Peri-abortion contraceptive counseling: A systematic review of randomized controlled trials.

OBJECTIVE: To assess the effects of peri-abortion contraceptive counseling interventions.
METHODS: We performed a systematic review of randomized controlled trials (RCTs) that compared the effect of different types of peri-abortion contraceptive counseling interventions and were published as original papers in scientific journals. The literature search was performed in June 2021 in PubMed, Central Cochrane Library (CENTRAL), Scopus, and Google Scholar; without restrictions in language or publication date. Two independent authors identified studies that met the inclusion and exclusion criteria and extracted the data. The risk of bias was assessed using the Cochrane tool, and evidence certainty was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Whenever possible, meta-analyses were performed. The protocol was registered at PROSPERO (CRD42020187354).
RESULTS: Eleven RCTs were eligible for inclusion (published from 2004 to 2017), from which nine compared enhanced versus standard counseling. Pooled estimates showed that, compared to standard counseling, enhanced counseling was associated with a higher incidence of effective contraceptive use (>3 months) (relative risk [RR], 1.12; 95% confidence interval [CI], 1.09-1.16), although no significant difference was found in the incidence of long-acting reversible contraceptive use (RR, 1.25; 95% CI, 0.68-2.29), contraceptive uptake (RR, 1.06; 95% CI, 0.98-1.15), and obstetric event occurrence (RR, 0.91; 95% CI, 0.57-1.47). Certainty of evidence was very low for all outcomes. In addition, two studies compared contraceptive counseling provided by physicians versus that provided by non-physicians, which did not show significant differences.
CONCLUSIONS: Enhanced contraceptive counseling may favor effective contraceptive use but may not affect the rate of obstetric event occurrence. Also, the studies did not find a difference in the effects of counseling interventions given by different providers. Since evidence certainty was very low, future well-designed RCTs are needed to make informed decisions. REGISTRATION: The study protocol was registered at PROSPERO (CRD42020187354).

Introduction

Worldwide, from 2015 to 2019, approximately 121.0 million women had unintended pregnancy annually, of which 61% ended in abortion [1]. After a safe abortion procedure (either medical or surgical), fertility is not compromised, and women can start ovulation as early as eight days after abortion [2]. Thus, the risk of a further unintended pregnancy and abortion is not negligible [3].

Peri-abortion contraceptive counseling (either shortly before or shortly after abortion) could help prevent unintended pregnancies and other abortions [4]. However, these counseling interventions are provided using different strategies, structures, content, and healthcare providers [5] and seem to show heterogeneous results [6, 7].

Previous systematic reviews that evaluated peri-abortion contraceptive counseling [3, 6] were performed several years ago and did not assess the certainty of the evidence. Therefore, we performed a systematic review to summarize the available data from randomized controlled trials (RCTs) that evaluated the effects of peri-abortion contraceptive counseling interventions.

Methods

Design, protocol information, and patient involvement

We performed a systematic review, which was written according to the PRISMA 2020 statement. The study protocol was registered at PROSPERO (CRD42020187354), and there were no subsequent changes to the protocol. Raw data of the included studies can be accessed at https://figshare.com/s/a62bcb6af46d3e692327. Of note, patients and other relevant actors were not involved in this review

Eligibility criteria

We performed a systematic review that assessed all RCTs that were published as original papers in scientific journals, which compared the effect of different types of peri-abortion (either shortly before or shortly after abortion) contraceptive counseling interventions (which could involve material and/or human resources). We defined standard counseling as the intervention regularly practiced in the study context and enhanced counseling as the new intensified strategy considered for the trial. No restrictions in language or publication date were applied.

Information sources and search strategy

We performed a literature search of four sources: PubMed, Central Cochrane Library (CENTRAL), Scopus, and Google Scholar. Since Google Scholar sorts its results starting with those that have the best match with the search terms, we consider that evaluating the first 100 results would include all relevant studies on the subject in this repository, a methodology that has been used in previous systematic reviews [8-11].

We searched the articles using the terms “counseling” (A), “abortion” (B), and “randomized controlled trial” (C), with the following syntax: A AND B AND C. The detailed search strategies for each search source are available in .

Selection process

The search was performed in two steps: 1) systematic search in four databases and 2) review of all references of the studies included in Step 1.

For step 1, we performed a literature search in June 2021, downloaded all results to an EndNote X8 document, and eliminated duplicated articles using this software. Subsequently, we assessed the titles and abstracts of each reference to identify potential studies for inclusion. Lastly, we assessed the full text of these potential studies to determine their eligibility.

For Step 2, we reviewed all references of studies that were included in Step 1 and collected new articles that met the inclusion criteria.

Both steps were performed independently by two authors. When disagreements were found, they were discussed by all authors and resolved by consensus.

Data collection process

Two authors independently extracted the following information for the included studies into a Microsoft Excel sheet: author, year of publication, year of collection, title, country, population (inclusion and exclusion criteria), setting, peri-abortion contraceptive counseling given to the intervention and comparator groups (using the Template for Intervention Description and Replication (TIDieR) data extraction tool) [12], and results for all outcomes assessed in the studies. In case of disagreements, the full-text articles were reviewed again by all authors.

Outcomes of interest

We evaluated the effect of contraceptive counseling interventions on contraceptive use (when an effective contraceptive method was used for more than three months), contraceptive uptake (when selected immediately after counseling), and obstetric event recurrence.

We considered effective contraceptive methods as any of the following: oral contraceptives, patch, ring, monthly injectable, quarterly injectable, condom, implant, vaginal ring, contraceptive patch, intrauterine device (IUD), intrauterine system (IUS), and sterilization or vasectomy. We considered long-acting reversible contraceptives (LARC) as any of the following: IUD, IUS/hormonal IUD, and implant. We considered obstetric events as either an unintended pregnancy or another induced abortion after counseling.

Evaluation time was considered as the moment in which the result was evaluated. This definition was applied for the outcomes of “use” and “uptake.” Moreover, the follow-up time was considered as the maximum time that the participants were followed in each study. This definition was applied for the outcome of “occurrence of an obstetric event.”

Risk-of-bias assessment

To evaluate the risk of bias of included RCTs, we used the Cochrane risk-of-bias tool for randomized trials [13], which assesses the risk of bias in seven domains: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcomes assessment, incomplete outcome data, selective reporting, and other potential threats to validity.

Synthesis methods

Whenever more than one study assessed a similar PICO (Population, Intervention, Control, and Outcome) question and the frequency of study events was greater than one in each group, we performed meta-analyses to summarize their results.

We assessed heterogeneity using an I2 statistic, and heterogeneity was arbitrarily categorized using cutoff points agreed by the authors as not important (I2 < 40%), moderately significant (I2 = 40%–75%), and considerable (I2 > 75%) [13]. We considered it appropriate to use random-effects models due to the overall heterogeneity of the interventions received by the participants in each study [14]. The data were processed using Review Manager 5.4 software.

Publication bias was not statistically assessed since the number of studies pooled for each meta-analysis was less than ten [14].

Certainty assessment

To assess the certainty of the evidence for each outcome, we used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology [15, 16], which evaluates the study design, risk of bias, inconsistency, indirectness, imprecision, and publication bias.

Results

Study selection

We found 908 articles in the database search. After duplicates were removed, we screened 681 articles, from which 60 underwent full-text review. Then, 50 articles were excluded (detailed reasons for excluding these records are shown in ), and 10 studies were included [17-26]. Subsequently, we screened the 284 references of these 10 articles, from which one new study was included [27], for a total of 11 included studies (.

Study characteristics

Studies’ characteristics are summarized in and presented at length in . Moreover, the characteristics of the interventions in each study were identified in detail with the help of the TIDieR tool (.

The 11 included studies were published between 2004 and 2017 but performed between 1999 and 2016. All were published in full-text in english. Three studies were performed in the USA [19, 20, 26], while the other eight were conducted in different countries. Regarding the continents, of 11 studies, four were performed in North America [19, 20, 23, 26], three in Europe [17, 22, 24], two in Asia [25, 27], one in East Africa [21], and one in South America [18].

Of the 11 included studies, seven showed the age means, ranging from 22.8 to 26.8 years. Furthermore, seven studies reported the frequency of previous abortion in their populations, ranging from 27.6% [18] to 50.5% [19]. The sample size ranged from 43 to 2336, and the follow-up period ranged from immediately to 16 weeks.

The included studies assessed two comparisons: nine studies compared enhanced contraceptive counseling and standard contraceptive counseling, provided to women before or after an abortion, while the other two studies compared abortion provision and contraceptive counseling, provided by physicians versus non-physician (nurses in one study and midwives in the other study) (. Furthermore, of 11 studies, six reported that the intervention was adjusted to the needs of each patient [17, 18, 20, 22, 25, 26], three [23, 24, 27] did not specify it, and two were not [19, 21] (more details in ).

Risk of bias in studies

Among the 11 included studies, only one had a low risk of bias in all Cochrane Tool items (Whitaker 2016) [26], while nine adequately generated the randomization sequence, seven appropriately concealed allocation, three blinded participants and personnel, two blinded outcome evaluators, seven did not report a significant number of missing outcome data, and four had a protocol available where no selective outcome reporting was found ().

Summary of the results

We found that nine studies compared standard care and enhanced contraceptive counseling [17–20, 22, 24–27], while the other two studies compared contraceptive counseling provided by a physician versus non-physician [21, 23].

Regarding the comparison of standard and enhanced contraceptive counseling, the definition of each outcome differed across studies, as detailed in . Moreover, each study had a particular way to enhance their regular contraceptive counseling, such as the addition of pre-abortion counseling sessions [17], enhancement of contraception provision [24], personalized contraceptive counseling [22], use of audiovisual material [19, 20], several stage counseling [18], mobile phone interventions [25], and motivational interview [26], as detailed in .

Pooled analysis showed that, compared to standard care, enhanced contraceptive counseling might increase the incidence of effective contraceptive method use (eight RCTs; relative risk [RR], 1.12; 95% CI, 1.09–1.16; I2 = 93%), may have little to no effect on the incidence of LARC use (three RCTs; RR, 1.25; 95% CI, 0.68–2.29; I2 = 68%), may have little to no effect on the incidence of effective contraceptive method uptake (five RCTs; RR, 1.06; 95% CI, 0.98–1.15; I2 = 84%), and may have little to no effect on the incidence of obstetric event occurrence (three RCTs; RR, 0.91; 95% CI, 0.57–1.47; I2 = 63%); however, the evidence is very uncertain for these results. Meta-analyses are shown in , and the Summary of Findings table is shown in .

Regarding the comparison of counseling provided by physicians and non-physicians, two RCTs were included: Olavarrieta 2015 (N = 884) and Makenzius 2017 (N = 803) [21, 23]. Due to the differences in the control group of the studies, we did not perform a meta-analysis.

Olavarrieta 2015 [23] compared counseling provided by physicians with counseling provided by nurses and did not find significant differences in the proportion of women prescribed contraceptives (nurse group: 99.1%, physician group: 98.7%), in the type of contraceptive prescribed, and in the proportion of women leaving the facility with at least one contraceptive method (96.7% vs 97.3%). However, the use of an intrauterine device was higher in the “physician group” than in the “nurse group” (31.3% vs 24.0%), while condom use was higher in the “nurse group” than in the “physician group” (19.2% vs 10.6%).

Makenzius 2017 [21] compared counseling provided by physicians and counseling provided by midwifes, and did not find significant differences in the proportion of women who received contraceptive counseling (midwife group: 98%, physician group: 98%), and in the accepted contraceptive method (74% vs 77%).

Discussion

Two previous systematic reviews also assessed the effect of enhanced and standard peri-abortion contraceptive interventions [3, 6]. The systematic review of Ferreira [6] had its last search in 2007, which included three RCTs [17, 22, 24], and did not find any differences regarding contraceptive acceptance and use. The systematic review of Stewart [3] had its last search in 2014, included six RCTs [17, 18, 20, 22, 24, 27], and did not find differences in subsequent unplanned pregnancy rate, uptake of LARC, or continued use of selected contraceptive methods [3, 6]. Our review assessed all these outcomes and included a total of nine RCTs that compared standard and enhanced interventions, five of which were not in previous systematic reviews [3, 6].

Contraceptive use

Regarding the contraceptive use outcome, the meta-analysis showed that the enhanced counseling group had a higher incidence of this outcome compared with the standard counseling group. However, study results were heterogeneous. Four studies had a high uptake incidence in their control group (Bender, 85.2%; Langston, 73.5%; Schunmann, 98.6%; Zhu, 89.4%), so the enhanced counseling group could not have a much higher incidence; therefore, it was not surprising that the intervention did not seem to be beneficial.

As enhanced interventions seemed to have a higher effect on contraceptive use, six studies primarily viewed personalized counseling as enhanced antisense counseling [17, 18, 20, 22, 25, 26]. Personalized counseling consisted mainly of providing information about different contraceptive methods [17, 20, 24, 25] for approximately 30 min [18, 22]. However, interventions were moderately heterogeneous across studies and varied in the provision of contraceptive methods, from studies providing free contraception [18, 27] to others providing a 3-month provision only for specific methods like pills, IUD, and implants [24].

The study that had more weight (45.4%) in the forest plot was Zhu’s study, a study conducted in China, in which the intervention was a combination of individual and group counseling and included the women’s significant others [27]; however, as most included studies in the meta-analysis [17, 20, 22, 24, 25, 27], the Zhu study has an overall unclear risk of bias due to failures in blinding of personal and participants.

Uptake

Regarding the uptake outcome, the meta-analysis did not show a significant difference among the standard and enhanced counseling groups. However, study results were heterogeneous. Similar to what was described for the use outcome, in this case, the studies in which enhanced counseling did not seem to have a benefit showed a higher use incidence in the control group (Carneiro, 95.9%; Davidson, 95.8%; Langston, 91.7%), so it was not surprising that the intervention did not seem to be beneficial in these studies. However, the other two studies, which seem to show a benefit in the enhanced group, had a lower uptake incidence in the control group (Schunmann, 81.20%; Whitaker, 74.19%). This may be because their “uptake” definition did not include some hormonal contraceptive types, such as implant and monthly injectable.

LARC use has been the main objective of contraception campaigns in the last years [28]. We found a slight trend in enhanced counseling compared to standard counseling, which is represented by two studies with a larger population; however, in the meta-analyses, we found that “contraceptive use” is similar in the enhanced counseling and standard counseling groups. Of the three meta-analyzed studies for LARC use, while two suggested a benefit of the enhanced intervention, Bender 2004 [17] did not. However, given this study’s high risk of bias (including randomization problems causing the study groups to have different basal characteristics and lack of adjusted analysis for possible confounding factors), its results should be taken with caution. Currently, no clear consensus has been found that defines how long a person must be evaluated to guarantee the contraceptive method’s effectiveness. We consider that the evaluation period was noticeably short in the studies as the outcome was a long-term method.

Enhanced counseling at the time of abortion seems to reduce the occurrence of obstetric events; however, it is necessary to consider that the certainty of the evidence for all outcomes was very low, so future studies are needed to confirm this result and elicit if this possible benefit may be due to patient-centered counseling, explanation of myths, or other components [6] and if a higher effect can be achieved with a group or individual interventions in which the significant other is included [27].

No previous systematic reviews studied the difference between counseling provided by a physician and that by a non-physician. We did not conduct a meta-analysis for this comparison since the studies were quite different. Olavarrieta and Makenzius showed that, compared to physicians, non-physicians tend to prescribe more contraceptives but have fewer users taking contraceptives home [21, 23] and prescribe fewer IUDs [23]. However, more studies are needed to make a reliable conclusion.

Limitations and strengths

Some limitations must be considered when interpreting the results of this systematic review. Mainly, most RCTs did not show a minimally informative description of what counseling was provided to the control and intervention groups, which prevented them from fully understanding their results, which could be improved using TIDieR [12] and following the CONSORT checklist [29]. This is important since the effectiveness of counseling interventions may depend on several factors [30], including communication skills of the providers, considering key aspects of the patient’s life to develop the intervention [31, 32], and considering the woman’s family plan [6], need of information, and past experiences with contraception [7], in addition to their preferences that should be consistent with the contraceptive methods they use [33]. Likewise, the included studies did not report an evaluation of the counseling quality nor the user satisfaction.

Other important limitations were as follows: 1) few studies had a low risk of bias, and most failed in blinding. 2) Enhanced interventions were moderately heterogeneous across studies. It is expected to have certain heterogeneity since different contexts need different interventions. However, some counseling guidelines, such as those of the World Health Organization [20] and the United States Agency for International Development [34], can be used in future studies to establish certain components that are minimally assessed in contraceptive counseling interventions [34]. 3) Outcomes had different definitions across studies [7]. 4) Studies usually do not detail important information to understand their results, such as abortion restrictions and feasibility in their settings, although it seems that, of 11 studies, six were performed in countries where abortion is legal on request and three in a restrictive setting [7]. Future RCTs must consider these limitations.

Likewise, it is necessary to acknowledge that all included studies seem to have been performed considering sex or having a uterus and did not ask about gender identity, and we found no information regarding the effect of different types of counseling in specific groups, such as transgender man or nonbinary individuals, in which counseling may need to consider specific components [35].

However, to date, this is the most comprehensive systematic review that has assessed the effects of peri-abortion contraceptive counseling, summarizing information that may be useful to informed decision-making.

Conclusion

We found that enhanced contraceptive counseling may increase the use of effective contraception but may not seem to affect the occurrence of obstetric events (pregnancies or abortions). Moreover, studies have not been able to find a difference in the effects of counseling interventions given by different providers. However, given that the certainty of the evidence was very low, future well-designed RCTs are needed to make an informed decision.

PRISMA 2020 checklist.

(DOCX)

Click here for additional data file.

Search terms.

(DOCX)

Click here for additional data file.

List of studies that were assessed in full-text and excluded.

(DOCX)

Click here for additional data file.

Characteristics of the studies, in extenso.

(DOCX)

Click here for additional data file.

Definition of the outcomes assessed in the meta-analyses in each study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Bender´s study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Schunmann´s study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Nobili´s study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Zhu’s study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Lagnston´s study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Carneiro´s study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Davidson´s study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Smith´s study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Olavarrieta´s study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Whitaker´s study.

(DOCX)

Click here for additional data file.

Detail of the interventions received in Makenzius´s study.

(DOCX)

Click here for additional data file.

(XLSX)

Click here for additional data file.

12 Oct 2021

PONE-D-21-29042Peri-abortion contraceptive counseling: a systematic review of randomized controlled trialsPLOS ONE

Estimado Taype-Rondan,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 26 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Saludos cordiales,

Dylan A Mordaunt, MB ChB, FRACP, FAIDH

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

3. Thank you for stating the following financial disclosure:

"Self-financed"

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c) If any authors received a salary from any of your funders, please state which authors and which funders.

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Additional Editor Comments:

Thank you for your submission. With regards to publication criteria (https://journals.plos.org/plosone/s/criteria-for-publication):

1) This study appears to present the results of original research.

2) Results reported do not appear to have been published elsewhere.

3) Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail. There are some minor suggestions made by a number of reviewers before publication is accepted.

4) Conclusions are presented in an appropriate fashion and are supported by the data.

5) The article is presented in an intelligible fashion and is written in standard English.

6) The research meets all applicable standards for the ethics of experimentation and research integrity.

7) The article adheres to appropriate reporting guidelines and community standards for data availability.

Additional points:

- Thank you for submitting your systematic review in a structured format- there's a conflict between whether you've submitted in the 2009 or 2020 format of PRISMA.

- I would also suggest reviewing your manuscript with regards to the AMSTAR2 checklist (or an equivalent), to maximise the measured quality of this SR and consider including this as a supplementary file.

- It would be useful to clarify whether there are any differences between the PROSPERO protocol and the methods that were followed in the manuscript.

- The cut-offs used for heterogenity assessment and the choice to quantitatively synthesise are interesting- it would be useful to reference and give an explaination for why this was felt to be warranted as it could be a point of criticism.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: I Don't Know

Reviewer #5: Yes

Reviewer #6: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: No

Reviewer #5: Yes

Reviewer #6: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Gonzales-Huaman and co-authors performed a systematic review about peri-abortion contraceptive counseling interventions.

The introduction builds a logical context for the article, the purpose of which is clear and well defined, appropriate physiopathological background is given, and key concepts are defined. I think the motivation for the present research is clearly expressed.

Data comprised in the tables is clear and consistent with the article’s content. The statistical methods used are appropriate.

The literature is analyzed and critically appraised. Ideas are acknowledged appropriately and accurately; there are no instances of plagiarism, and reference citations are complete and accurate.

Reviewer #2: 1. The article has not been published elsewhere.

2. The statistical analysis has been performed appropriately without performing a meta-analysis for counselling provided by physicians and midwives.

3. The article is not presented in an intelligible fashion or is written in standard English.

4. It is not necessary

5. The article adheres to appropriate reporting guidelines and community standards for data availability

Reviewer #3: This is a relevant systematic review which is intended to provide robust evidence regarding the effectiveness of peri-abortion contraceptive counseling in several settings towards reduction of the incidences of repeat abortions.

The manuscript has been well written with full considerations for the requirements for the condcut and reporting of sytematic reviews and meta analyisis.

There are however few gramatical errors that needs to be corrected and suggestiosn towards improving the quality of the report.

Please find below further comments on the manuscript.

ABSTRACT

Comment 1: The time frame for the studies included in the systematic review is conspicuously missing. This should be reflected not in the abstract.

Comment 2: Also include the databases searched by the authors ad whether there were language restrictions in the search.

Conclusion

Comment 3: The authors stated in the conclusion “There is no evidence that involvement of different professionals influences contraceptive use”. It is not clear how this was arrived at since only two studies out of 11 compared influence of the involvement of different professionals in counselling. Rather due to the paucity of RCT that compared the two approaches, there is limited evidence that involvement of different professionals influences contraceptive use.

Key messages

Comment 4: The key messages from this study has not been well highlighted in this section. The following statements should be deleted from this section during revision:

•We conducted a systematic review and meta-analysis of 11 RCTs to determine the effect of peri-abortion contraceptive counseling.

• We evaluated the effect of contraceptive counseling on peri-abortion contraceptive use to assess the contribution of this strategy to reducing future pregnancies.

Replace the above with information that highlights key messages like whether this was the first RCT on the subject matter, uniqueness of study, findings, conclusions, and recommendations:

Introduction

Page 4, lines 2-3: Globally, abortion is a complex situation for people with uterus (cis, trans and non-binary people). [2].

Comment 5: This statement may not be relevant to the context. Please delete

Page 4, Lines 14-17: Therefore, we performed a systematic review to summarize the available data on randomized controlled trials (RCTs) effects of peri-abortion contraceptive counseling intervention on contraceptive use and obstetric outcomes.

Comment 6: Paraphrase to: Therefore, we performed a systematic review to summarize the available data from randomized controlled trials (RCTs) that evaluated the effects of peri-abortion contraceptive counseling intervention on contraceptive use and obstetric outcomes

Methods

Page 4, line 24, Page 5 lines 1-2: and enhanced the new strategy considered for the trial) and were published as original papers in scientific journals

Comment 7: and enhanced counselling as the new strategy considered for the trial) and were published as original papers in scientific journals.

Information sources and search strategy

Page 5, lines 6-8: We performed a literature search of four sources: PubMed, Central Cochrane Library (CENTRAL), Scopus, and Google Scholar (for this, we only assessed the first 100 results).

Comment 8: It is not clear why only the first 100 results from google scholar was assessed. This should be elucidated upon.

Outcomes of interest

Comment 9: The authors have listed various definition of terms considered for this study but has not referenced these considerations for objectivity in assessment of these studies in relation to widely accepted definitions. This should be included in the revision.

Results

Page 11, lines 1-2: In addition, the proportion of women leaving the facility with at least one contraceptive method was similar in the “nurse group” than in the “physician group”

Comment 10: Change to: In addition, the proportion of women leaving the facility with at least one contraceptive method was similar in both groups

Discussion

This section has been well written and exhaustive

Page 11, line 18: which include six RCTs

Comment 11: which included six RCTs

Limitations

The authors have highlighted the main limitations to this study and interpretation of results.

Strength

However, to date, this is the most comprehensive systematic review that has assessed the effects of peri-abortion contraceptive counseling, summarizing information that may be useful to informed decision-making.

Comment 12: This message should be adapted as part of the key message from this study.

References

The journal names should be written as they are abbreviated in the list of index medicus for all the references quoted.

Reviewer #4: INTRODUCTION: There are some grammatical errors that need to be corrected. The aim of the study in the last paragraph of the introduction on page 4 is not clear.

RESULTS: Wrong use of tenses and few grammatical errors.

DISCUSSION: In page 12, paragraph 3, in the 1st sentence, what do the authors mean by ' the study had more weight'?

Reviewer #5: 1. Summary of Research

In this work, the authors sought to undertake a systematic review and meta-analysis of 11 RCTs to determine the effect of peri-abortion counseling. This review concluded that enhanced contraceptive counseling may favour effective contraceptive use but may not affect the rate of obstetric event occurrence, though the certainty of the evidence was low.

Below are some comments for the authors:

2. Specific Areas

Methods:

In the first paragraph under the under the sub-heading ‘outcome of interest’-page 6, authors should kindly note that all injectable contraceptives are hormonal. So the monthly and quarterly injectables are implied. Authors should kindly take note of this.

Again, Intrauterine system (IUS) is used interchangeable with hormonal IUD.

Language editing is recommended in the 2nd paragraph under the sub-heading ‘outcome of interest’. Specifically “we considered standard care or routine counseling to all interactions with patients preestablished by the hospital, institution or the research group”

Limitations and Strengths

Were there any limitations in the area of language bias and how was it addressed since the various studies were undertaken in different continents with heterogeneous cultural diversities.

3. Additional Comments

Inclusion of line numbers on manuscript could have been helpful for the review processes.

Reviewer #6: manuscript needs to be shortened. Authors should also engage a statistician. Consider using the forest plot. also can you include a table that shows the articles reviewed and results at a glance? thank you for great review

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Daniela-Roxana Matasariu

Reviewer #2: No

Reviewer #3: Yes: DR GODWIN O. AKABA,MBBS,MSc,MPH,FWACS

Reviewer #4: No

Reviewer #5: Yes: Dr. Timothy K. Adjei

Reviewer #6: Yes: Emmanuel Ugwa

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: PLOS ONE SYSTEMATIC REVIEWE, COMMENTS _GOA.docx

Click here for additional data file.

13 Nov 2021

Here we answer to each of the reviewers commentaries:

Journal Requirements:

• 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

o We have made the changes according to the PlosOne templates.

• 2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

o We did a reference check and we found that the reference list is complete and correct.

• 3. Thank you for stating the following financial disclosure: "Self-financed"

o Ok, please tell us if any other detail is required.

Additional points:

• Thank you for submitting your systematic review in a structured format- there's a conflict between whether you've submitted in the 2009 or 2020 format of PRISMA.

o We follow the format of PRISMA 2020 format.

• I would also suggest reviewing your manuscript with regards to the AMSTAR2 checklist (or an equivalent), to maximise the measured quality of this SR and consider including this as a supplementary file.

o We agree. We attached as a supplementary file such AMSTAR 2 evaluation.

• It would be useful to clarify whether there are any differences between the PROSPERO protocol and the methods that were followed in the manuscript.

o We agree. We added the following as the first paragraph of the “Methods” section: “We performed a systematic review, which was written according to the PRISMA 2020 statement. The study protocol was registered at PROSPERO (CRD42020187354), and there were no subsequent changes to the protocol.”

• The cut-offs used for heterogenity assessment and the choice to quantitatively synthesise are interesting- it would be useful to reference and give an explaination for why this was felt to be warranted as it could be a point of criticism.

o In order to clarify this, we have added the following in the “Synthesis methods” sections of the Methods subheading: “heterogeneity was arbitrarily categorized using cutoff points agreed by the authors as not important (I2 < 40%), moderately significant (I2 = 40%–75%), and considerable (I2 > 75%)”

Review Comments to the Author

Reviewer #1:

• Gonzales-Huaman and co-authors performed a systematic review about peri-abortion contraceptive counseling interventions.

The introduction builds a logical context for the article, the purpose of which is clear and well defined, appropriate physiopathological background is given, and key concepts are defined. I think the motivation for the present research is clearly expressed.

Data comprised in the tables is clear and consistent with the article’s content. The statistical methods used are appropriate.

The literature is analyzed and critically appraised. Ideas are acknowledged appropriately and accurately; there are no instances of plagiarism, and reference citations are complete and accurate.

o Thank you very much for your kind commentaries.

Reviewer #2:

• 1. The article has not been published elsewhere.

• 2. The statistical analysis has been performed appropriately without performing a meta-analysis for counselling provided by physicians and midwives.

• 3. The article is not presented in an intelligible fashion or is written in standard English.

• 4. It is not necessary

• 5. The article adheres to appropriate reporting guidelines and community standards for data availability

o Thank you very much for your kind commentaries.

Reviewer #3:

• This is a relevant systematic review which is intended to provide robust evidence regarding the effectiveness of peri-abortion contraceptive counseling in several settings towards reduction of the incidences of repeat abortions.

• The manuscript has been well written with full considerations for the requirements for the condcut and reporting of sytematic reviews and meta analyisis.

• There are however few gramatical errors that needs to be corrected and suggestiosn towards improving the quality of the report.

o We agree. We have performed an in-deep reading of the manuscript and corrected all the typos.

ABSTRACT

• Comment 1: The time frame for the studies included in the systematic review is conspicuously missing. This should be reflected not in the abstract.

o We agree. We added the publication period of the studies in the results section of abstract: “Eleven RCTs were eligible for inclusion (published from 2004 to 2017)”.

• Comment 2: Also include the databases searched by the authors ad whether there were language restrictions in the search.

o We agree. We added the databases to the abstract: “The literature search was performed in June 2021 in PubMed, Central Cochrane Library (CENTRAL), Scopus, and Google Scholar; without restrictions in language or publication date.”

CONCLUSION

• Comment 3: The authors stated in the conclusion “There is no evidence that involvement of different professionals influences contraceptive use”. It is not clear how this was arrived at since only two studies out of 11 compared influence of the involvement of different professionals in counselling. Rather due to the paucity of RCT that compared the two approaches, there is limited evidence that involvement of different professionals influences contraceptive use.

o We agree. We correct the wording of this section. “Also, the studies did not find a difference in the effects of counseling interventions given by different providers.”

Key messages

• Comment 4: The key messages from this study has not been well highlighted in this section. The following statements should be deleted from this section during revision:

o We conducted a systematic review and meta-analysis of 11 RCTs to determine the effect of peri-abortion contraceptive counseling.

o We evaluated the effect of contraceptive counseling on peri-abortion contraceptive use to assess the contribution of this strategy to reducing future pregnancies.

o Replace the above with information that highlights key messages like whether this was the first RCT on the subject matter, uniqueness of study, findings, conclusions, and recommendations:

� We agree, and rewritten this section, as follows:

• “Previous systematic reviews (Ferreira 2009 and Stewart 2015) were performed several years ago and did not assess the certainty of the evidence. Thus, we updated the evidence regarding peri-abortion contraceptive counseling.

• Peri-abortion contraceptive counseling may increase effective contraceptive use, while we did not find significant improvements in other outcomes. Also, we found no evidence of the difference in the effects when comparing contraceptive counseling provided by different providers.

• To date, this is the most comprehensive systematic review that has assessed the effects of peri-abortion contraceptive counseling, summarizing information that may be useful to informed decision-making. Since evidence certainty was very low, future well-designed RCTs are needed.”

.

Introduction

• Comment 5: This statement may not be relevant to the context. Please delete: Page 4, lines 2-3: Globally, abortion is a complex situation for people with uterus (cis, trans and non-binary people). [2].

o We agree. We removed this sentence.

• Comment 6: Page 4, Lines 14-17: Therefore, we performed a systematic review to summarize the available data on randomized controlled trials (RCTs) effects of peri-abortion contraceptive counseling intervention on contraceptive use and obstetric outcomes.

Paraphrase to: Therefore, we performed a systematic review to summarize the available data from randomized controlled trials (RCTs) that evaluated the effects of peri-abortion contraceptive counseling intervention on contraceptive use and obstetric outcomes

o We agree. We followed your suggestion and added this sentence to the end of the introduction: “Therefore, we performed a systematic review to summarize the available data from randomized controlled trials (RCTs) that evaluated the effects of peri-abortion contraceptive counseling interventions”

Methods

• Comment 7:

Say: Page 4, line 24, Page 5 lines 1-2: and enhanced the new strategy considered for the trial) and were published as original papers in scientific journals

Should say: and enhanced counselling as the new strategy considered for the trial) and were published as original papers in scientific journals.

o We agree. We edited this sentence as follows: “We defined standard counseling as the intervention regularly practiced in the study context and enhanced counseling as the new intensified strategy considered for the trial.”

Information sources and search strategy

• Page 5, lines 6-8: We performed a literature search of four sources: PubMed, Central Cochrane Library (CENTRAL), Scopus, and Google Scholar (for this, we only assessed the first 100 results).

Comment 8: It is not clear why only the first 100 results from google scholar was assessed. This should be elucidated upon.

o We clarified this section in the manuscript adding the following in the first paragraph of the "Information sources and search strategy" section:

“Since Google Scholar sorts its results starting with those that have the best match with the search terms, we consider that evaluating the first 100 results would include all relevant studies on the subject in this repository, a methodology that has been used in previous systematic reviews (8-11).”

Outcomes of interest

• Comment 9: The authors have listed various definition of terms considered for this study but has not referenced these considerations for objectivity in assessment of these studies in relation to widely accepted definitions. This should be included in the revision.

o For the purpose of this study, since there are no uniform definitions in the literature, the authors considered the definitions and cut-off points described in the manuscript. In order to clarify this, we have added the following in the second paragraph of the “Outcomes of interest " section: “We considered effective contraceptive methods as any of the following: oral contraceptives, patch, ring, monthly injectable, quarterly injectable, condom, implant, vaginal ring, contraceptive patch, intrauterine device (IUD), intrauterine system (IUS), and sterilization or vasectomy. We considered long-acting reversible contraceptives (LARC) as any of the following: IUD, IUS/hormonal IUD, and implant. We considered obstetric events as either an unintended pregnancy or another induced abortion after counseling.”

Results

• Page 11, lines 1-2: In addition, the proportion of women leaving the facility with at least one contraceptive method was similar in the “nurse group” than in the “physician group”

Comment 10: Change to: In addition, the proportion of women leaving the facility with at least one contraceptive method was similar in both groups

o We agree. We followed your suggestion and edited this sentence.

“did not find significant differences in the proportion of women prescribed contraceptives (nurse group: 99.1%, physician group: 98.7%), in the type of contraceptive prescribed, and in the proportion of women leaving the facility with at least one contraceptive method (96.7% vs 97.3%).”

Discussion

• This section has been well written and exhaustive

• Page 11, line 18: which include six RCTs

Comment 11: which included six RCTs

o We agree. We made this change.

Limitations

• The authors have highlighted the main limitations to this study and interpretation of results.

• However, to date, this is the most comprehensive systematic review that has assessed the effects of peri-abortion contraceptive counseling, summarizing information that may be useful to informed decision-making.

Comment 12: This message should be adapted as part of the key message from this study.

o We agree. We added the following to the key messages: “To date, this is the most comprehensive systematic review that has assessed the effects of peri-abortion contraceptive counseling, summarizing information that may be useful to informed decision-making. Since evidence certainty was very low, future well-designed RCTs are needed.”

References

• The journal names should be written as they are abbreviated in the list of index medicus for all the references quoted.

o We agree. We edited the references as suggested.

Reviewer #4:

INTRODUCTION

• There are some grammatical errors that need to be corrected. The aim of the study in the last paragraph of the introduction on page 4 is not clear.

o We agree. We removed this sentence as it was confusing.

RESULTS:

• Wrong use of tenses and few grammatical errors.

o We agree. We proofread this section with the help of a native English language writer.

DISCUSSION:

• In page 12, paragraph 3, in the 1st sentence, what do the authors mean by ' the study had more weight'?

o We agree. It was clarified by putting the weight in the forest plot (45.4%).

Reviewer #5:

Methods:

• In the first paragraph under the under the sub-heading ‘outcome of interest’-page 6, authors should kindly note that all injectable contraceptives are hormonal. So the monthly and quarterly injectables are implied. Authors should kindly take note of this.

• Again, Intrauterine system (IUS) is used interchangeable with hormonal IUD.

o Thank you very much for both commentaries, we agree and therefore we have edited the text according to your comment. We eliminated some redundant contraceptives:

“We considered effective contraceptive methods as any of the following: oral contraceptives, patch, ring, monthly injectable, quarterly injectable, condom, implant, vaginal ring, contraceptive patch, intrauterine device (IUD), intrauterine system (IUS), and sterilization or vasectomy. We considered long-acting reversible contraceptives (LARC) as any of the following: IUD, IUS/hormonal IUD, and implant”.

• Language editing is recommended in the 2nd paragraph under the sub-heading ‘outcome of interest’. Specifically “we considered standard care or routine counseling to all interactions with patients preestablished by the hospital, institution or the research group”

o We agree. We edited the text according to your comment.

Limitations and Strengths:

• Were there any limitations in the area of language bias and how was it addressed since the various studies were undertaken in different continents with heterogeneous cultural diversities.

o Although we had no language restrictions, at the end all included RCTs were published in english. To clarify this, we have added the following sentence in the second paragraph of the “study characteristics” subheading: “All were published in full-text in english.”

Additional Comments

• Inclusion of line numbers on manuscript could have been helpful for the review processes.

o We agree. We made the changes according to the PlosOne templates.

Reviewer #6:

• manuscript needs to be shortened. Authors should also engage a statistician. Consider using the forest plot. also can you include a table that shows the articles reviewed and results at a glance? thank you for great review

o We agree. We edited the text based on the previous comments and tried to reduce the number of words as possible. We have included the forest plots as the figure 2.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

17 Nov 2021

Peri-abortion contraceptive counseling: a systematic review of randomized controlled trials

PONE-D-21-29042R1

Dear Dr. Taype-Rondan,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Dylan A Mordaunt, MB ChB, FRACP, FAIDH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for your resubmission and for addressing all of the suggestions. This meets the criteria for publication.

Reviewers' comments:

14 Dec 2021

PONE-D-21-29042R1

Peri-abortion contraceptive counseling: a systematic review of randomized controlled trials

Dear Dr. Taype-Rondan:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Dylan A Mordaunt

Academic Editor

PLOS ONE

Table 1

Characteristics of included studies.

Author, year (country)	Randomized unit	Participants	Number of patients allocated (I, C)	Control group and intervention group	Maximum follow-up	Funding
Studies that have compared enhanced versus standard peri-abortion contraceptive counseling
Bender, 2004 (Iceland)	Women	Women who requested first-trimester pregnancy termination.	276 (148, 128)	C: Routine counseling, defined as post-abortion routine contraceptive counseling, given once by a nurse or a midwife without special training in contraceptive counseling (duration not specified) + leaflets by a social worker + physician evaluation for contraception prescription.	6 months	Not specified
				I: Routine counseling + pre-abortion personalized contraceptive counseling given once by a specially trained family planning nurse (duration not specified)
Schunmann, 2006 (United Kingdom)	Weeks	Women presenting at the abortion clinic without an obstetric indication for pregnancy termination.	377 (199, 178)	C: Standard care, defined as a pre-abortion brief discussion about contraception at the outpatient clinic given once (provider and duration not specified) + post-abortion contraceptive discussion with a nurse given once (duration not specified) and contraception provision.	4 months	Not specified
				I: Standard care + pre-abortion or post-abortion expert advice given once by a physician (interview lasted 10–20 min) and enhanced provision of certain contraception methods (three-month pills, implants, or IUD/IUS).
Nobili, 2007 (Italy)	Women	Women who requested pregnancy termination.	43 (22, 21)	C: Standard care, defined as post-abortion referral of women to a community health center.	3 months	Not specified
				I: Standard care + pre-abortion personalized contraceptive counseling (consisting of a patient-centered interview, information, and education; election of a contraceptive method; and understanding checking), given once by a psychologist and gynecologist for 30 min.
Zhu, 2009 (China)	Hospital	Women seeking any abortion.	1147 (592, 555)	C: Post-abortion essential package, defined as the provision of information for women in groups (times, provider, and duration not specified) and referral to women to existing family planning services	6 months	EU 6th Framework Programme
				I: Post-abortion comprehensive package, defined as a group and individual education for women and male involvement, free provision of contraception, and referral to existing family planning services given once (provider and duration not specified)
Langston, 2010 (USA)	Women	Women seeking a first-trimester abortion.	222 (114, 108)	C: Standard care, defined as contraceptive counseling given once by a physician (content and duration left to the physician discretion).	3 months	A grant from an anonymous foundation.
				I: Standard care + pre-abortion standardized structured counseling using visual and audio material (duration not specified) and contraception provision given once by the research coordinator.
Carneiro, 2011 (Brazil)	Women	Women who had undergone an abortion.	246 (123, 123)	C: Standard care, defined as post-abortion group educational counseling provided by a nurse for 30–40 min provided once and follow-up interview to verify use with gynecologist once.	6 months	Not specified
				I: Standard care + Post-abortion individually personalized three-stage counseling (education and information, guided information, free provision of chosen contraceptive, and verification of their understanding of their use) provided only once for 30 min by two trained providers.
Smith, 2015 (Cambodia)	Healthcare provider	Women who sought induced abortion and had a mobile phone	500 (249, 251)	C: Standard care, defined as post-abortion family planning counseling at the clinic given once (provider and duration not specified) + the offer of a follow-up appointment at the clinic and the provision of a hotline number operated at Marie Stopes International Cambodia.	12 months	The Marie Stopes International Innovation Fund and The UK Medical Research Council
				I: Standard care + mobile phone-based intervention consisting of six automated interactive voice messages at the time of their preference by a counselor for three months.
Davidson, 2015 (USA)	Weeks	Women presenting for a surgical abortion.	192 (97, 95)	C: Standard care, defined as pre-abortion contraception counseling given once by clinic staff + stress management video given once (duration not specified).	None	Grant Society Family Planning Research Funding
				I: Standard care + long-acting contraception informative video given once by clinic staff (duration not specified).
Whitaker, 2016 (USA)	Women	Women seeking an abortion.	60 (29, 31)	C: Standard care, defined as returning to usual care and receiving only non-standardized counseling given once by a clinic physician (duration not specified).	3 months	National Health Institute
				I: Standard care + seven-step motivational interview given once, provided by a physician or social worker (duration not specified).
Studies that have compared peri-abortion contraceptive counseling given by physicians versus that given by non-physicians
Olavarrieta, 2015 (Mexico)	Women	Women looking for medical abortion	1017 (514, 503)	C: Abortion and post-abortion contraceptive method counseling provided by a physician who had recently joined the clinic staff and had never provided medical abortion or had only previously managed medical abortion under supervision, given once (duration not specified).	15 days	Department of Reproductive Health and Research, UNDP, UNFPA, UNICEF, WHO, and the World Bank.
				I: Abortion and post-abortion contraceptive method counseling provided by a nurse with no prior abortion experience, given once (duration not specified).
Makenzius, 2017 (Kennya)	Healthcare provider	Women with signs of incomplete abortion.	810 (409, 401)	C: Abortion and post-abortion contraceptive counseling was given once (duration not specified) and was provided by a physician with a mean of 8.8 years of professional practice and 8.4 years of clinical experience in post-abortion counseling.	10 days	The Swedish Research Council on Health, Working Life and Welfare
				I: Abortion and post-abortion contraceptive counseling was given once (duration not specified) and was provided by a midwife with a mean of 22.4 years of professional practice and 2.7 years of clinical experience in post-abortion counseling.

I, intervention; C, control.

Table 2

Summary of Findings (SoF) table.

Studies design: Randomized controlled trials.Population: Women who underwent an abortion.Intervention: enhanced peri-abortion contraceptive counseling interventions.Control: standard peri-abortion contraceptive counseling interventions.
Outcomes	No. of participants and studies (I, intervention; C, control)	Standard care	Enhanced counseling	Relative effect (95% CI)	Risk difference (95% CI)	Certainty of the evidence (GRADE)
Use of effective contraception	I: 1124, C: 972(8 RCTs)	784 per 1000	878 per 1000	RR 1.12(1.09 to 1.16)	94 more per 1000 (71 more to 125 more)	Very low 1,2.3⨁◯◯◯
Use of long-acting reversible contraceptives	I: 83, C:56(3 RCTs)	193 per 1000	241 per 1000	RR 1.25(0.68 to 2.29)	48 more per 1000 (62 fewer to 249 more)	Very low 1,2,4,5⨁◯◯◯
Uptake of an effective contraceptive method	I: 616, C: 534(5 RCTs)	880 per 1000	933 per 1000	RR 1.06(0.98 to 1.15)	53 more per 1000 (18 fewer to 132 more)	Very low 1,2.3⨁◯◯◯
Occurrence of an obstetric event	I: 104, C: 120(3 RCTs)	112 per 1000	100 per 1000	RR 0.91(0.57 to 1.47)	10 fewer per 1000 (47 fewer to 52 more)	Very low 1,2,5⨁◯◯◯

1. RCTs with a high risk of bias.

2. Intervention and control groups received different interventions in each study.

3. Heterogeneity I2 > 75%.

4. Wide confidence intervals.

5. Heterogeneity I2 >40%.