The world health community has affirmed the “basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children” (UN,1994).] The gap in unmet need for modern contraception varies, but exists in all countries (Guttmacher 2016).
Contraception is primary health care. All patients with reproductive potential should be counseled regarding their reproductive preferences and offered contraception as needed as a part of routine abortion and primary care (CDC QFP 2014, Bellanca 2013).
Optimal contraceptive counseling supports patients in making fully-informed decisions by providing unbiased information about the full range of options. Given the social and historical context in which some communities’ reproduction has been devalued, counseling should not direct patients towards the selection of any specific method or method type, but rather be responsive to each patient’s priorities and concerns (Dehlendorf 2014) and include information on the risks, benefits, and side effects of the various methods.
The quality and effectiveness of contraceptive counseling has been validated by a patient-centered measure of interpersonal quality in family planning (IQFP) (Dehlendorf 2018, 2016).Patients are more likely to be satisfied with their counseling and continue to use and like their selected method after 6 months if they responded that they felt as if their provider:
- Respected them as a person
- Let them say what matters about their method
- Took their preferences seriously
- Gave them enough information to make a decision.
The following core principles of quality family planning that can guide best practices in contraceptive counseling have been set forth by the CDC (CDC QFP 2014).
- Establish and maintain rapport with the patient
- Assess the patient’s needs and personalize discussions accordingly
- If the patient has a strong interest in one method, ask permission before providing information on others.
- Consider methods that align with patient priorities, such as
- Changes to menstrual bleeding
- Route, ease of use, or remembering
- Privacy from a partner or parents
- Highly effective
- No hormones
- Impact on sex or pleasure
- Work with the patient interactively to establish a plan
- Anticipate and address barriers to accurate/consistent use for chosen method.
- Provide information that can be understood and retained by the patient
- Simplify the choice process using visual aids.
- Confirm patient understanding
- Use active learning strategies such as teach back.
Addressing bias in family planning
Guided by ethical principles of patient-centered care, and informed by the history of reproductive oppression affecting marginalized communities, we encourage patient-centered decision-making that is grounded in patient preferences (Dehlendorf 2018, 2014).Studies have documented provider bias encouraging long-acting methods for low income and patients of color, while discouraging their removal (Amico 2018, Dehlendorf 2016), Low-income and patients of color are more likely to rate their family planning visits less positively, and perceive (or experience) race-based discrimination and pressure to use contraception and limit family size when compared to white, higher-income women (Brandi 2018; Becker 2008).
Understanding and addressing one’s own biases is a life-long process and requires that providers acknowledge and challenge their assumptions about certain individuals or communities. The impacts of bias on contraceptive care become less pronounced if a provider invests in the patient’s experience and preferences, rather than in a particular method or outcome. (See related content in Chapter 2)
- Avoid delays by sending prescriptions to pharmacy, mailing, or pre-packing for pick up.
- Dispensing 12 months is safe, effective, and improves continuation (Foster 2006).
- Provide virtual or telehealth visits for counseling and initiation for some methods.
- Initiate a bridging method as needed, pending a follow-up or in person visit for IUD, implant, sterilization, or DMPA (consider SQ home administration):
- Use evidence-based extended use for all methods (Ti 2020, Ali 2017), if desired by patient.
- Both contraceptive initiation and LARC removal upon request are essential services.
|Evidence-Based Extended Use|
|Method||FDA-approved duration||Evidence-based duration|
|Paragard®||10 years||12 years|
|Liletta®||6 years||7 years|
|Mirena®||5 years||7 years|
|Nexplanon||3 years||5 years|
Counseling for side effects and common concerns
Many patients have used various contraceptive methods and may have strong opinions about a method based on their preferences and personal experience.Investing in a patient’s experience requires listening to, and identifying, a patient’s preferences.
Tip: First, empathize. Then validate and normalize the patient’s concern. Then you can ask follow-up questions to understand more about the concern so that you can provide reassurance and offer information and options in a patient-centered manner.