Abstract
Mobile phones for health (mHealth) hold promise for delivering behavioral interventions. We evaluated the effect of automated interactive voice messages promoting contraceptive use with a focus on long-acting reversible contraceptives (LARCs) among women in Bangladesh who had undergone menstrual regulation (MR), a procedure to "regulate the menstrual cycle when menstruation is absent for a short duration." We recruited MR clients from 41 public- and private-sector clinics immediately after MR. Eligibility criteria included having a personal mobile phone and consenting to receive messages about family planning by phone. We randomized participants remotely to an intervention group that received at least 11 voice messages about contraception over 4 months or to a control group (no messages). The primary outcome was LARC use at 4 months. Adverse events measured included experience of intimate partner violence (IPV). Researchers recruiting participants and 1 analyst were blinded to allocation groups. All analyses were intention to treat. The trial is registered with ClinicalTrials.gov (NCT02579785). Between December 2015 and March 2016, 485 women were allocated to the intervention group and 484 to the control group. We completed follow-up on 389 intervention and 383 control participants. Forty-eight (12%) participants in the intervention group and 59 (15%) in the control group reported using a LARC method at 4 months (adjusted odds ratio [aOR] using multiple imputation=0.95; 95% confidence interval [CI]=0.49 to 1.83; P=.22). Reported physical IPV was higher in the intervention group: 42 (11%) intervention versus 25 (7%) control (aOR=1.97; 95% CI=1.12 to 3.46; P=.03) when measured using a closed question naming acts of violence. No violence was reported in response to an open question about effects of being in the study. The intervention did not increase LARC use but had an unintended consequence of increasing self-reported IPV. Researchers and health program designers should consider possible negative impacts when designing and evaluating mHealth and other reproductive health interventions. IPV must be measured using closed questions naming acts of violence.
Highlights
Bangladesh has seen a rapid increase in use of contraception over the last 40 years; among married women in Bangladesh, 12% wanted to delay or Effects of Phone Messages to Support Contraceptive Use in Bangladesh www.ghspjournal.org stop childbearing but were not using a method in 2014.1 48% of all pregnancies in Bangladesh are estimated to be unintended, leading to health, social, and economic costs for women and their families.[2,3] The type of contraceptives women use has implications for unintended pregnancies: long-acting reversible contraceptives (LARCs)—intrauterine devices (IUDs) and implants—are the most effective reversible methods, with failure rates of between 0.1% and 0.8% in the first year of typical use.[4]
Reported physical intimate partner violence (IPV) was higher in the intervention group: 42 (11%) intervention versus 25 (7%) control when measured using a closed question naming acts of violence
Women were recruited from 41 health facilities sampled from 93 eligible clinics: clinics located in Chittagong, Dhaka, or Sylhet division,[1] were an Marie Stopes Bangladesh (MSB) facility or a government facility supported by Ipas Bangladesh, had a minimum monthly menstrual regulation (MR) case load of 20, and had no other intervention study underway at the start of recruitment
Summary
Bangladesh has seen a rapid increase in use of contraception over the last 40 years; among married women in Bangladesh, 12% wanted to delay or Effects of Phone Messages to Support Contraceptive Use in Bangladesh www.ghspjournal.org stop childbearing but were not using a method in 2014.1 48% of all pregnancies in Bangladesh are estimated to be unintended, leading to health, social, and economic costs for women and their families.[2,3] The type of contraceptives women use has implications for unintended pregnancies: long-acting reversible contraceptives (LARCs)—intrauterine devices (IUDs) and implants—are the most effective reversible methods, with failure rates of between 0.1% and 0.8% in the first year of typical use.[4] In contrast, short-acting methods have higher typical-use failure rates of 4% (the injectable), 7% (the pill), and 13% (male condoms).[4] LARCs have low levels of discontinuation and high user satisfaction.[5,6] In Bangladesh, 62% of married women of reproductive age use contraception, but just 2% use a LARC and 30% of contraceptive users discontinue their method within a year.[1] awareness of contraceptive methods in Bangladesh is high,[7] many women lack accurate information on method attributes, for long-acting methods, and fear of negative effects is common.[7] Increased information provision about LARCs has been shown to increase uptake of these methods.[8]. We evaluated the effect of automated interactive voice messages promoting contraceptive use with a focus on long-acting reversible contraceptives (LARCs) among women in Bangladesh who had undergone menstrual regulation (MR), a procedure to “regulate the menstrual cycle when menstruation is absent for a short duration.”
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