SAN FRANCISCO – When it comes to counseling women about contraceptive care and family planning, many primary care physicians fall short, according to Christine Dehlendorf, MD.
“Providing contraceptive care and family planning care is part of what we do as preventive care for women of reproductive age, but we don’t always do it as often as we should,” Dr. Dehlendorf said at the UCSF Annual Advances in Internal Medicine meeting. “We don’t often take the initiative of making sure that women’s contraceptive needs are being met at all visits when we engage with them.”
Dr. Christine Dehlendorf
“Many of you might think that’s okay, because we’re only talking about it when women come in for family planning visits,” said Dr. Dehlendorf of the departments of family and community medicine and obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. “In fact, this is something that is an ongoing need for women. We should be using every opportunity to make sure we’re helping them, even if it’s just by initiating the conversation and providing referrals as appropriate.”
Some might think that the best approach to contraceptive decision making involves recommending the most highly effective methods, such as long-acting reversible contraceptives, which have a risk of failure that’s 20 times lower than that of short-acting hormonal methods. Examples of counseling approaches used in that context include tiered effectiveness, in which the clinician presents methods in order of effectiveness, and motivational interviewing, a counseling approach developed for use in people with addictions.
However, Dr. Dehlendorf said she prefers to view contraceptive choice as a decision driven by women’s values and preferences.
“We know that effectiveness is very important to women, but we also know that things like side-effect profile and control over the [contraceptive] method are important as well,” she explained. “These strong features reflect women’s different assessments of the desirability of different outcomes associated with contraceptive use.
“For example, some women think that the possibility of amenorrhea with progestin IUDs or Depo-Provera is a great thing, and other people think it would be horrible,” Dr. Dehlendorf noted. “It has nothing to do with safety or effectiveness; this has to do with how women view that characteristic in the context of their own values and preferences.”
The differential value that women may place on contraceptive effectiveness also relates to different perceptions they have of the possibility of an unplanned pregnancy in their lives, and how important that is to avoid.
“In general, in the public health and clinical dialogue, the idea is that an unplanned pregnancy is an inherently bad pregnancy,” Dr. Dehlendorf said. “The conventional dialogue involves the notion of intentions and plans: Are they intending or planning to get pregnant? Intentions being timing-based ideas of when to get pregnant, and plans being concrete steps they take to act on those intentions.”
However, an emerging body of literature has shown that there are other dimensions of how women think about the possibility of pregnancy in their lives that are distinct from intentions and plans, she said, such as desire, which is how strongly they intend or don’t intend to have a pregnancy, and feelings, their emotional orientation around the potential for a pregnancy in their life.
“You could argue that this is overcomplicating things, but that is not true,” Dr. Dehlendorf said. “Plans, intentions, desires, and feelings are all different concepts, and some of them are more or less relevant to individual women, and they don’t always align with each other. That’s very much in conflict with how we conventionally talk about pregnancy in women’s lives.”
Examples from qualitative research have fleshed this out.
In one recently published study, researchers led by Jenny A. Higgins, PhD, of the department of gender and women’s studies at the University of Wisconsin–Madison, asked women about their views on IUDs. One woman said, “I guess one of the reasons that I haven’t gotten an IUD yet is like, I don’t know, having one kid already and being in a long-term committed relationship, it takes the element of surprise out of when we would have our next kid, which I kind of want. I’m in that weird position. I just don’t want to put too much thought and planning into when I have my next kid.”
Other women view an unplanned pregnancy as emotionally welcome.
In a longitudinal study that measured prospective pregnancy intentions and feelings among 403 women in Austin, Tex., one woman said, “Another pregnancy is definitely not the right path for me, and I’m being very careful with birth control. But if I somehow ended up pregnant, would I embrace it and think it’s for the best? Absolutely.”
Another study participant said, “I don’t want more kids and was hoping to get my tubes tied. We can’t afford another one. But if it happened, I’d still be happy. I’d be really excited. We’d rise to the occasion. Nothing would really change” (Soc Sci Med. 2015 May;132:149-155).
According to Dr. Dehlendorf, the lesson from such studies is that women are going to assess the importance of the efficacy of their contraceptive method differently, depending on how important it is for them to prevent an unintended pregnancy.
“They’re not going to make a decision about effectiveness the way we as clinicians might think that they should,” she said. “So, assuming that highly effective methods are the best methods for all women because of their effectiveness ignores the variability in preferences, and it also doesn’t take into account women’s strong feelings about other aspects of contraceptive use, such as bleeding profiles and control over their methods.”
Shared decision making may be the best way to help women make a choice based on their preferences. In a study that Dr. Dehlendorf and her associates conducted in 348 women who were seen for contraceptive care in the San Francisco Bay area, two habits were associated with contraceptive continuation: investing in the beginning, and eliciting the patient’s perspective (Am J Obstet Gynecol. 2016 Jul;215[1]:78.e1-9). “Investing in the beginning consists of greeting the patient warmly, making small talk, and treating the patient as a person,” she said. “That was the most highly influential aspect of the interaction. Building rapport and decision support helps women choose a method that’s a good fit for them.
“We also know that women like this method of counseling, but this approach might not be for everyone,” Dr. Dehlendorf cautioned. “Some women don’t want your suggestions, even if it’s grounded in their preferences. They just want to get the method that they came in for. The right thing is to acknowledge that, but you can also ask women if they want to hear about other methods, because some women might not know about all of their options.”
Dr. Dehlendorf reported having no relevant financial disclosures.