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Breaking the Contraceptive Barrier: Techniques for Effective Contraceptive Consultations

(Published September 2008)

Patient-Centered Approach to Contraception

"Medical care should be inspired by compassion and guided b y scienc."1
- Bertrand Russell

Effective contraceptive strategies require more than knowing the latest evidence-based medicine findings and putting your pen to the prescription pad. Each woman has her own story, with unique circumstances and needs that affect her ability to access and use contraception effectively. Filtering the findings from evidence-based medicine through your understanding of each woman’s story and adapting your approach accordingly helps to ensure that every patient makes the best contraceptive choices.

An approach to contraception that is tailored to each woman involves collecting a sexual history, understanding a woman’s reproductive health plan, and delivering patient-centered care.

Collecting a sexual history

Make contraception a mainstream and regular topic of conversation with patients. For each patient, collect an appropriate sexual history to guide patient care and contraceptive choices. This process begins with a medical history that can help identify which methods are most appropriate for that woman. But a sexual history goes beyond a traditional medical history.

For more information on taking a complete sexual history, see ARHP’s “What You Need to Know: Talking to Patients About Sex and Sexuality” Clinical Fact Sheet (www.arhp.org/factsheets).

Understanding a woman’s reproductive health plan

It is important that health care providers understand each woman’s reproductive health plan and help her create one if she doesn’t have one. Helpful questions to ask include:

  • How important is it to avoid pregnancy now?
  • What would you do if you became pregnant now?
  • What is your desired family size?
  • What is your intended timing for pregnancy?
  • Do you have health issues that need to be addressed before you become pregnant?

Other questions that will help you understand each woman’s circumstances include:

  • What are your contraceptive preferences?
  • What factors influence your contraceptive choices?
  • Are you trying to prevent sexually transmitted infections (STIs) as well as prevent pregnancy?

It is also important to explore her sexual orientation, as orientation does not always predict behavior. Women who identify as lesbians may at times have sex with men and need to know about condoms and emergency contraception.

These discussions also should explore lifestyle issues that affect adherence. Ask questions that seem pertinent, such as whether the patient can remember to take a pill every day; whether her partner is receptive to using barrier methods every time they have intercourse; whether she can afford the contraceptive method; and whether there are insurance barriers.

Health care providers also need to listen to women’s preconceptions about and attitudes toward contraceptive methods. Listen as the patients talks and you may discern that she is concerned about using hormonal methods; she doesn’t understand that female sterilization is not easily reversed; or she is unaware that other contraceptive methods are much more effective than withdrawal or barrier methods. Gail’s case study illustrates the importance of collecting a complete sexual history and understanding a patient’s reproductive health plan to help her make the most appropriate contraceptive choice.

Gail. Gail is 18 years old. She is sexually active and about to start college. She hopes to become a pediatrician. Once she starts college, the student health insurance will not cover contraceptives.

In this case, Gail has an insurance barrier to overcome. She also has professional aspirations that should encourage her to make contraception a priority. She may be motivated to use emergency contraception if she is aware of the option and if the need arises. Asking her about her contraceptive preferences may reveal that she does not want to have to remember to take a pill every day or that she has multiple partners and preventing STIs may be as important as preventing pregnancy. An intrauterine device (IUD) would effectively cover her contraceptive needs for years, but perhaps she doesn’t know that an IUD may be appropriate for her.

Collecting a complete sexual history and understanding or helping a patient create a reproductive health plan can help you understand many of the factors that inform her decisions about contraception.

Delivering patient-centered care

Delivering patient-centered care enhances relationships with patients and patient satisfaction with providers. A patient’s satisfaction with their provider is associated with more consistent contraceptive use among women who use oral contraceptives. A Guttmacher study found that nearly half of the women who used oral contraceptives (OCs), and were dissatisfied or only somewhat satisfied with their providers, used OCs inconsistently, whereas only one-third of the women who were very satisfied with their providers used OCs inconsistently. The study also found that women who see the same clinicians at each visit are less likely to have missed one or more pills in the previous three months than women who see different clinicians at each visit.2

A complete sexual history and a reproductive health plan make it much easier for health care providers to deliver patient-centered care, establish trust, and help patients use contraception effectively. But there may be barriers to overcome within a health care setting before the most effective patient-centered care can be delivered.

Someone in every office or clinic should be comfortable discussing all contraceptive methods with patients. It is important to help a patient be aware of all contraceptive options, the efficacy of each method, the potential for using multiple methods, and even any non-contraceptive benefits. It is also important that everyone in the office or clinic, including the front office staff, support each patient’s choices.

Ideally, every office or clinic should have someone who is capable of inserting IUDs and implants and fitting diaphragms. A 2002 survey of ob/gyns revealed that 20 percent had not inserted an IUD in the previous year.3

Women need an opportunity to discuss all of their contraceptive concerns. Having health educators available will help make time available for more complete counseling. Whenever possible, both the woman and her partner should participate in these discussions.

Health care providers should take the time to review contraceptive options with women who are switching methods. Many women choose either condoms or no contraception at all because they don’t know about other highly effective options.4 It is also important for health care providers to be available to discuss side effects after patients start using OCs.5 In one study of contraceptive continuation for two months after initiation, 22 percent of women called and 9 percent scheduled visits with their health care providers.6 Counseling about OCs also should address the benefits of and misconceptions about their use.5

Other elements of patient-centered care include:2

  • Providing ongoing support for contraceptive use
  • Improving women’s knowledge of contraceptive risks and benefits
  • Anticipating and managing side effects
  • Examining a woman’s current attitudes toward pregnancy at each visit, recognizing that women’s reproductive goals change
  • Addressing logistical and cost barriers

Finally, health care providers should give women information resources. Written materials that include all of the contraceptive methods should be available in exam rooms. These materials should contain information about the efficacy and side effects for each method. Make sure the materials are written at a literacy level suitable for your patient population, and offer Web site suggestions to patients for more information.

Web Sites That Have High-Quality Information About Contraceptive Methods

ARHP can provide free fact sheets on a variety of topics at an appropriate reading level for patients. Visit www.arhp.org/ healthmatters to download reproducible fact sheets for your office or clinic.

Other sources of information include:

References

  1. Grimes DA. Technology follies: the uncritical acceptance of medical innovation. JAMA. 1993;269:3030-3.
  2. Guttmacher Institute. Improving contraceptive use in the United States. In Brief. 2008 Series, No.1 April 2008.
  3. Stanwood NL, Garrett JM, Konrad TR. Obstetrician-gynecologists and the intrauterine device: a survey of attitudes and practice. Obstet Gynecol. 2002;99:275-80.
  4. Isaacs JN, Creinin MD. Miscommunication between health care providers and patients may result in unplanned pregnancies. Contraception. 2003;68:373-6.
  5. Leeman L. Medical barriers to effective contraception. Obstet Gynecol Clin N Am. 2007;34:19-29.
  6. Rosenberg MJ, Waugh MS, Burnhill MS. Compliance, counseling and satisfaction with oral contraceptives: a prospective evaluation. Fam Plann Perspect. 1998;30:89-92, 104.