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At a glance

There are a number of different kinds of contraceptive methods. You should select your birth control through voluntary, informed choice.

Birth Control Methods

Many elements need to be considered when choosing a contraceptive method. These include safety, effectiveness, availability (including accessibility and affordability), side effects, user control, reversibility, and ease of removal or discontinuation. Contraceptive methods should be chosen through voluntary, informed choice.

You should also consider dual protection from Human Immunodeficiency Virus (HIV) and other sexually transmitted infections (STIs). Although hormonal contraceptives and intrauterine devices (IUDs) are highly effective at preventing pregnancy, they do not protect against STIs, including HIV. Consistent and correct use of the external (male) latex condom reduces the risk for HIV infection and other STIs, including chlamydia, gonorrhea, and trichomoniasis.

Resources for Health Care Providers‎

Reversible methods of birth control, intrauterine contraception, hormonal methods, barrier methods, fertility awareness-based methods, lactational amenorrhea methods, emergency contraception, permanent methods of birth control.

Bradley SEK, Polis CB, Micks EA, Steiner MJ. Effectiveness, safety, and comparative side effects. In: Cason P, Cwiak C, Edelman A, et al, eds. Contraceptive Technology . 22nd ed. Jones & Bartlett Learning; 2023:130–131.

Métodos anticonceptivos

Emergency contraception (emergency birth control)

Anticoncepción de emergencia

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Brief educational strategies for improving contraception use in young people

Global high rates of unplanned pregnancy and abortion among young women demonstrate the need for increased access to modern contraceptive services. In sub‐Saharan Africa, the birth rate for those aged 15 to 19 years is 121 per 1000. In the USA, 6% of teens aged 15 to 19 years became pregnant in 2010. Most pregnancies among young women to age 25 are unintended.

The aim was to identify brief educational interventions for improving contraceptive use among young people that are feasible for implementing in a clinic or similar setting with limited resources.

Search methods

To 7 March 2016, we searched for studies in CENTRAL, PubMed, POPLINE, Web of Science, ClinicalTrials.gov and ICTRP.

Selection criteria

We considered randomized controlled trials (RCTs) that assigned individuals or clusters as well as non‐randomized studies (NRS). We included young people to age 25.

The intervention had to be sufficiently brief for a clinic, i.e. one to three sessions of 15 to 60 minutes plus potential follow‐up. The strategy had to emphasize one or more effective methods of contraception. Primary outcomes were pregnancy and contraceptive use.

Data collection and analysis

We assessed titles and abstracts identified during the searches. One author extracted and entered the data into Review Manager; a second author verified accuracy. We examined studies for methodological quality.

For dichotomous outcomes, we calculated the Mantel‐Haenszel odds ratio (OR) with 95% confidence interval (CI). For continuous variables, we computed the mean difference (MD) with 95% CI. We used adjusted measures for cluster RCTs, typically ORs, that the investigators reported. For NRS, which need to control for confounding, we also used reported adjusted measures. We did not conduct meta‐analysis due to varied interventions and outcome measures.

Main results

We found 11 studies, published from 1983 to 2015, that included a total of 8338 participants. Ten were from the USA and one was from China. We focused here on intervention effects for our primary outcomes. Five studies showed some effect on contraceptive use. Of three RCTs that examined innovative counseling, one showed an intervention effect. At one year, adolescents with developmental counseling were more likely to use contraception effectively than those with standard counseling (OR 48.38, 95% CI 5.96 to 392.63).

Three studies used an audiovisual tool plus counseling; two reported some effect on contraceptive use. An NRS with young men, aged 15 to 18, examined a slide‐tape presentation plus reproductive health consultation. At one year, the intervention group was more likely than the standard‐care group to report using an effective contraceptive and having a partner who used oral contraceptives (OCs), both at last intercourse (reported adjusted OR 1.51 and 1.66, respectively). Another study utilized a computer program for contraceptive decision‐making plus standard counseling for women to age 20. At one year, fewer women in the intervention group at one site had not used OCs compared with the counseling‐only group (3.4% versus 8.8%; reported P = 0.05).

Three RCTs provided phone follow‐up after counseling, one of which showed an effect on contraceptive use among women age 16 to 24. Women who received counseling plus phone calls to encourage contraceptive use were more likely than the counseling‐only group to report consistent OC use at three months (OR 1.41, 95% CI 1.06 to 1.87) and six months (OR 1.39, 95% CI 1.03 to 1.87). Also at three months, they were more likely to report condom use at last sex (OR 1.45, 95% CI 1.03 to 2.03).

Two cluster randomized trials trained providers on contraceptive methods and counseling. One trial with an intervention effect tested comprehensive contraceptive services for women to age 25, postabortion. At six months, the comprehensive‐service group was more likely than the standard‐care group to use an effective contraceptive (reported adjusted OR 2.03, 95% CI 1.04 to 3.98) and to use condoms consistently and correctly (reported adjusted OR 5.68, 95% CI 3.39 to 9.53).

Authors' conclusions

Few studies tested brief strategies for young people. We noted heterogeneity across studies in participants' ages and life situations. Of five studies with some effect, one provided moderate‐quality evidence; four were older studies with low‐quality evidence. More intensive strategies could be more effective, but would also be challenging for many clinics to implement.

Plain language summary

Brief teaching methods to improve contraceptive use among young people

Young people up to age 25 have high rates of unplanned pregnancy. They need modern birth control methods and services. We wanted to find ways to educate young people about birth control that are brief enough for clinic use.

To 7 March 2016, we ran computer searches for randomized and non‐randomized studies. The teaching strategy could involve up to three sessions of 15 to 60 minutes plus follow‐up. The effort had to address an effective method of birth control. Main outcomes were pregnancy and birth control use.

We found 11 studies from 1983 to 2015 that included 8338 women. Ten studies were from the USA and one was from China. We focused here on the five studies that showed some effect. Two tested special counseling. At one year, teens with special counseling for their age used birth control more effectively than those with standard counseling.

Two studies used audiovisual tools plus counseling. One trial provided a slide‐tape presentation on sexual health for young men. At one year, the treatment group was more likely than the control group to use an effective contraceptive and have a partner who used oral contraceptives (OCs). The other used a computer program for decision‐making for young women. At one year, more women in the intervention group at one site used OCs compared with the control group. Two other studies showed some effect. In one, young women with phone follow‐up and counseling were more likely to have consistent OC use at three months and six months than the group with counseling only. Also at three months, they were more likely to report condom use at last sex. One trial that assigned sites compared an enhanced package of birth control services after abortion versus standard care. At six months, the enhanced‐service group was more likely to use effective contraception and use condoms consistently and correctly.

Few studies tested brief teaching methods for young people. About half of the studies had some effect, but they differed in methods and in ages and life situations of the young people. More intense strategies could work better, but would be difficult for many clinics to use. Overall, study quality was low.

Summary of findings

Summary of findings for the main comparison.

a Significant differences between study arms for primary outcomes in this review

Summary of findings 2

Summary of findings 3, description of the condition.

Millennium Development Goal 5 of the United Nations included increased access to contraception among young women ( UN 2015 ). In sub‐Saharan Africa, South Central Asia, and Southeast Asia, 68% of women aged 15 to 19 years want to avoid pregnancy but are not using a modern contraceptive method, and the figure is 51% for women aged 20 to 24 years old ( Darroch 2011 ). In addition, 87% of unintended pregnancies occur among women who do not use a modern contraceptive method. In low‐ and middle‐income countries (LMICs), 33 million women from 15 to 24 years old have an unmet need for contraception ( MacQuarrie 2014 ). Among unmarried women in this age group, the need ranges from 7% in Ukraine to 70% in Senegal. For married young women, the comparable figures are 8% in Indonesia and 46% in Ghana.

Of the 16 million births per year to adolescents 15 to 19 years old, 95% occur in LMICs ( Chandra‐Mouli 2014 ). In sub‐Saharan Africa, the birth rate for young women aged 15 to 19 years old is 121 per 1000 ( UN 2015 ). The next‐highest birth rate is 86 per 1000 young women in Latin America and the Caribbean. The average for 'developing regions' is 56 per 1000 (( UN 2015 ). Complications from pregnancy and childbirth are the leading cause of death in this age group. Many adolescents choose abortion, which may be unsafe due to local restrictions. Three‐fourths of unsafe abortions, as well as other causes of maternal mortality, could be prevented by improved access to modern contraception ( WHO 2011 ). In the USA, 6% of teenagers aged 15 to 19 years became pregnant in 2010 ( Kost 2014 ). When based on those who had ever had sex, the pregnancy rate was 12.7%. Furthermore, 82% of the pregnancies among women 15 to 19 years old in 2008 were unintended, as were 64% of those among women 20 to 24 years old ( Finer 2014 ). Young women 18 to 19 years old represented 69% of all teenage pregnancies. Rates for adolescent pregnancies, births, and abortions have decreased markedly since 1990. Of teenage women in the USA at risk of unintended pregnancy, 59% reportedly use highly effective contraception ( Guttmacher 2015 ). The male condom is the most common method at first sex and at most recent sex ( Martinez 2011 ; Guttmacher 2015 ).

Women under 25 years of age who use modern contraceptives have higher typical rates for contraceptive failure within the first 12 months compared with women 25 years of age and older. First‐year contraceptive failure rates were 13% to 14% for women younger than 25 years of age versus 8% for women aged 30 years and older ( Kost 2008 ). When examined for pill use, younger age was a significant predictor of failure along with intent to have more children, being currently married, and parity. For condom use, the same factors were important, as were race or ethnicity and poverty status.

Description of the intervention

Behavioral strategies to improve contraception use include counseling or education in clinical settings ( Jaccard 2013 ). The intervention can take the form of traditional oral or written communication, or may involve the use of mobile phones or other technology ( Guse 2012 ; Gilliam 2014 ). A strategy could be conducted through single or multiple sessions and targeted to individuals, couples, or groups ( Robin 2004 ). Clinic‐based interventions are less likely to have multiple sessions or be multifaceted than school‐based or community‐based interventions, which may be considered educational programs or communication campaigns ( Lopez 2013a ).

Family planning services may provide counseling as well as improve access to contraception ( Blank 2012 ; Chandra‐Mouli 2014 ). Global high rates of unplanned pregnancy and abortion among adolescents and young women demonstrate the need for increased access to modern contraceptive information and services. Such access has been recognized internationally as a human rights issue for young women ( UNFPA 2010 ). However, numerous barriers exist and may vary across geographical settings. These include regulations and policies that prohibit young or unmarried women from accessing some or any contraception ( Ross 2013 ; Chandra‐Mouli 2014 ); attitudes or beliefs that lead parents, teachers, and providers to discourage young women or withhold contraceptive information or services ( Biddlecom 2008 ; Bankole 2010 ; Ross 2013 ); and young women’s lack of knowledge, skills, or resources to access the available information and services ( Chandra‐Mouli 2014 ). Even in the context of youth‐friendly services, unmarried or nulliparous young women may have limited access to the most effective contraceptive methods, such as intrauterine contraception ( Wilson 2012 ; Rubin 2013 ). Because adolescents’ needs and preferences vary, young women should have access to the full complement of methods ( Comm Adolescence 2014 ). Meeting the needs of adolescents in different contexts may require a range of information channels and communication approaches ( Chandra‐Mouli 2014 ).

Why it is important to do this review

Several reviews have examined educational strategies to improve contraceptive use. These may include interventions for preventing HIV or sexually transmitted infections (STIs), as well as for improving contraceptive use and preventing pregnancy ( Oringanje 2009 ). Some include studies of varying designs ( Blank 2012 ). A Cochrane review of educational interventions addressed theory‐based strategies and found that programs for youth often have multiple sessions ( Lopez 2013b ). Postpartum education to improve contraceptive use among teenage mothers may occur in the clinic or home, depending on local standards of care and the particular project ( Lopez 2015 ).

In this review, we examined behavioral strategies to improve contraceptive use among young people to age 25 years. The intervention must have involved counseling or education to improve knowledge of effective contraception and appropriate method use. Such efforts can help young people choose an appropriate contraceptive method and continue to use the preferred type. The focus of such strategies is preventing unintended pregnancy.

While multifaceted interventions help address the complexity of contraception behavior, most contraception counseling occurs in a clinical setting. Time and counseling expertise are often limited, along with knowledge about specific contraceptive methods, such as long‐acting reversible contraception ( Harper 2013 ; Lewis 2013 ). We tried to identify interventions that focus on contraception use by young people and are feasible for clinical settings.

Criteria for considering studies for this review

Types of studies.

We considered randomized controlled trials (RCTs) and non‐randomized studies (NRS). RCTs include trials that assigned individuals or clusters, such as clinics. The NRS had to be prospective and have a comparison group. The design and conduct of educational interventions may be influenced by funding limitations, clinic logistics, and ethics regarding who receives the new program. Therefore evidence from RCTs about what may help inform people about choosing contraceptives is limited ( Halpern 2013 ; Lopez 2013b ). Considering NRS broadened the base from which to draw evidence.

Types of participants

We included study participants aged 25 years or younger. Participants may have been initiating contraceptive use, switching to a different method, or continuing use of the same method. We also included women who were postpartum or postabortion.

The age range for adolescence and young adulthood varies in research and policymaking. While contraceptive counseling for adolescents may focus on those aged 14 to 19 years, some scientists consider 20 to 25 years of age a period of "extended adolescence" or "emerging adulthood" ( Jaccard 2013 ). Societal changes may delay independence and the assumption of adult roles. Healthcare policy organizations have considered 10 to 15 years old as the lower age cutoff for adolescence and 18 to 24 years old as the upper limit ( DHHS 2008 ; Gavin 2009 ; WHO 2014 ; UN 2015 ). Peer education for sexual health among young people has included ages 10 to 24 years ( Tolli 2012 ). Contraceptive service interventions for young people in healthcare settings have participants up to 25 years of age ( Blank 2012 ).

Types of interventions

We considered educational strategies to improve contraceptive use among young people. The intervention had to be sufficiently brief or focused for implementing in a clinic or similar setting with limited time or staffing. Strategies had to be one to three sessions of 15 to 60 minutes each, and may have been conducted with individuals or groups. Methods could include direct oral communication or the use of video or an Internet‐based program. Additional education or reminders may have been provided by phone call or mobile phone messaging. Another Cochrane review addresses mobile phone interventions but has different inclusion criteria ( Smith 2015 ). Interventions may have been developed for school‐based or community‐based clinics. A classroom‐based strategy could have been feasible if it had a single session or was computer‐based, but multiple lessons or a detailed curriculum would be too intensive for most clinics. The comparison condition may have been another educational strategy, usual care, other health education, or no intervention.

The behavioral strategy being tested had to emphasize one or more reversible methods of contraception. The intervention should have addressed modern family planning methods and included those considered more effective in preventing pregnancy. Effectiveness is 99% with correct and consistent use of the more effective methods, and typical‐use effectiveness ranges from 90% to 99% ( Trussell 2011 ; WHO 2015 ). These methods include pills, injectables, the contraceptive patch, the vaginal ring, lactational amenorrhea, and emergency contraception. Further, long‐acting methods such as intrauterine contraception and implants have typical‐use effectiveness of greater than 99%. Of the fertility awareness‐based methods, sometimes known as 'natural family planning,' only the sympto‐thermal method may have typical‐use effectiveness greater than 90%; effectiveness is 98% with correct and consistent use ( WHO 2015 ).

Types of outcome measures

Primary outcomes.

Included studies must have had one of the measures listed below.

use of a new method
improved use or continuation of a method
Pregnancy (at least six months after the intervention began)

Contraceptive use could have been assessed in a variety of ways, such as consistent use or improved adherence. Where we found multiple measures within a study, we focused on the investigator’s assessment of consistent use or use at last sex. If we did not find one of those preferred measures, we accepted the method used by the investigator.

For high quality evidence, the time frames for assessment were 6 months or more for contraception use and 12 months or more for pregnancy. The longer time frames provide more meaningful outcome measures.

Secondary outcomes

These measures evaluate whether the study groups differed after the intervention in thinking about contraception, regardless of whether behavior changed.

Knowledge of contraceptive effectiveness or effective method use
Attitude about contraception or a specific contraceptive method

The time frame for assessment was three months or more. For high‐quality evidence, the time frame was six months or more.

Search methods for identification of studies

Electronic searches.

To 7 March 2016, we searched for eligible studies in PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), POPLINE, and Web of Science. Searches started from the inception of each database. We also searched for recent studies via ClinicalTrials.gov and the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP). We have shown the search strategies with the search end dates in Appendix 1 .

Searching other resources

We examined the reference lists of reviews and other relevant articles to find studies we may have missed in our electronic searches.

Selection of studies

We assessed for inclusion all titles and abstracts identified during the literature search. One author reviewed the search results, and a second author examined the reports identified for appropriate categorization. We obtained and examined the full‐text articles for studies that appeared eligible for the review. The authors resolved any discrepancies by discussion.

Data extraction and management

Two authors conducted the data extraction. One author entered the data into Review Manager (RevMan) ( RevMan 2014 ), and a second author checked accuracy. These data include the study characteristics, risk of bias, and outcomes. We focused on the primary and secondary outcomes for this review, which do not include all outcomes from each study. We resolved discrepancies through discussion.

Assessment of risk of bias in included studies

Intervention fidelity.

We used an existing framework to assess the quality of the educational strategy ( Borrelli 2011 ). Domains of treatment fidelity are study design, training of providers, delivery of treatment (intervention), receipt of treatment, and enactment of treatment skills. The framework was intended for assessing current trials. The criteria of interest for our review are listed below.

Study design: had a curriculum or treatment manual
Prior training of providers: specified providers' credentials
Project‐specific training: provided standardized training for the intervention
Delivery: assessed providers' adherence to the protocol
Receipt: assessed clients' understanding and skills regarding the intervention

For the assessment of evidence quality, we downgraded the studies that met fewer than four of these five criteria.

Research design

We evaluated the included RCTs for methodological quality in accordance with recommended principles ( Higgins 2011 ), and entered the information into the 'Risk of bias' tables. We considered the randomization method, allocation concealment, blinding, and losses to follow‐up and early discontinuation.

For the NRS considered for inclusion, we used the Newcastle‐Ottawa Quality Assessment Scale (NOS) ( Higgins 2011 ; Wells 2014 ). Of the two NOS versions, i.e. for case‐control and cohort studies, the latter was more pertinent here ( Appendix 2 ). The developers are examining the criterion validity and construct validity of this scale, as well as the inter‐rater reliability and intra‐rater reliability. The scale does not yet have an overall scoring or threshold for a 'good' or 'poor' quality study. The NOS has eight items within three domains: selection (representativeness), comparability (due to design or analysis), and outcomes (assessment and follow‐up). A study can receive one star (✸) for meeting each criterion. The exception is comparability (design or analysis), for which a study can receive two stars (for design and analysis). We adapted the NOS items as suggested by the developers ( Wells 2014 ).

Measures of treatment effect

For the dichotomous outcomes, we calculated the Mantel‐Haenszel odds ratio (OR) with 95% confidence interval (CI). An example is the proportion of young women who initiated use of a particular contraceptive method. Fixed effect and random‐effects give the same result if no heterogeneity exists, as when a comparison includes only one study. For continuous variables, we computed the mean difference (MD) with 95% CI. RevMan uses the inverse variance approach ( RevMan 2014 ).

Cluster randomized trials may use a variety of strategies to account for the clustering. When available, we used adjusted measures that the investigators considered the primary effect measures. Odds ratio (OR) is an appropriate effect measure and is commonly provided when adjusted analyses are obtained using cluster‐adjusted logit models with or without covariates. However, if an appropriate adjusted OR was not available from the report, we considered other effect measures, e.g. rate ratio, hazard ratio, or incidence difference. Where multivariate models were used, we did not analyze the treatment effect, as that would usually require individual participant data. Instead we presented the results from adjusted models as reported by the study investigators.

Non‐randomized studies

Given the need to control for confounding factors in NRS, we used adjusted measures for the primary effect measures when available. OR is an appropriate effect measure for both cohort and case‐control studies and is commonly provided when adjusted analyses are obtained using logistic regression models. However, we considered other effect measures if an appropriate adjusted OR was not available from the report. The effect measure may have been an odds ratio, risk ratio, or hazard ratio.

Investigators used a variety of adjustment strategies. We specified whether confounding was considered in the design (e.g. matching, stratification). In the Characteristics of included studies and Effects of interventions , we identified the confounding factors considered in the design and analysis. As noted for cluster RCTs above, when investigators used multivariate models, we did not analyze the treatment effect but presented the results from the adjusted models. If the report did not provide adjusted measures for the primary analysis, we used unadjusted measures. If data were available for unadjusted dichotomous outcomes, we calculated the OR with 95% CI.

Unit of analysis issues

If clustering was part of the design, we assessed whether the study investigators properly adjusted the estimates to account for clustering effects. Cluster RCTs may use various methods of accounting for the clustering, such as multilevel modeling. We noted the specific methods used in the results for each included study. We presented the results as reported by the investigators.

Dealing with missing data

We wrote to investigators to request missing data, such as sample sizes for analysis and actual numbers for outcomes presented in figures. However, we limited our requests to studies less than 10 years old, as well as studies that had a report within the past five years. Investigators are unlikely to have access to data from older studies. In some cases, we had obtained additional information for an earlier review that included the specific study.

Assessment of heterogeneity

Due to the variability in educational interventions, we were unable to conduct meta‐analysis; statistical heterogeneity was irrelevant. However, we addressed heterogeneity due to differences in study design, populations, interventions, outcome measures, and analysis. We examined any differences across studies by participant age group. Studies may focus on adolescents to age 18 or 19 versus young people up to age 25. The location and setting may influence the design and results. The type of outcome measure may affect results, and we have addressed this below. In addition, we synthesized results by the type of intervention, e.g. counseling, counseling plus reminders, or counseling plus improved access to services. The last includes providing contraceptives free or at reduced cost to one or more study groups.

Data synthesis

To assess the quality of evidence and address confidence in the effect estimates, we applied principles from GRADE (Grades of Recommendation, Assessment, Development and Evaluation) ( Higgins 2011 ; GRADE 2013 ). As meta‐analysis was not viable due to varied interventions and outcome measures, a typical 'Summary of findings' table was not feasible. Also, the criteria for NRS and RCTs differ. We did provide a 'Summary of findings' table for the main results, although we did not conduct a formal GRADE assessment for all outcomes ( GRADE 2013 ).

We based our assessment of the body of evidence on the quality of evidence from the included studies. For the RCTs, we entered the information into the 'Risk of bias' tables. For the NRS, we used the Newcastle‐Ottawa Quality Assessment Scale (NOS) as noted earlier ( Appendix 2 ). Evidence quality included the design, implementation, and reporting of the intervention and the study. The information on intervention fidelity was part of the overall assessment. We have listed the criteria for downgrading the quality of the evidence below.

Intervention fidelity information for fewer than four criteria
NRS: not meeting at least one NOS criterion for selection
RCT: inadequate randomization sequence generation or allocation concealment, no information for either one, or the study was not randomized
NRS: no stars for comparability, i.e. not controlling for any confounding
No objective measure for outcome assessment, e.g. pregnancy test or record or contraceptive use (clinic records of depot medroxyprogesterone acetate (DMPA) injections)
Follow‐up less than 6 months for contraceptive use and less than 12 months for pregnancy
Loss to follow‐up greater than 20%

Description of studies

Results of the search.

The database searches yielded 625 unduplicated references ( Figure 1 ). We added 8 items from other sources for a total of 633. We discarded 592 references based on the title or abstract. After reviewing the full text of 41 articles or abstracts, we excluded 26 items that did not meet the eligibility criteria (19 primary reports plus 7 secondary references). We included 15 items, i.e. 11 primary reports from studies that met the eligibility criteria plus 4 secondary references. We placed one trial that had only produced an abstract to date in Studies awaiting classification until a report is available with four‐month outcome data. Searches of clinical trials listings produced 107 unduplicated trials; we listed 3 in Ongoing studies . The others were not relevant or were listings for completed trials we had already considered.

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Study flow diagram.

Included studies

Of 11 studies, 9 were individually randomized trials, 2 were cluster randomized trials, and 2 were non‐randomized studies. Ten studies were conducted in the USA and one was carried out in China. Participants were typically recruited from primary care sites and family planning clinics.

Publication dates for these reports ranged from 1983 to 2015. Four trials provided details on sample size calculations. The total number of participants was 7765. Sample sizes for the studies that assigned individuals ranged from 33 to 1155 with a median of 228. Four studies that randomized individuals had 100 or fewer participants; two had approximately 1000. Of the two trials that randomized sites, or clusters, one included 2336 women from 16 clinics, and the other had 1500 women from 40 clinics. The effective sample sizes for those two trials would be smaller due to the assignment of groups rather than individuals.

Because these studies tested clinic‐based interventions, most focused on educating individuals. One had a group session and partner involvement as well as individual contact ( Zhu 2009 ). Studies with phone follow‐up or text messages had multiple contacts with participants. Most studies focused on teenagers, a few included young people up to age 24 or 25 years, and two had age ranges from 18 years to 24 or 25 years.

We categorized the interventions as counseling ( Marcy 1983 ; Jay 1984 ; Ceperich 2011 ), counseling plus audiovisual methods ( Danielson 1990 ; Chewning 1999 ; Gilliam 2004 ), counseling plus phone calls or text messages ( Kirby 2010 ; Berenson 2012 ; Trent 2015 ), and counseling plus training of providers ( Zhu 2009 ; Harper 2015 ).

Some studies focused on a specific contraceptive method, e.g. oral contraceptives (OCs) ( Jay 1984 ; Chewning 1999 ; Gilliam 2004 ; Berenson 2012 ), long‐acting reversible contraception (LARC) ( Harper 2015 ), or the injectable DMPA ( Trent 2015 ). Others addressed 'more effective methods' ( Zhu 2009 ; Ceperich 2011 ) or various methods ( Marcy 1983 ; Danielson 1990 ; Kirby 2010 ).

Excluded studies

Studies were typically excluded for not having an eligible intervention. Some interventions did not address contraception, while others were too intensive to meet the criteria for a brief strategy. Details can be found in Characteristics of excluded studies .

Risk of bias in included studies

Figure 2 summarizes our assessments of risk of bias for the overall review; Figure 3 provides our assessment for each study. Because we adapted the 'Risk of bias' tables to accommodate criteria for non‐randomized studies, some categories are not relevant to an RCT or to an NRS. We left those categories blank so that an empty cell in Figure 3 indicates the criterion was 'not applicable' and distinguishes between 'unclear' and no assessment.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Blank cells indicate the criterion was not relevant due to study design and therefore was not assessed.

We looked for evidence of intervention fidelity in the included studies. Table 4 lists the included studies by major type of intervention. Our assessment of evidence quality includes intervention fidelity reporting.

LARC: long‐acting reversible contraception MI: motivational interviewing OC: oral contraceptive RN: registered nurse

Seven of the nine RCTs specified the randomization method; most used a computer‐generated sequence ( Jay 1984 ; Gilliam 2004 ; Kirby 2010 ; Berenson 2012 ; Harper 2015 ; Trent 2015 ), while one used coin tossing ( Zhu 2009 ).

The two NRS used alternate assignment ( Danielson 1990 ; Chewning 1999 ). Both met some of the NOS selection criteria. Danielson 1990 also met the comparability criteria due to adjusting the analysis for potential confounding factors.

Three RCTs provided the method of allocation concealment ( Gilliam 2004 ; Ceperich 2011 ; Trent 2015 ). Berenson 2012 communicated they did not conceal allocation from the investigators, which may have referred to blinding. One cluster randomized trial stated the clinics were unaware of assignment until study began ( Harper 2015 ). The other four RCTs had no information on concealment.

Seven studies mentioned some blinding. These were primarily participants ( Danielson 1990 ; Harper 2015 ) and outcome assessors ( Jay 1984 ; Kirby 2010 ; Berenson 2012 ; Harper 2015 ). Three mentioned research personnel ( Gilliam 2004 ; Kirby 2010 ; Trent 2015 ), but none of the studies could feasibly mask the intervention providers due to the types of interventions. Zhu 2009 stated the interviewers (assessors) were not blinded to intervention group. Three trials had no information on blinding ( Marcy 1983 ; Chewning 1999 ; Ceperich 2011 ).

Incomplete outcome data

Six trials lost 20% or more to follow‐up; they are listed below by the percent lost. Two had major differential losses between the intervention and control groups ( Jay 1984 ; Gilliam 2004 ).

Zhu 2009 : 44% special intervention; 40% comparison
Berenson 2012 : 44% counseling; 43% counseling + phone; 45% standard care
Jay 1984 : 42% nurse‐counselor group; 23% peer‐counselor group
Trent 2015 : 34% intervention; 28% control
Kirby 2010 : 25% overall
Gilliam 2004 : 24% overall (11% intervention; 40% control)

Other potential sources of bias

Of six studies that assessed pregnancy, two used medical records or home pregnancy tests, while the others had self reports. In addition to self report for pregnancy, Berenson 2012 used medical records and Harper 2015 used home pregnancy tests and medical records. Under‐reporting is possible since women may not have reported an abortion, which could have been done at another clinic.

Most studies had self‐reported contraceptive use, but two had objective measures. The use of a biomarker to assess pill use strengthened the results of Jay 1984 . Trent 2015 used clinic records of on‐time injections for DMPA.

Effects of interventions

See: Table 1 ; Table 2 ; Table 3

For studies that used multivariate models, we have presented the results from the adjusted models. Other reports did not contain sufficient data for analysis in this review, so we have presented the results as reported by the investigators. For reports that did not provide a P value when the comparison groups did not differ significantly, we used 'NS' in the data table to indicate no significant difference.

We present the results by type of intervention. Table 5 summarizes the various strategies explained below and the intervention effects. The studies show some heterogeneity in participant ages and recruitment source. Most studies recruited young women from family planning clinics, but one used a medical clinic to reach young men. Others focused on young women who were pregnant or were postabortion.

AV: audiovisual method DMPA: depot medroxyprogesterone acetate IUD: intrauterine device LARC: long‐acting reversible contraception OC: oral contraceptive

Three RCTs examined innovative methods for counseling. Two trials compared a newer method to standard contraceptive counseling ( Marcy 1983 ; Jay 1984 ), while one provided the control group with a general pamphlet on women's health ( Ceperich 2011 ).

Marcy 1983 compared developmental counseling versus conventional counseling for adolescents, age 13 to 18 years (N = 80). This developmental counseling addressed the particular social and psychological concerns of adolescents. The Characteristics of included studies table provides the principles and constructs of this approach. Effective contraceptive use was defined as follows: medical chart showed refilled contraceptive prescriptions regularly during year; participant kept intrauterine device (IUD) in place; at clinic appointment, participant stated she was using foam and condom together or using diaphragm and spermicidal jelly together; participant abstained from intercourse. At one year, adolescents in the intervention group were more likely to be effective users of contraception (odds ratio (OR) 48.38, 95% confidence interval (CI) 5.96 to 392.63; participants = 78) ( Analysis 1.1 ). The wide CI indicates imprecision in the estimate.

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Comparison 1 Developmental versus conventional counseling, Outcome 1 Effective user of contraception at 1 year.

Jay 1984 compared peer counseling versus nurse counseling to improve adherence to oral contraceptives (OCs) among adolescents (N = 57). Participants ranged in age from 14 to 19 years old. Non‐adherence was measured with the score from a four‐factor Guttman scale: became pregnant during the previous month; missed appointment; reported missing three or more OCs during the month; and at follow‐up had absence of urinary fluorescence (a marker added to the OCs). At four months, the peer‐counseling and nurse‐counseling groups did not differ significantly in their non‐adherence scores ( Analysis 2.1 ).

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Comparison 2 Peer counseling versus nurse counseling, Outcome 1 OC non‐adherence (Guttman score) at 4 months.

The intervention in Ceperich 2011 was based primarily on motivational interviewing and addressed reducing risk for alcohol‐exposed pregnancy. Participants were university students, 18 to 24 years old (N = 228). The intervention involved a single session lasting about an hour. The control group received a pamphlet on women's health. At four months, the treatment group was less likely than the control group to report using ineffective contraception, but the difference was not statistically significant ( Analysis 3.1 ).

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Comparison 3 Motivational interviewing versus pamphlet on health, Outcome 1 Ineffective contraceptive use at 4 months.

Counseling plus audiovisual

Three studies used some type of audiovisual presentation or computer tool as an adjunct to counseling. Two were older NRS with alternate assignment to intervention groups ( Danielson 1990 ; Chewning 1999 ). One was a small RCT ( Gilliam 2004 ).

Danielson 1990 focused on young men aged 15 to 18 years. The analysis of contraceptive use outcomes included 522 young men who were sexually active; 1195 participated in the intervention. The experimental group viewed an audiovisual presentation (slide‐tape) on reproductive health, which addressed fertility, sexually transmitted infections (STIs), contraception, and abstinence. The slide‐tape was followed by a healthcare visit focused on contraception, e.g. consistency of contraceptive use, use of back‐up methods, and condom use. For analysis, the logistic regression models included potential confounding variables such as baseline demographics, sexual activity, and contraceptive use. The comparison groups reportedly did not differ significantly for contraceptive methods used in the previous year and frequency of birth control use. Two items on contraceptive use associated with the intervention were open‐ended questions: main method used in the past year and method used at last intercourse. Contraceptive effectiveness was categorized as no method, method less effective than condom, condom alone, and method more effective than condom alone (primarily OCs). Since the report did not provide the 95% CI, we show the P values as provided in the report. At one year, the intervention group was more likely than the control group to have used an effective method at last intercourse (reported adjusted OR 1.51; P < 0.05); the difference was also apparent within the subgroup not sexually active at baseline (reported adjusted OR 2.53; P < 0.01) ( Analysis 4.1 ). The intervention group was also more likely to have a partner who used OCs at last intercourse (reported adjusted OR 1.66; P < 0.05), and the difference was evident within the subgroup not sexually active at baseline (reported adjusted OR 3.06; P < 0.01) ( Analysis 4.1 ). For contraceptive knowledge, the analysis included all participants who completed follow‐up and had complete data (N = 971). Within the subgroup that was sexually active at baseline, the intervention group was more likely than the control group to agree that OCs were safe (reported adjusted OR 1.68; P < 0.05) ( Analysis 4.2 ). Overall, the intervention group was more likely than the control group to understand fertility timing in the menstrual cycle (reported adjusted OR 1.37; P < 0.01) ( Analysis 4.2 ).

Comparison 4 Audiovisual + consultation versus usual care, Outcome 1 Contraceptive use at 1 year.

Comparison 4 Audiovisual + consultation versus usual care, Outcome 2 Contraception knowledge at 1 year.

Gilliam 2004 provided a multicomponent intervention of counseling, a videotape about OCs, and written material. The comparison group received usual care. Participants were pregnant at age 25 or younger (N = 33). At one year, the experimental and comparison groups did not differ significantly in the proportions that continued OC use ( Analysis 5.1 ) or those who switched contraceptive method ( Analysis 5.2 ). The investigators noted the sample size was not sufficient to detect a 20% difference between groups, due to resource limitations.

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Comparison 5 Multicomponent intervention versus routine counseling, Outcome 1 Continuation of oral contraceptives at 1 year.

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Comparison 5 Multicomponent intervention versus routine counseling, Outcome 2 Switched contraceptives by 1 year.

In Chewning 1999 , the intervention was standard counseling plus a computer program for contraceptive decision‐making compared with standard counseling alone. Participants were women, 20 years old or younger (N = 949). The investigators presented results by clinic due to site differences in populations and in protocols for the standard counseling (see Characteristics of included studies ). They did not provide sample sizes by study arm for analysis. The intervention was not significantly associated with number of months on OCs ( Analysis 6.1 ) or with pregnancy ( Analysis 6.2 ) at either site. At the Chicago site, 3.4% of the intervention group did not start using OCs compared with 8.8% of the control group (reported P = 0.05). At the Madison site, knowledge of OCs was greater for the intervention group compared with the control group (reported P = 0.031) ( Analysis 6.1 ).

Comparison 6 Computer‐aided decision‐making versus usual counseling, Outcome 1 Continuous outcomes at 1 year.

Comparison 6 Computer‐aided decision‐making versus usual counseling, Outcome 2 Dichotomous outcomes at 1 year.

Counseling plus phone calls or text messages

Three RCTs utilized phone follow‐up in addition to contraceptive counseling. Two made personal phone calls after the clinic visit to encourage and assist with contraceptive use ( Kirby 2010 ; Berenson 2012 ). The third trial provided text messages for appointment reminders and education ( Trent 2015 ).

Kirby 2010 used motivational interviewing during phone calls to improve contraceptive use for adolescents, aged 14 to 18 years (N = 805). After the initial clinic visit, nine calls could be provided in 12 months: monthly for the first six months and then every other month. The comparison group had usual care from the reproductive health clinic, e.g. calls to report abnormal results or respond to patients' inquiries. Only 30% of calls were completed (mean of 2.7 per participant). The regression analyses treated time either continuously or discreetly, and controlled for baseline values and other significant covariates. The intervention and control groups did not differ significantly at 6, 12, or 18 months in the reported percentages for hormonal contraceptive use at last sex ( Analysis 7.1 ), condom use at last sex ( Analysis 7.2 ), or use of hormonal contraceptive or condom at last sex ( Analysis 7.3 ). The investigators provided additional results. Self‐reported pregnancy did not differ significantly for the two groups at study end (27% treatment; 23% control) ( Analysis 7.4 ). Pregnancy rates from clinic charts were much lower than those from self report, but participants did not necessarily use the same clinic.

Comparison 7 Motivational phone calls versus usual care, Outcome 1 Hormonal contraceptive use at last sex.

Comparison 7 Motivational phone calls versus usual care, Outcome 2 Condom use at last sex.

Comparison 7 Motivational phone calls versus usual care, Outcome 3 Use of hormonal contraceptive or condom at last sex.

Comparison 7 Motivational phone calls versus usual care, Outcome 4 Pregnancy by 18 months.

For Berenson 2012 , the three study conditions were special counseling about OCs plus monthly follow‐up phone calls (C + P), special counseling (SC) about OC use, and usual clinic services. The women were 16 to 24 years old and recruited from five reproductive health clinics serving low‐income women (N = 1155). The investigators did not report any differences as significant. They used P < 0.017 (0.05/3) to indicate significance as an adjustment for multiple comparisons among three intervention groups. In this review, we had two comparisons and considered P < 0.05 to indicate significance: C + P versus SC and SC versus standard care (usual clinic services). The C + P group was more likely than the SC group to report consistent OC use at three months (OR 1.41, 95% CI 1.06 to 1.87; participants = 767) and at six months (OR 1.39, 95% CI 1.03 to 1.87; participants = 767) ( Analysis 8.1 ). Inconsistent condom users were asked about condom use. At three months, the C + P group was more likely than the SC group to report condom use at last sex (OR 1.45, 95% CI 1.03 to 2.03; participants = 767) ( Analysis 8.2 ). The C + P and SC groups did not differ significantly for any outcome at 12 months. The SC and standard care groups did not differ in OC use or condom use at any time point ( Analysis 8.3 ; Analysis 8.4 ). Regarding attitudes, women in the C + P group were more likely than those in the SC group to recommend OC use to a friend at three months (OR 1.52, 95% CI 1.11 to 2.09; participants = 623) and at six months (OR 1.68, 95% CI 1.20 to 2.36; participants = 545) ( Analysis 8.5 ). However, the SC group was less likely than the standard care group to recommend OC use to a friend at six months (OR 0.65, 95% CI 0.46 to 0.91; participants = 538) ( Analysis 8.6 ). Pregnancy rates from medical records did not differ significantly across comparison groups ( Analysis 8.7 ; Analysis 8.8 ).

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Comparison 8 Counseling + phone calls versus counseling versus standard care, Outcome 1 Consistent OC use: counseling + phone versus counseling.

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Comparison 8 Counseling + phone calls versus counseling versus standard care, Outcome 2 Condom use at last sex: counseling + phone versus counseling.

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Comparison 8 Counseling + phone calls versus counseling versus standard care, Outcome 3 Consistent OC use: counseling versus standard care.

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Comparison 8 Counseling + phone calls versus counseling versus standard care, Outcome 4 Condom use at last sex: counseling versus standard care.

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Comparison 8 Counseling + phone calls versus counseling versus standard care, Outcome 5 Would recommend OC use to a friend: counseling + phone versus counseling.

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Comparison 8 Counseling + phone calls versus counseling versus standard care, Outcome 6 Would recommend OC use to a friend: counseling versus standard care.

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Comparison 8 Counseling + phone calls versus counseling versus standard care, Outcome 7 Pregnancy by 12 months (counseling + phone vs counseling).

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Comparison 8 Counseling + phone calls versus counseling versus standard care, Outcome 8 Pregnancy by 12 months (counseling vs standard care).

Trent 2015 addressed adherence to DMPA injection appointments for urban women, 13 to 21 years old (N = 100). This pilot project was not powered for efficacy analysis. Both groups received standard care, i.e. clinic appointment reminders and a call from a nurse manager after missing a scheduled re‐injection appointment. The intervention group received daily text reminders for appointments starting three days before a scheduled appointment for DMPA injection. The intervention also included monthly health messages about use of condoms, weight control, DMPA side effect management, and STI testing. Intervention participants were called for a missed appointment or for no reply to an appointment reminder or other text message. The intervention and control groups did not differ significantly in the proportions that completed any injection cycle of three months each ( Analysis 9.1 ).

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Comparison 9 Text messages for injection appointments versus routine care, Outcome 1 Completed cycles.

Counseling plus provider training

Two cluster randomized trials trained providers on the intervention, including contraception counseling. Zhu 2009 provided comprehensive contraceptive counseling for participants. Harper 2015 focused on promoting long‐acting reversible contraception (LARC) such as intrauterine contraception (IUC) and the subdermal implant.

Zhu 2009 compared comprehensive counseling versus standard counseling for women aged 25 years or younger (16 sites; N = 2336). Participants had visited one of the study hospitals in China for an abortion. Providers had specific training for each intervention group. Both study arms had group counseling and referral to family planning services. The comprehensive package also included individual counseling, free provision of contraceptives, and involvement of male partner. The investigators used conditional logistic regression to account for hospital matching and robust variance estimates to account for clustering at the hospital level. Final models that were adjusted for potential confounding factors indicated significant effects. The investigators estimated relative effects using an interaction term to account for baseline differences. By six months, the comprehensive and standard counseling groups did not differ significantly for use of any contraceptive method or regular OC use ( Analysis 10.1 ) or for "unwanted" pregnancy or abortion ( Analysis 10.2 ). Women in the comprehensive counseling group were more likely to report using an effective contraceptive method at six months compared with those in the standard care group (reported adjusted OR 2.03, 95% CI 1.04 to 3.98) ( Analysis 10.1 ). The comprehensive‐counseling group was also more likely to use condoms consistently (reported adjusted OR 2.32, 95% CI 1.55 to 3.46), correctly (reported adjusted OR 2.78, 95% CI 1.81 to 4.26), as well as both consistently and correctly (reported adjusted OR 5.68, 95% CI 3.39 to 9.53) ( Analysis 10.3 ).

Comparison 10 Comprehensive versus standard counseling, Outcome 1 Contraceptive use at 6 months.

Comparison 10 Comprehensive versus standard counseling, Outcome 2 Pregnancy or abortion by 6 months.

Comparison 10 Comprehensive versus standard counseling, Outcome 3 Condom use at 6 months.

For Harper 2015 , providers at the intervention sites received training on LARC counseling and insertion of an IUD and implant. The other sites received no special training and provided usual care. Participants were women, 18 to 25 years old (40 sites; N = 1500). The primary outcome was LARC uptake at the clinic visit, but the report did not provide continuation data. For pregnancy rates, the investigators used Cox proportional hazards models with shared frailty to account for clustering. The study groups did not differ for pregnancy at one year based on unadjusted analysis ( Analysis 11.1 ) as well as covariate‐adjusted analysis ( Analysis 11.2 ). However, women from abortion care sites were more likely to become pregnant than those from family planning sites (reported adjusted OR 2.11, 95% CI 1.53 to 2.90) ( Analysis 11.2 ). The investigators also reported a significant interaction effect between visit type and the intervention ( Analysis 11.2 ). In further analysis, the investigators found that more women in the intervention group who chose LARCs could obtain the method in family planning visits (73%) than in abortion visits (44%).

Comparison 11 LARC training versus no LARC training for providers, Outcome 1 Pregnancy (per 100 person‐years) by 12 months.

Comparison 11 LARC training versus no LARC training for providers, Outcome 2 Pregnancy by visit type by 12 months.

Summary of main results

Five studies showed some evidence of strategy effectiveness. In some cases, lack of effect may be attributable to small sample sizes. The 'Summary of findings' tables contain results for our primary outcomes for which the study arms differed significantly. We have presented them in order of evidence quality.

Special counseling plus phone follow‐up was more effective than counseling alone on use of OCs and condoms among young women, 16 to 24 years old ( Table 1 ). Two other types of special counseling also had effects on contraceptive use compared with standard care ( Table 2 ). For women age 25 and younger, who were postabortion, a comprehensive package of contraceptive services resulted in more use of effective contraceptives and condoms. An intervention of developmental counseling led to more adolescents who used an effective contraceptive.

Utilizing an audiovisual tool plus counseling showed some associations with contraceptive use ( Table 3 ). Interventions included an audiovisual presentation (slide‐tape) plus reproductive health consultation for male adolescents, and a computer‐assisted decision aid plus standard counseling for young women, age 20 years and younger.

Three studies had results for our secondary outcomes of knowledge or attitude. Danielson 1990 and Chewning 1999 reported the intervention group had better knowledge of OCs compared with the control group. Berenson 2012 showed that women with counseling plus phone follow‐up were more willing to recommend OCs to a friend compared with women in the counseling‐only group.

Overall completeness and applicability of evidence

We did not find any studies in low‐ or middle‐income countries (LMIC) with high fertility rates for adolescents. As noted earlier, 95% of the 16 million births per year to adolescents 15 to 19 years old occur in LMIC ( Chandra‐Mouli 2014 ). In our review, 10 of the 11 included studies came from the USA, which had a 2014 birth rate of 24 per 1000 for 15‐ to 19‐year old adolescents. The remaining study was from China, where the comparable birth rate has been less than 8 per 1000 for the past decade. China's 'one‐child' policy, introduced in 1979, included mass education as well as mandatory IUD insertion, sterilization, and abortion ( Wang 2012 ). Although the Chinese government modified the program in the mid‐1990s ( Wang 2012 ), and further relaxed it in 2013 ( Connett 2015 ), the fertility rate remains low. In contrast, United Nations data show the birth rate for 15‐ to 19‐year‐old women in low‐income countries was 98 in 2014, and virtually all the rates over 90 were in Africa ( World Bank 2015 ). In LMIC combined, the fertility rate for young women 15 to 19 years old was 49. In many areas, young people may not have access to contraceptives due to cultural, economic, or logistical barriers. Studies to improve access may not have met our inclusion criteria, e.g. if they were not evaluating brief interventions or did not have a comparison group.

Most studies in our review recruited young women in family planning clinics. One focused on young men in medical offices and others on young women who were pregnant or postabortion. The types of interventions varied from novel counseling strategies to utilizing technology as an adjunct to counseling or to training providers on counseling and provision of more effective contraceptives.

Overall, we identified relatively few brief interventions for young people. Expansion of our search to include non‐randomized studies produced two additional studies that were eligible. Lengthier or more intensive interventions are more likely to be effective but may not be feasible for many clinics. Some community‐based interventions for young married people in LMIC were associated with improvements in contraceptive communication and uptake ( Sarkar 2015 ). However, many of those programs were multifaceted and did not meet our inclusion criteria.

Quality of the evidence

Of 11 studies, one provided high‐quality evidence, one was moderate quality, and one was high quality for the pregnancy outcome and moderate quality for contraceptive use ( Table 6 ). The main reasons for downgrading the quality of the evidence were not having an objective outcome measure (7 studies), high loss to follow‐up (5 studies), and limited reporting on intervention fidelity (4 studies). The four older studies that had evidence of very low quality were published before the development of standards for reporting trials in the late 1990s. The Consolidated Standards of Reporting Trials (CONSORT) statement was widely adopted in 2010 ( Schulz 2010 ). Of five studies that showed some effect, four provided evidence of low or very low quality.

C: contraceptive use outcome NA: not applicable NOS: Newcastle‐Ottawa Quality Assessment Scale NRS: non‐randomized study P: pregnancy outcome

a Downgrading: (1) intervention fidelity information < 4 criteria; (2) NRS: no NOS selection criterion met; (3a) risk of bias high for randomization sequence generation or allocation concealment or provided no information on either, or study was non‐randomized; (3b) NRS: no stars for comparability, i.e. control for confounding; (4) no objective outcome measure; (5) follow‐up < 6 months for contraceptive use or < 12 months for pregnancy; (6) loss to follow‐up > 20% b _ indicates not downgraded for that outcome

Sensitivity analysis

We planned to look separately at the studies with evidence of moderate or high quality. Only one study with evidence of intervention effect fit into that category ( Berenson 2012 ). That large RCT provided six monthly phone calls after counseling to encourage contraceptive use.

Given the difficulty and expense of assessing contraceptive use objectively, having an objective outcome measure might be considered too restrictive. Removing that criterion would bring only one trial with an intervention effect into the moderate‐quality range ( Zhu 2009 ).

Potential biases in the review process

As mentioned earlier, we did not attempt to contact investigators for details about studies that were more than 10 years old. We may have lacked information for grading the evidence quality in some studies. However, investigators are not likely to have access to details of older studies.

Agreements and disagreements with other studies or reviews

Several systematic reviews have studied interventions for young people. The scope generally differed from ours, so we cannot make direct comparisons. In one review, clinic‐based interventions for young people included new clinics, outreach, and provision of emergency contraception or condoms ( Blank 2012 ). Many of the 23 studies did not test an educational strategy, and some were not comparative. Two studies overlapped with those included in our review; others we excluded. The researchers reported the field lacked good‐quality studies of effectiveness and needed better outcome measures. A systematic review of interventions for adolescents addressed the broad area of sexual health ( Guse 2012 ). Of 10 studies, some were school‐based, which we considered for another review in development. Others were single‐arm, focused on HIV/STI rather than contraception, or did not have a behavioral outcome. Another review examined interventions using motivational interviewing to improve contraceptive use among women of child‐bearing age ( Wilson 2015 ). Three of eight reports (from two trials) overlapped with our review ( Kirby 2010 ; Ceperich 2011 ). Their meta‐analyses indicated an improvement in contraceptive use by four months but not by eight months. The researchers included data from two time points in the same trial. They did not see any intervention effect on pregnancies or births at 12 or 24 months.

A Cochrane review examined mobile phone interventions for improving contraceptive use ( Smith 2015 ). We included only one of five RCTs in our review due to different age ranges, and the investigators used a different outcome measure ( Trent 2015 ). The researchers did not find much evidence of effect in their review. A newer mobile phone intervention, based in Ghana, reported some effect ( Rokicki 2015 ). Text messages addressed to young women, age 14 to 23, included unidirectional and interactive strategies. Both methods reduced the likelihood of pregnancy and increased knowledge compared with the control group, but weekly messages for 12 weeks may be too intensive for most clinics.

Other recent efforts are promising but have not yet reported on contraceptive continuation. A brief counseling intervention for adolescents showed higher long‐acting reversible contraception (LARC) uptake at the initial visit, but has not yet reported on continuation at four months ( Wilson 2014 ). A cluster RCT in this review focused on women 18 to 25 years old. Providers were trained in LARC counseling and insertion. The report showed LARC uptake was greater for the intervention group but did not provide continuation at one year ( Harper 2015 ). Gilliam 2014 developed an iOS app for use in a clinic waiting room. The app addresses LARC as well as the range of contraceptive methods. A pilot RCT tested the app among women 15 to 30 years old. Use of the app increased knowledge of contraceptive effectiveness and interest in an implant. However, the study had no follow‐up, so outcomes did not include actual contraceptive use. Garbers 2015 tested the feasibility of an Internet‐based video on IUD use with a pre‐ and post‐test design. Participants were women age 18 to 45 years. For the full sample and for those 18 to 25 years old, knowledge about IUD use increased significantly, as did intent to use an IUD in the next three months. The study did not have any follow‐up to assess actual IUD use.

Chernick 2015b tested a referral system to family planning for adolescents who visit the emergency department. The strategy had a standard provider's script based on the transtheoretical model to encourage behavior change. The non‐randomized study compared results for the intervention group to records of non‐participants. The primary outcome was follow‐up for family planning within two months. Feasibility of the intervention was limited, as it only reached about one‐third of eligible adolescents. An ongoing study is using text messages to motivate and educate adolescents who visited the emergency department ( Chernick 2015a ).

Implications for practice

We found relatively few studies that tested brief strategies for this age group. About half the studies had some effect on contraceptive use or pregnancy. Types of interventions varied widely. One trial showed that phone follow‐up after counseling improved use of oral contraceptives and condoms. Other studies with some effect were generally older and had limited reporting. Their strategies included motivational interviewing for university women, comprehensive contraceptive services for young women postabortion, and developmental counseling on contraception for adolescents. One provided an audiovisual presentation plus counseling for young men, while another utilized a computer‐assisted decision aid and counseling for young women. We did not find many studies with contraceptive services tailored for younger people, even though their developmental stage may warrant adapting counseling to be effective.

Implications for research

The need is still great for strategies to improve contraceptive use among young people that are feasible for clinics. We examined RCTs and non‐randomized studies, but identified few brief strategies focused on this age group. Of five studies with some effect, one provided moderate quality evidence; four were older studies with low quality evidence. Many interventions for youth were too intensive to meet the criteria for brevity. While more extensive programs may be effective, they are unlikely to reach many young people if most clinics cannot implement them. Other potential studies focused on knowledge and intent to use contraceptives, but did not assess the behavioral outcomes of contraceptive use or pregnancy. A few examined contraceptive uptake at the initial visit but did not report on continuation. The field needs well‐designed and carefully implemented studies that test practical interventions to improve contraceptive use among young people.

Acknowledgements

We based the search strategies on earlier work of Carol Manion from FHI 360.

Appendix 1. Search strategy

Pubmed (7 march 2016).

("Contraception"[Mesh] OR "Contraception Behavior"[Mesh] OR "Contraceptive Agents"[Mesh] OR "Contraceptive Devices"[Mesh] OR pregnancy[ti] OR "family planning" OR contraceptive[tiab] OR contraception[tiab]) AND (educat*[ti] OR counsel*[ti] OR behavioral[ti] OR behavioural[ti] OR communicat*[ti] OR choice[ti] OR continuation[ti] OR adherence[ti]) AND (adolescent[MeSH] OR young adult[MeSH]) NOT (abortion[ti]) AND ( ( Clinical Trial[ptyp] OR Comparative Study[ptyp] OR Evaluation Studies[ptyp] ) )

CENTRAL (Issue 12, 2015 (15 December 2015))

Title, Abstract, Keywords: contracept* AND Record Title: educat* OR counsel* OR behavioral OR behavioural OR communicat* OR choice OR continuation OR adherence OR (pregnancy AND prevent*) AND Title, Abstract, Keywords: adolescent* OR teenage* OR youth OR young NOT Record Title: abortion

POPLINE (15 December 2015)

All Fields: youth OR young (adults OR women) Keyword: Contraception AND Education AND Contraceptive Usage AND Comparative Studies

Web of Science (15 December 2015)

(from All Databases)

TOPIC: (contracept*) AND TITLE: educat* OR counsel* OR behavioral OR behavioural OR communicat* OR choice OR continuation OR adherence OR (pregnancy AND prevent*) AND TOPIC: (adolescent* OR teenage* OR youth OR young) NOT TITLE: (abortion) Refined by: DOCUMENT TYPES: ( CLINICAL TRIAL ) Timespan: All years. Search language=Auto

ClinicalTrials.gov (16 November 2015)

Search Terms: youth OR adolescent OR adolescents OR young OR teen Study Type: Interventional Interventions: (contraception OR contraceptive OR pregnancy prevention OR family planning) AND (educational OR counseling OR behavioral OR communication OR continuation OR adherence) Title: NOT (advance OR palliative OR depression OR depressed OR suicide OR suicidal OR obese OR obesity)

WHO ICTRP (16 November 2015)

Title: youth OR adolescent OR adolescents OR young Intervention: contraception OR contraceptive OR pregnancy prevention OR family planning Recruitment status: All

Appendix 2. Newcastle‐Ottawa Quality Assessment Scale for cohort studies

Developers' version of the instrument ( Wells 2014)

Note : A study can be awarded a maximum of one star (✸) for each numbered item within the Selection and Outcome categories. A maximum of two stars can be given for Comparability.

1) Representativeness of the exposed cohort

a) truly representative of the average _______________ (describe) in the community ✸ b) somewhat representative of the average ______________ in the community ✸ c) selected group of users eg nurses, volunteers d) no description of the derivation of the cohort

2) Selection of the non exposed cohort

a) drawn from the same community as the exposed cohort ✸ b) drawn from a different source c) no description of the derivation of the non exposed cohort

3) Ascertainment of exposure

a) secure record (eg surgical records) ✸ b) structured interview ✸ c) written self report d) no description

4) Demonstration that outcome of interest was not present at start of study

a) yes ✸ b) no

Comparability

1) Comparability of cohorts on the basis of the design or analysis

a) study controls for _____________ (select the most important factor) ✸ b) study controls for any additional factor ✸ (This criterion could be modified to indicate specific control for a second important factor.)

1) Assessment of outcome

a) independent blind assessment ✸ b) record linkage ✸ c) self report d) no description

2) Was follow‐up long enough for outcomes to occur

a) yes (select an adequate follow up period for outcome of interest) ✸ b) no

3) Adequacy of follow up of cohorts

a) complete follow up; all subjects accounted for ✸ b) subjects lost to follow up unlikely to introduce bias; small number lost: > ____ % (select an adequate %) follow up, or description provided of those lost) ✸ c) follow up rate < ____% (select an adequate %) and no description of those lost d) no statement

Data and analyses

Comparison 1, comparison 2, comparison 3, comparison 4, comparison 5, comparison 6, comparison 7, comparison 8, comparison 9, comparison 10, comparison 11, characteristics of studies, characteristics of included studies [ordered by study id].

DMPA: depot medroxyprogesterone acetate IUD: intrauterine device LARC: long‐acting reversible contraception OC: oral contraceptive OR: odds ratio RCT: randomized controlled trial STI: sexually transmitted infection

Characteristics of excluded studies [ordered by study ID]

HIV: human immunodeficiency virus OC: oral contraceptive

Characteristics of studies awaiting assessment [ordered by study ID]

LARC: long‐acting reversible contraception RCT: randomized controlled trial

Characteristics of ongoing studies [ordered by study ID]

RCT: randomized controlled trial STI: sexually transmitted infection WHO: World Health Organization

Contributions of authors

L Lopez initiated the review and developed the search strategies. L Lopez and T Grey reviewed the search results and full text of relevant articles. They extracted, entered, and checked the data. M Chen contributed to the analysis sections of the Methods. He reviewed the assessment of evidence quality and helped with the statistical interpretation of results. EE Tolley contributed to the Background and the Criteria for considering studies. All authors reviewed and commented on the manuscript.

Sources of support

Internal sources.

No sources of support supplied

External sources

Support for conducting the review at FHI 360

Declarations of interest

Laureen Lopez has no known conflict of interest.

Thomas Grey has no known conflict of interest.

Elizabeth Tolley has no known conflict of interest.

Mario Chen has no known conflict of interest.

References to studies included in this review

Berenson 2012 {published and unpublished data}.

Berenson AB, Rahman M. A randomized controlled study of two educational interventions on adherence with oral contraceptives and condoms . Contraception 2012; 86 ( 6 ):716‐24. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Ceperich 2011 {published and unpublished data}

Ceperich SD, Ingersoll KS. Motivational interviewing + feedback intervention to reduce alcohol‐exposed pregnancy risk among college binge drinkers: determinants and patterns of response . Journal of Behavioral Medicine 2011; 34 ( 5 ):381‐95. [ PMC free article ] [ PubMed ] [ Google Scholar ]
Ingersoll KS, Ceperich SD, Nettleman MD, Karanda K, Brocksen S, Johnson BA. Reducing alcohol‐exposed pregnancy risk in college women: initial outcomes of a clinical trial of a motivational intervention . Journal of Substance Abuse Treatment 2005; 29 ( 3 ):173‐80. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Chewning 1999 {published data only}

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Gilliam 2004 {published data only (unpublished sought but not used)}

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Harper 2015 {published data only (unpublished sought but not used)}

Harper CC, Rocca CH, Thompson KM, Morfesis J, Goodman S, Darney PD, et al. Reductions in pregnancy rates in the USA with long‐acting reversible contraception: a cluster randomised trial . Lancet 2015; Vol. 386, issue 9993:562–8. [ PubMed ]

Jay 1984 {published data only}

Jay MS, DuRant RH, Shoffitt T, Linder CW, Litt IF. Effect of peer counselors on adolescent compliance in use of oral contraceptives . Pediatrics 1984; 73 ( 2 ):126‐31. [ PubMed ] [ Google Scholar ]

Kirby 2010 {published and unpublished data}

Kirby D, Raine T, Thrush G, Yuen C, Sokoloff A, Potter SC. Impact of an intervention to improve contraceptive use through follow‐up phone calls to female adolescent clinic patients . Perspectives on Sexual and Reproductive Health 2010; 42 ( 4 ):251‐7. [ PMC free article ] [ PubMed ] [ Google Scholar ]

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Trent 2015 {published and unpublished data}

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References to studies excluded from this review

Aubrey 2014 {published data only}.

Aubrey JS, Behm‐Morawitz E, Kim K. Understanding the effects of MTV's 16 and Pregnant on adolescent girls' beliefs, attitudes, and behavioral intentions toward teen pregnancy . Journal of Health Communication 2014; 19 ( 10 ):1145‐60. [ PubMed ] [ Google Scholar ]

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Castaño 2012 {published data only}

Castaño PM, Bynum JY, Andrés R, Lara M, Westhoff C. Effect of daily text messages on oral contraceptive continuation: a randomized controlled trial . Obstetrics and Gynecology 2012; 119 ( 1 ):14‐20. [NCT00677703] [ PubMed ] [ Google Scholar ]
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Charron‐Prochownik D, Sereika SM, Becker D, White NH, Schmitt P, Powell AB 3rd, et al. Long‐term effects of the booster‐enhanced READY‐Girls preconception counseling program on intentions and behaviors for family planning in teens with diabetes . Diabetes Care 2013; 36 ( 12 ):3870‐4. [ PMC free article ] [ PubMed ] [ Google Scholar ]

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Ekstrand M, Larsson M, Darj E, Tydén T. Advance provision of emergency contraceptive pills reduces treatment delay: a randomised controlled trial among Swedish teenage girls . Acta Obstetricia et Gynecologica Scandinavica 2008; 87 ( 3 ):354‐9. [ PubMed ] [ Google Scholar ]

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Erickson PI. Lessons from a repeat pregnancy prevention program for Hispanic teenage mothers in east Los Angeles . Family Planning Perspectives 1994; 26 ( 4 ):174‐8. [ PubMed ] [ Google Scholar ]

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Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women's sexual and contraceptive behaviors . Journal of Pediatric and Adolescent Gynecology 2004; 17 ( 2 ):87‐96. [ PubMed ] [ Google Scholar ]

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Núñez Rocha GM, Alanís Alanís MJ, Alanís Salazar J, Salinas Martínez AM, Garza Elizondo ME, Villarreal Ríos E. Differences in the use of family planning methods by adolescent females according to the education model utilized during pregnancy. Monterrey, Mexico [Diferencias en la utilizacion de metodos de planificacion familiar por mujeres adolescentes en Monterrey, Mexico, segujn el modelo de educacion sanitaria utilizado]. Revista Española de Salud Pública 2005; 79 ( 1 ):69‐77. [ PubMed ] [ Google Scholar ]

Roye 2007 {published and unpublished data}

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Stephenson 2008 {published data only}

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Topatan 2015 {published data only}

Topatan S, Demirci N. The efficiency of reproduction health education given to adolescents during the postpartum period . Journal of Pediatric and Adolescent Gynecology 2015; 28 ( 5 ):297‐303. [ PubMed ] [ Google Scholar ]

Ullman 1996 {published data only}

Ullman R, Lathrop L. Impact of free condom distribution on the use of dual protection against pregnancy and sexually transmitted disease . Canadian Journal of Human Sexuality 1996; 5 ( 1 ):25‐9. [ PubMed ] [ Google Scholar ]

Van Dover 1985 {published data only}

Dover LJ. Influence of Nurse‐Client Contracting on Family Planning Knowledge and Behaviors in a University Student Population . Ann Arbor, MI (USA): University Microfilms International, 1985. [ Google Scholar ]
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Dover LJ. Use of nurse‐client contracting to reduce risk of unintended pregnancy in an adolescent population . Annual Meeting of American Public Health Association; 1985 November 17‐21; Chicago (IL) . Chicago: American Public Health Association, 1985. [http://files.eric.ed.gov/fulltext/ED269699.pdf]

References to studies awaiting assessment

Wilson 2014 {published data only}.

NCT02157285. Influence of Peer Mentoring on Adolescent Contraceptive Decision Making (ImPACCT) . https://clinicaltrials.gov/ct2/show/NCT02157285 (accessed 28 May 2015).
Wilson S, Ratcliffe S, Schreiber C. Impact of peer adolescent counseling on contraceptive choice in teens (IMPACCCT) . Contraception 2014; 90 ( 3 ):296. [ Google Scholar ]

References to ongoing studies

Chernick 2015a {published data only}.

Chernick LS. A pilot study using text messaging to communicate with adolescent females in the pediatric emergency department (T2I) . https://clinicaltrials.gov/show/NCT02093884 (accessed 5 October 2015).

Downs 2015 {published data only}

Downs JS. Teen video study to reduce risky driving and sexual behavior in adolescents (TVS) . https://clinicaltrials.gov/ct2/show/NCT02049710 (accessed 2 October 2015).
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Stein 2015 {published data only}

Stein L. Contraceptive awareness and reproductive education . https://clinicaltrials.gov/ct2/show/NCT01627574 (accessed 5 October 2015).

Additional references

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COMMENTS

Contraception Relationships and Sex Education lesson plan
Contraception Relationships and Sex Education lesson plan - for use with Contraception Choices website www.contraceptionchoices.org This lesson plan has been designed as a 1 hour class for use with students to provide detailed information about contraceptive methods and practical considerations when considering starting or switching contraception.
CONTRACEPTION GRADE Lesson 1 CALM - Teaching Sexual Health
4and should only be used as a back up method and not as routine birth control. C. BIRTH CONTROL KIT (SENIOR HIGH) (15-20 min) Students examine and learn about specific contraceptive methods. The Birth Control Kit (Senior High) is an optional tool that may be used to assist in teaching the common methods of contraception. The use of oral
Lesson Plan – Contraception Part I - Advocates for Youth
1) Critical thinking skills to evaluate the benefits of various methods of contraception. RESOURCE MATERIALS FOR TEACHER: [Teacher’s Note: If you are able to get any sample birth control methods to include in the envelopes, that is ideal, but pictures from the internet or simply the Contraceptive Chart used with this lesson can suffice if ...
Family planning/contraception methods
Between 2000 and 2020, the number of women using a modern contraceptive method increased from 663 million to 851 million. An additional 70 million women are projected to be added by 2030. Between 2000 and 2020, the contraceptive prevalence rate (percentage of women aged 15–49 who use any contraceptive method) increased from 47.7 to 49.0% (5).
Contraception | Reproductive Health | CDC
Birth Control Methods. Many elements need to be considered when choosing a contraceptive method. These include safety, effectiveness, availability (including accessibility and affordability), side effects, user control, reversibility, and ease of removal or discontinuation. Contraceptive methods should be chosen through voluntary, informed choice.
Patient education: Birth control; which method is right for ...
The only injectable method of birth control currently available in the United States is medroxyprogesterone acetate or DMPA (Depo-Provera). This is a progestin hormone, which is long-lasting. DMPA is injected deep into a muscle, such as the buttock or upper arm, once every three months.
Grade 8: Condoms and Other Birth Control Methods
Grade 8: Condoms and Other Birth Control Methods . Overview . Students review methods of birth control, then focus on correct condom use and benefits. Students participate in a small group activity where they lineup the steps of using a condom in correct order, then watch their teacher and/or a video describe the steps and demonstrate on their ...
Module 2: Contraceptive Methods - gfmer.ch
Contraceptive methods Part 2 - Progestogen-only contraceptives. Contraceptive methods Part 3. Contraceptive methods Part 4. B. Assignment. Complete and submit your answers to the multiple-choice questions (MCQs) for the module. You will receive the link to the MCQs by email. Complete and submit the short paperwork assignment.
Mechanisms of action and effectiveness of contraceptive ...
Mechanisms of action and effectiveness of contraceptive methods Method How it works Effectiveness: pregnancies per 100 women per year with consistent and correct use Effectiveness: pregnancies per 100 women per year as commonly used Combined oral contraceptives (COCs) or “the pill” Prevents the release of eggs from the ovaries (ovulation)
Brief educational strategies for improving contraception use ...
In sub‐Saharan Africa, South Central Asia, and Southeast Asia, 68% of women aged 15 to 19 years want to avoid pregnancy but are not using a modern contraceptive method, and the figure is 51% for women aged 20 to 24 years old (Darroch 2011). In addition, 87% of unintended pregnancies occur among women who do not use a modern contraceptive method.