Addressing potential pitfalls of reproductive life planning with patient-centered counseling

doi:10.1016/j.ajog.2016.10.004

American Journal of Obstetrics and Gynecology

Volume 216, Issue 2, February 2017, Pages 129-134

https://doi.org/10.1016/j.ajog.2016.10.004 Get rights and content

Engaging women in discussions about reproductive goals in health care settings is increasingly recognized as an important public health strategy to reduce unintended pregnancy and improve pregnancy outcomes. “Reproductive life planning” has gained visibility as a framework for these discussions, endorsed by public health and professional organizations and integrated into practice guidelines. However, women’s health advocates and researchers have voiced the concern that aspects of the reproductive life planning framework may have the unintended consequence of alienating rather than empowering some women. This concern is based on evidence indicating that women may not hold clear intentions regarding pregnancy timing and may have complex feelings about achieving or avoiding pregnancy, which in turn may make defining a reproductive life plan challenging or less meaningful. We examine potential pitfalls of reproductive life planning counseling and, based on available evidence, offer suggestions for a patient-centered approach to counseling, including building open and trusting relationships with patients, asking open-ended questions, and prioritizing information delivery based on patient preferences. Research is needed to ensure that efforts to engage women in conversations about their reproductive goals are effective in both achieving public health objectives and empowering individual women to achieve the reproductive lives they desire.

Section snippets

Potential Pitfalls of Reproductive Life Planning

In published guidance regarding reproductive life planning, providers encourage women to actively consider whether and when they intend to pursue pregnancy, and then promote effective contraceptive methods among women who do not desire pregnancy and offer preconception counseling to women who desire pregnancy.1, 3, 22, 24 While it is emphasized that women will move between categories over time³ and more recent materials acknowledge that women may be unsure about their intentions,²² the

A Patient-centered Approach

Discussing pregnancy desires, feelings, and goals in health care settings has the potential to empower women to make informed decisions about their reproductive lives. However, as discussed, the reproductive life planning framework as narrowly applied carries inherent risks, including the risk that providers will overlook critical dimensions of women’s thoughts and feeling about pregnancy and alienate women who do not conform to normative expectations about when and under what circumstances

Implications for Practice

Drawing on the literature summarized above, in addition to published literature about patient-centered counseling related to contraception,¹⁵ we suggest an approach that we term “patient-centered reproductive goals counseling.” Figure depicts the relationships between patient-centered reproductive goals counseling and subsequent preconception and/or contraceptive counseling, within the broader framework of patient-centered family planning care. We propose the following 3 key components of

Conclusion

Family planning counseling and care that is first and foremost patient centered has the potential to promote healthy outcomes for women and families while supporting and protecting reproductive autonomy. An ongoing critical discussion about how to incorporate patient-centered counseling into discussions about reproductive goals will be important as providers and health systems attempt to operationalize these concepts. Additional work is needed to explore and test the components of

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Cited by (111)

Family building and pregnancy experiences of cisgender sexual minority women
2024, AJOG Global Reports
Although 10% to 20% of cisgender women aged 18 to 40 years have a sexual minority identity (eg, bisexual, lesbian, and queer), there is limited research on the family building and pregnancy experiences of sexual minority cisgender women. Improving our understanding of the family building and pregnancy experiences of cisgender sexual minority women is critical for improving the perinatal health of this population.
This study aimed to compare the mode of family building, past pregnancy experiences, and future pregnancy intentions among cisgender sexual minority women by sexual orientation.
This is an observational study which was conducted using cross-sectional data collected in 2019 from a national sample of 1369 cisgender sexual minority women aged 18 to 45 years.
Most participants (n=794, 58%) endorsed multiple sexual orientations, most commonly queer (n=641, 47%), lesbian (n=640, 47%), and/or bisexual (n=583, 43%). There were 243 (18%) cisgender sexual minority women who were parents. Pregnancy was used by 74% (181/243) of women to build their families. Among participants who used pregnancy, 60% (108/181) became pregnant through sexual activity with another parent of the child, whereas 27% (64/243) of women used donor sperm. An additional 10% (n=24) became parents through second-parent adoption, 10% (n=25) through adoption, and 14% (n=35) through step-parenting. Bisexual women more often used sexual activity to become parents (61/100, 61%) compared with queer (40/89, 45%) and lesbian women (40/130, 31%). In contrast, lesbian (50/130, 39%) and queer (25/89, 27%) women more often used donor sperm to become parents compared with bisexual women (11/100, 11%). Among the 266 (19%) cisgender sexual minority women who had ever been pregnant, there were 545 pregnancies (mean, 2.05 pregnancies per woman). Among those pregnancies, 59% (n=327) resulted in live birth, 23% (n=126) resulted in miscarriage, 15% (n=83) resulted in abortion, and 2% (n=9) resulted in ectopic pregnancy. A quarter of women had future pregnancy intentions, with no differences by sexual orientation. Overall, few participants (16%) reported that all of their healthcare providers were aware of their sexual orientation.
Cisgender sexual minority women primarily built their families through pregnancy and a quarter have future pregnancy desires. In addition, there were important differences in family building methods used by sexual orientation. Providers should be aware of the pregnancy and family-building patterns, plans, and needs of cisgender sexual minority women.
Assessing comprehension of the Parenting/Pregnancy Attitudes, Timing, and How Important (PATH) questions through cognitive interviewing
2023, Contraception
PATH, "Parenting/Pregnancy Attitudes, Timing, and How Important," is a method for providers to engage in a person-centered discussion about reproductive desires. This study sought to assess patient understanding of and receptivity to PATH questions.
Cognitive interviews were conducted with young adult (aged 18–29 years) patients at a federally qualified health center in New York (n = 10).
Participants demonstrated clear comprehension and comfort with the PATH questions.
These data provide needed patient-driven support for the Centers for Disease Control and the Society of Family Planning’s recommendation to implement PATH questions as a patient-centered method for discussing an individual’s reproductive desires.
These data provide needed person-driven support for the Centers for Disease Control and Prevention and the Society of Family Planning’s recommendation to implement PATH questions as a patient-centered method for discussing an individual’s reproductive desires.
Testing the validity and reliability of the Person-Centered Contraceptive Counseling (PCCC) Performance Measure in a Real-World Contraceptive Access Program
2023, Contraception
To validate the Person-Centered Contraceptive Counseling (PCCC) patient-reported outcome performance measure and assess for differences by sociodemographic attributes using survey data from a multistate contraceptive access program.
This analysis explored internal reliability and construct validity of the PCCC using survey data from 1413 patients who visited 15 health centers in Washington state and Massachusetts that had partnered with Upstream USA.
Multiple psychometric indicators provided evidence of reliability and validity. Significant associations between the highest PCCC rating and conceptually-related survey questions (i.e., experience with bias/coercion and shared decision-making) provided further evidence of construct validity.
Our findings demonstrate that the PCCC is valid and reliable. The results also highlight differences in experience of care by patient-reported race and ethnicity, income level, and language.
Family Planning and Reproductive Health in Cystic Fibrosis
2022, Clinics in Chest Medicine
Evaluating the MyPath web-based reproductive decision support tool in VA primary care: Protocol for a pragmatic cluster randomized trial
2022, Contemporary Clinical Trials
Counseling to identify and support individuals' desires for family formation is a key component of preventive health care that is often absent in primary care visits. This study evaluates a novel, web-based, person-centered intervention to increase the frequency and quality of communication about reproductive goals and healthcare needs in Veterans Health Administration (VA) primary care.
We describe a hybrid type 1 effectiveness-implementation cluster randomized controlled trial in seven VA healthcare systems testing a web-based reproductive health decision support tool (MyPath). VA primary care providers are enrolled and randomized to intervention or usual care arms. Veterans scheduled to see intervention-arm providers receive a text message inviting them to use MyPath ahead of their appointment; Veterans scheduled to see control-arm providers receive usual care. Target enrollment is 36 providers and 456 Veterans. Outcomes are assessed by Veteran self-report after the visit and at 3- and 6-months follow-up. The primary outcome is occurrence of reproductive health discussions involving shared decision making; secondary outcomes include measures of communication, knowledge, decision conflict, contraceptive utilization, and receipt of services related to prepregnancy health. Data on implementation barriers, facilitators and cost are collected.
The trial is ongoing with no results to report. We have enrolled 36 primary care providers across 7 VA healthcare systems and recruitment of Veterans is ongoing.
Results will inform efforts to increase the quality and person-centeredness of reproductive healthcare delivery in primary care and to operationalize and scale up use of digital decision support tools in clinical settings.
Trial Registration:http://ClinicalTrials.gov Identifier: NCT04584294
Trial Status: Recruiting.
A systematic review exploring the contraception values and preferences of sex workers, transmasculine individuals, people who inject drugs, and those living in humanitarian contexts
2022, Contraception
We sought to systematically review the literature on values and preferences regarding contraception among individuals within selected key populations.
As part of a larger set of reviews on patients’ and providers’ values and preferences related to contraception globally, we searched ten electronic databases for articles from January 1, 2005 to July 27, 2020. No language restrictions were applied. Data was independently abstracted by two authors and study rigor was assessed using an 8-item measure developed by the Evidence Project for quantitative studies and an adapted CASP checklist for qualitative studies.
We identified 12 studies that met our inclusion criteria examining selected key populations, including sex workers, transmasculine individuals, people who inject drugs, or those living in humanitarian contexts. Seven key themes that spoke to values and preferences emerged related to: autonomy, perceived effectiveness and safety, birth spacing and family outcomes, impacts on sexual experience, hormonal effects (e.g. desire for non-hormonal method or perception that the method is more natural as compared to hormonal methods), physical attributes (e.g. appearance and/or ease of use), and stigma. Six studies were of high rigor, five were of moderate rigor, and one was of low rigor. One study described the values and preferences of two of the selected key populations. The research available on the values and preferences of sex workers regarding methods of contraception was limited to female condoms.
Consideration of the values and preferences of individuals within selected key populations can inform providers, programme managers and policy makers participating in the delivery of contraceptive care. Contraceptive research among sex workers, transmasculine individuals, people who inject drugs, or those living in humanitarian contexts is quite limited; further research is needed to better understand the values and preferences of these populations.

View all citing articles on Scopus

: L.S.C. was supported by a Department of Veterans Affairs (VA) Health Services Research and Development Career Development award (14-412). A.R.A.A. was supported by an infrastructure grant for population research from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health (NIH) (P2CHD047879). C.D. was supported by National Institute on Minority Health and Health Disparities of the NIH award number P60MD006902. S.B. was supported by 1R21HD076327-01A1 from the NICHD. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the VA.

: P.C. serves on advisory boards or as a consultant for Teva Pharmaceuticals (ParaGard), Allergan (Liletta), Medicines 360 (Liletta), Bayer AG (Mirena, Skyla, and intrauterine device in development), ContraMed (intrauterine device in development), and Evofem (spermicide in development). She is a trainer and speaker for Merck (Nexplanon, NuvaRing), Allergan (Liletta), and Medicines 360 (Liletta). The remaining authors report no conflicts of interest.

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Clinical OpinionAddressing potential pitfalls of reproductive life planning with patient-centered counseling

Section snippets

Potential Pitfalls of Reproductive Life Planning

A Patient-centered Approach

Implications for Practice

Conclusion

Lancet

Womens Health Issues

Soc Sci Med

Contraception

Womens Health Issues

Womens Health Issues

Contraception

Soc Sci Med

Womens Health Issues

Patient Educ Couns

Patient Educ Couns

Midwifery

Am J Obstet Gynecol

Contraception

Reproductive life planning to reduce unintended pregnancy. Committee opinion no. 654

Obstet Gynecol

Recommendations to improve preconception health and health care–United States. A report of the CDC/ATSDR preconception care work group and the select panel on preconception care

MMWR Recomm Rep

Providing quality family planning services: recommendations of CDC and the US Office of Population Affairs

MMWR Recomm Rep

Declines in unintended pregnancy in the United States, 2008-2011

N Engl J Med

Pregnancy-related mortality in the United States, 1998 to 2005

Obstet Gynecol

Fetal and perinatal mortality, United States, 2005

Natl Vital Stat Rep

Clinical Opinion
Addressing potential pitfalls of reproductive life planning with patient-centered counseling