, since adherence and continuation are fundamentally important to the successful use of hormonal contraceptives.
在全球范围内，激素避孕法是目前使用最广泛的可逆性避孕方法之一。尽管其理论有效性很高，但实际使用效果却低得多。在很大程度上，这种差异反映了坚持避孕方案的困难以及长期持续使用的比例较低。
确定辅助技术对提高激素避孕方法的依从性和持续使用率的有效性。
我们在计算机化数据库中检索了比较客户-提供者干预措施与标准计划生育咨询的随机对照试验（RCT）。来源包括Cochrane系统评价数据库、医学索引数据库、荷兰医学文摘数据库、人口与计划生育数据库、拉丁美洲和加勒比卫生科学数据库、心理学文摘数据库、临床试验.gov和国际临床试验注册平台。
我们纳入了将强化咨询技术或客户-提供者干预措施与常规计划生育咨询进行比较的随机对照试验。干预措施包括小组激励；结构化、同伴或多成分咨询；以及强化预约提醒或下次用药提醒。结局指标包括停药情况、停药原因、漏服避孕药和按时注射的次数以及妊娠情况。
第一作者评估了检索到的所有标题和摘要，以确定其是否符合纳入标准。两位作者独立从纳入的研究中提取数据。使用RevMan软件，我们计算了所有二分变量结局的比值比和连续数据的均值差。这些研究差异很大，因此我们未进行荟萃分析。
我们找到了八项随机对照试验；只有一项试验显示实验性干预措施具有统计学意义上的显著益处。在该试验中，与接受常规咨询的女性相比，接受关于注射用避孕药醋酸甲羟孕酮（DMPA）的重复结构化信息的女性在12个月时停用该方法的可能性较小（比值比0.27；95%置信区间0.16至0.44）。干预组因月经紊乱而停药的可能性也较小（比值比0.20；95%置信区间0.11至0.37）。在另一项研究中，干预组因对避孕方法不满意而停药的可能性较小（比值比0.61；95%置信区间0.38至0.98），但总体持续使用率未受影响。
迄今为止，大多数研究表明改善依从性和持续使用率的策略并无益处。然而，这些试验存在重要局限性。三项试验样本量较小，四项试验随访失访率较高，而且各研究中的干预措施及其强度各不相同。高质量的研究是当务之急，因为依从性和持续使用率对于激素避孕法的成功使用至关重要。
