In this study, nearly half of women who underwent structured contraceptive counseling selected a CHC method that was different from the method they originally intended to use . After informed dialogue, one in four women who intended to use the pill selected another method (16.4% and 65.2% of these women chose the patch and ring, respectively) . Despite these important changes, women throughout Europe still prefer the pill, the method with which they are most familiar. This finding has been observed in previous reports [1, 14].
Although there are many reasons why women choose one form of contraception over another, we tried to determine the most common reasons that may have influenced women’s choices. Throughout Europe, ‘easy to use’ is an important reason for choosing the pill and patch. ‘Nondaily administration’ is important for women’s selection of the patch and ring. Matters of convenience seem to be especially important for women’s selection of the patch or ring. Women who did not choose the pill did so because of its daily use, the likelihood of forgetting it, ‘more convenient methods are available’, and because the efficacy of the pill is reduced by vomiting or diarrhea. The patch was often not selected because it is ‘not discrete, visible’ and ‘can fall off’. The ring was often not selected because women ‘do not like to use a foreign body’ and ‘more convenient methods are available’.
Knowledge of contraceptive methods obtained as a result of counseling appeared to be a major relevant factor. Women’s perceptions varied for each method, yet women who did not select a specified method were more likely to answer ‘do not know’ to a given statement than women who selected a particular method. If a woman is less knowledgeable about a method, her HCP can help her become better informed. This observation reinforces the need for HCPs to provide comprehensive contraceptive counseling that encourages an exchange of information between HCPs and women. For all listed reasons, the percentage of women who agreed with statements given to them was consistently high for the pill.
In Central and Eastern Europe, more women switched to the patch or ring after counseling. In these regions, we speculate that counseling made them overcome an initial lack of knowledge about alternatives to the pill; they often cited ‘recommended by my doctor’ as a reason for choosing the patch or ring. Indeed, other reports already indicated that HCP preferences had a greater influence on women’s contraceptive choices in Central and Eastern European countries compared with Northern European countries .
In Belgium and the Netherlands, women were less likely to cite ‘well-researched method’ as the reason they selected the pill, possibly because they believe the patch and ring are also well-researched methods. Safety concerns seemed to matter less in Belgium and the Netherlands, but played more of a prominent role in Russia and Ukraine.
The difference in the percentage of women who agreed that the pill, patch, or ring prevents pregnancy effectively may have been influenced by the relatively large number of women in the total study sample who selected the pill. Therefore, we specifically looked at perceptions of women who selected the method concerned. The percentages of women who agreed that their chosen method was effective in preventing pregnancy, easy to use, and effective in cycle regulation appeared to be similar for each method. Surprisingly, more women who chose the pill than the patch or ring thought the method had side effects and could be dangerous. Protection against certain forms of cancer was not recognized in any of the three methods. In a study that assessed the perceptions and attitudes of Swedish teenage girls (≤ 17 years old), many stated that hormonal contraceptives may cause negative side effects and damage to the body, especially during puberty . The current data indicate that even women who choose the pill may have negative perceptions about their method; these women may have chosen the pill because of a lack of knowledge about alternative methods.
In a recent study that surveyed women in France, Germany, Italy, Spain, and the United Kingdom, social and cultural differences between these countries influenced women’s decisions regarding their method of contraception . Among the selected countries in the CHOICE study, religion, socioeconomic status, and other factors may have influenced women’s contraceptive choices. In the Czech Republic and Slovakia, Poland, and Ukraine, we noted that women placed more emphasis on using discrete forms of contraception, including the pill and ring.
Although ‘easy to use’ and administration frequency were rated highly as selection criteria for the pill, patch, or ring in all countries, ‘convenience’ was cited less often by Austrian and Swiss women who selected the patch or ring compared with women in Poland, Russia, and Ukraine. We speculate that longstanding use of the pill may have contributed to a more negative image regarding the pill’s health risks (e.g. pill scares, media reports), which could have prompted women (even in countries where convenience is less important) to seek alternative contraceptive methods.
A recent study assessed women’s perceptions about the safety of COCs . Of 794 women who were at risk of unintended pregnancy, 56.0% stated that COCs were medically safe, 39.0% believed that COCs were unsafe, and 13.2% were not sure. The top reasons women thought COCs were unsafe included concerns about side effects (19.5%) and prior negative experiences with COCs (17.0%). In the CHOICE study, women who selected the patch or ring but not the pill were almost twice as likely to indicate that COCs have many side effects compared with women in the previous study .
In the CHOICE study, the analyses of the association between women’s choice of method and their perceptions were, among other factors, corrected for women’s age, HCP's most frequently recommended method, women's last (main) contraceptive method, as well as other factors. These factors influenced a woman’s decision-making process. However, we also assume that cost played a decisive role in women’s selection of a CHC method. In most of the 11 participating countries, the patch and ring are indeed considerably more expensive than generic COCs, but in general their price is quite similar to the newer, branded COCs. Surprisingly, only 13% and 22% of participants did not choose the patch or ring, respectively, because of cost. Nevertheless, in the Czech Republic and Slovakia and Russia, cost was a significant deterrent that prevented many women from selecting the ring.
Our analysis of the association between a woman’s selection of the pill, patch, or ring and her perceptions about these methods after counseling indicated that ease of use was the most important knowledge factor. In addition, women who chose a method had a positive impression about the method's efficacy, tolerability, safety, and cycle control. It was disappointing to see that, following counseling, so many women still indicated that they ‘did not know’ or had ‘no opinion’ about the advantages and disadvantages of the patch and ring (unless they had chosen this method). Furthermore, most women had an opinion (positive or negative) about the pill, irrespective of whether they had chosen it.
The CHOICE study had several limitations. First, the study focused on women who were considering a combined hormonal method – women considering other forms of contraception or who indicated prior to the counseling they would not consider one of the three CHC methods did not complete the questionnaires and were counseled in the usual way. This was a deliberate decision, in consultation with the ESC, since we wanted to assess to what extent women consider alternatives to the method they were contemplating, provided it was a viable alternative for them. Nevertheless, this focus limits the generalizability of the findings only to women in the same situation. Secondly, we did not assess contraceptive compliance, discontinuation rates, or user satisfaction. This would have necessitated the need for a follow-up visit, which would have been costly and was not the primary interest of the program. Furthermore, in Belgium, Russia, and Ukraine, HCP’s favorable attitudes towards the patch and ring may have influenced the information and advice they provided, leading to a greater proportion of women who selected the patch or ring . The questionnaire may have had limitations in that women could not find the answer they wished to select. After pilot-testing in a number of countries, we included more answer categories to the questions relating to method of choice over other methods, while leaving space for women to provide their own responses. It was reassuring to see that only 4-5% of participants used this space (summarized as ‘other’ in Tables 1 and 2). Finally, because of slow enrollment, we did not meet our target enrollment of 1500 women in the Netherlands, which diminished the accuracy of the estimated selection rates of the pill, patch, and ring in that country. We attribute low enrollment to the fact that in the Netherlands, general practitioners saw far fewer women per week for contraceptive advice than HCPs in other countries.
The results from the CHOICE study allow us to draw several conclusions. Informed dialogue between HCPs and women encourages women to select alternative contraceptive methods. The majority of women who selected the pill, patch, or ring stated that daily, weekly, or monthly use was an important consideration that factored into their final choice. ‘Daily use’ was the main reason why women who selected the patch or ring did not select the pill. ‘Easy to use’ was the most significant factor affecting women’s choices. Reasons beyond frequency of administration, including visibility of the method (e.g. patch), placement of foreign body inside the body (e.g. ring), and use of a well-known method versus use of a new, more innovative method, were important and varied significantly between countries. Additional knowledge of the various methods following counseling also played an important role. Surprisingly, a woman’s negative feelings about a particular method, especially the pill, did not always dissuade her from selecting it. In Central and Eastern Europe, women’s contraceptive decisions were more driven by safety concerns and HCP recommendations, whereas in Western Europe, women’s decisions were more driven by a less favorable opinion about the pill. While patch and ring use increased in all countries after counseling, women’s reasons for selecting or not selecting a particular method varied considerably between countries.