Contraceptive counseling and use with a focus on migrant women in Sweden

INTRODUCTION: Sweden has a high unmet need of contraception resulting in high rates of induced abortions compared with other Northern European countries. The highest abortion rates are seen among women 25-29 years of age. Findings show that Swedish women use less effective contraceptive methods despite the effectiveness of a method being reported as the most important factor when choosing a method. There are no consistent recommendations on how to provide contraceptive counseling. However, previous international studies have stated a higher uptake of long-acting reversible contraception (LARC) and lower pregnancy rates, after counseling focusing on the effectiveness of different methods. Additionally, earlier research states that migrant women in Sweden have lower contraceptive use and a higher proportion of abortions compared with non-migrants. Reasons for the lower use have been explained by access, language and knowledge barriers. However, not many Swedish studies have explored migrant women’s own perspectives on contraception.

AIM: This thesis aims to get a better understanding of migrant women’s contraceptive use and perspectives on contraception, but also to present a new way of providing contraceptive counseling. All with the aim of improving access and quality of contraceptive counseling and use.

METHODS: Study I was an observational cross-sectional study conducted at abortion clinics in Stockholm. This study aimed to compare contraceptive use and methods, ever-in life, at conception and future planned, after an induced abortion. The comparisons were conducted between migrants, second-generation migrants and non-migrant women. Study II was a cluster randomized controlled trial conducted at abortion, youth and maternal health clinics in Stockholm. The aim was to evaluate effects of structured contraceptive counseling on LARC uptake and pregnancy rates (Paper II). Further, we evaluated effects of LARC uptake and use, as well as satisfaction with the structured counseling among migrants, second-generation migrants and non-migrant participants (Paper III). Study III was a qualitative study using content analysis with an inductive approach. We performed interviews with foreign-born migrants from Iran, Iraq and Syria. In this study we aimed to explore the migrant women’s perceptions and experiences of contraceptive counseling and use.

FINDINGS: Migrants and second-generation migrants had a lower contraceptive use ever-in life compared with non-migrant participants. Further, differences were seen in contraceptive methods ever-in life but also planned to be used after the abortion, between the groups. More migrants and second-generation migrants planned to use a LARC method compared with non-migrants after the abortion. Migrants had received sexuality education and contraceptive counseling to a lower extent compared with second-generation migrants and non-migrants. Additionally, migrants stated to a lower extent that they did not have sufficient knowledge to choose a contraceptive method after the abortion compared with second-generation migrants and non-migrants (Study I). Participants who had received the structured contraceptive counseling had a higher LARC uptake compared with participants who had received routine counseling. Additionally, participants who had received the structured contraceptive counseling had less pregnancies at 12 months post-abortion (Paper II). Further, we found that the structured counseling increased LARC uptake and use at 12 months, when controlled for migration background. Also, all the participants were satisfied with the counseling material. However, migrants and second-generation migrants stated to a higher extent that the effectiveness chart was supportive in contraceptive choice as compared with non-migrants (Paper III) (Study II). The foreign-born migrants shared that taboos, such as having no premarital sex and no sex at a young age, influenced their perceptions and experiences of contraceptive counseling and use. They had developed own strategies to be able to use contraception despite the influence of these taboos. Further, the foreign-born migrants shared specific needs from the healthcare provider during the counseling encounter. These were to discuss myths and misconceptions regarding contraception, to receive counseling free of stress and without judgmental attitudes. Additionally, it was shared that audiovisual material can facilitate the counseling if receiving it in a language other than one’s native language (Study III).

CONCLUSION: A lower contraceptive use ever-in life was seen among migrants and second-generation migrants compared with non-migrants. Differences in contraceptive methods were also seen between the groups (Study I). Structured contraceptive counseling can increase LARC uptake and decrease pregnancy rates 12 months post-abortion (Paper II). Structured contraceptive counseling can also increase LARC uptake and use, when controlled for migration background. Additionally, a higher proportion of foreign-born migrants and second-generation migrants found the effectiveness chart to be supportive in contraceptive choice compared with non-migrants (Paper III) (Study II). Taboos influence foreign-born migrants’ perceptions and experiences of contraception, leading to development of own strategies and specific needs from the HCP during the contraceptive counseling (Study III).

List of scientific papers

I. Emtell Iwarsson K*, Larsson EC*, Gemzell-Danielsson K, Essén B, Klingberg-Allvin M. Contraceptive use among migrant, second-generation migrant and non-migrant women seeking abortion care: a descriptive cross-sectional study conducted in Sweden. BMJ Sex Reprod Health. 2019 Jan;bmjsrh-2018-200171. *Shared first authorship.
https://doi.org/10.1136/bmjsrh-2018-200171

II. Emtell Iwarsson K*, Envall N*, Bizjak I, Bring J, Kopp Kallner H, Gemzell-Danielsson K. Increasing uptake of long-acting reversible contraception with structured contraceptive counselling: cluster randomised controlled trial (the LOWE trial). BJOG. 2021 Aug;128(9):1546-1554. *Shared first authorship.
https://doi.org/10.1111/1471-0528.16754

III. Emtell Iwarsson K, Larsson EC, Bizjak I, Envall N, Kopp Kallner H, Gemzell-Danielsson K. Long-acting reversible contraception and satisfaction with structured contraceptive counselling among non-migrant, foreign-born migrant and second-generation migrant women: evidence from a cluster randomised controlled trial (the LOWE trial) in Sweden. BMJ Sex Reprod Health. 2022 Apr;48(2):128-136.
https://doi.org/10.1136/bmjsrh-2021-201265

IV. Emtell Iwarsson K, Klingberg-Allvin M, Gemzell-Danielsson K, Larsson EC. Perceptions and experiences of contraceptive counselling and use among foreign-born women from the Middle East: a qualitative study from Sweden. [Manuscript]