Individualized counseling optimal
By Melinda Young
Reproductive healthcare and contraceptive counseling have evolved in recent years to embrace patient-centered counseling and the reproductive justice framework. This focus should include the perinatal period, but that is not always the case, a new paper finds.1
The perinatal period is a critical time for supporting patients’ reproductive futures.1
“Counseling in the perinatal period is extremely varied,” says Jennifer Karlin, MD, PhD, an associate professor (specialty in family planning), family and community medicine, at the University of California, San Francisco.
“We don’t know what patient preferences are, and from our scoping review, we found people want individualized, flexible contraceptive counseling,” she says.
Contraceptive counseling must be individualized.
“Some might want written material; some might want a video,” Karlin says. “People want to be told about contraception and told about how important it is, and they want to be told at the times they want. Individualized contraceptive counseling is what they want.”
Patients do not want to be forced into talking about contraception, and they do not want to be pressured into selecting a specific method. (See article in this issue on how to improve contraceptive counseling.)
Investigators experienced challenges when trying to find studies that could answer their questions about what patients in the perinatal period preferred and how the delivery of contraceptive counseling was associated with patients’ experiences of counseling.
“We excluded 111 out of 295 articles because when they assessed for the relationship between contraceptive counseling, they used patients’ choice of a contraceptive method without actually asking them if that was their preference,” Karlin says. “The researchers assumed if patients were on a method, particularly long-acting reversible contraception (LARC), that they had a good experience of contraception counseling because of the offer and acceptance of LARC.”
But that does not mean patients have better outcomes. The bias is that investigators assumed patients were happy with counseling because they ended up with a contraceptive method they were using over time, she explains.
“Almost 50% of the studies said they were studying patient preferences, but they were actually studying preferences by proxy of method use, and we didn’t think that was studying patient preferences,” Karlin adds.
Other biases were toward LARC. Karlin and co-investigators found no evidence that researchers were thinking about that kind of bias until around 2018.
In 2022, the American College of Obstetricians and Gynecologists (ACOG) issued a committee statement that said OB/GYNs should adopt the reproductive framework of contraceptive counseling.
“The focus then was on patient-centered counseling and what it looks like when translated into research,” Karlin says. “Six studies tried to assess patients’ preferences in the peripartum period.”
There was an increase in studies on this topic after 2018. “From 2022 to 2024, you see a good number of studies that focused on patient-centered contraceptive care,” she adds.
The goal of prenatal contraceptive counseling should be to offer patients an opportunity to discuss contraception methods at a time that works best for them during their pregnancy. For most women, that would be after viability — or at least after the first trimester — when they are confident their pregnancy will continue.
Somewhere between 20 and 30 weeks would be optimal. Waiting until a patient is in labor or has just given birth is not ideal timing, and yet that happens. “We saw that people would deliver and then immediately their caregivers in the hospital would talk with them about contraception,” Karlin says.
Researchers found that many patients disliked being first told about contraception while they were in labor or after they gave birth, she says.
Patients who experience preterm labor typically are not in a good mental space to hear about contraception. They often are so worried about their newborns that they do not want to think about contraception, Karlin notes.
Providers may wait until the postpartum period to mention contraception because prenatal visits often have so many other things to cover. Patients may have gestational diabetes and/or preeclampsia or other medical conditions that require additional attention.
“Contraception is put to the wayside, and the irony is that’s the patient population [for whom] you want to encourage birth spacing more than you would for your healthy population of patients,” Karlin says.
Healthy pregnancy spacing is about a year after delivery. Shorter interval pregnancies are considered six months after delivery.
“In that population of people, you have higher rates of preterm birth and hemorrhaging, and higher rates of both maternal and infant mortality,” she says. “You also see those outcomes when somebody has preeclampsia or preterm birth. That’s what the literature worries about.”
Another reason for providers to not wait until the patient has given birth to mention contraception is because that time period is too late for some important methods, such as permanent contraception or post-placental intrauterine device (IUD) placement.
Patients who receive Medicaid need to give consent for permanent contraception 30 days before the procedure. This means contraception counseling should take place sometime near the beginning of the third trimester to ensure the sterilization form is signed 30 days before delivery.
A recent study found that patients interested in permanent contraception often are offered information and counseling on that option late in their pregnancy, causing an access barrier.2 (See Contraceptive Technology Update’s May 2024 issue.)
Karlin’s study of research on contraceptive counseling shows that as more providers address patients’ preferences and address provider bias, patients say they have better experiences when receiving contraceptive counseling.
“We need to ask people what it is they want to use,” Karlin says. “When we do that, we see patients have a great experience of contraceptive counseling in a patient-centered way.”
REFERENCES
- Karlin J, Newmark RL, Oberman N, Dehlendorf C. A scoping review of patient-centered perinatal contraceptive counseling. Matern Child Health J 2024; Aug 1. doi:10.1007/s10995-024-03946-y. [Online ahead of print].
- Viswanathan AV, Berg KA, Bullington BW, et al. Documentation of prenatal contraceptive counseling and fulfillment of permanent contraception: A retrospective cohort study. Reprod Health 2024;21:23.
