Focus on open-ended discussions
By Melinda Young
Here are some strategies to improve contraceptive counseling for all patients, including those who are pregnant:
Bring up the subject in a noncoercive way. “Patients don’t like to feel discriminated against or being pushed, and negative counseling experiences are what we prefer not to have,” says Jennifer Karlin, MD, PhD, an associate professor (specialty in family planning), family and community medicine, at the University of California, San Francisco.
Karlin introduces the idea of contraceptive counseling to pregnant patients by saying, “At some point, we’d like to talk about your plan for contraceptive care after you deliver, and is now a good time to discuss that?”
If the patient says “no,” then she responds, “OK, we’ll bring that up later if you want to do that.”
Be aware that patients learn in different ways. Besides timing, providers need to be cognizant of the different ways people learn.
“Do you want to talk about it with me? Do you learn better from video or paper? How best do you learn information?” Karlin says. “That’s really important because everyone learns differently and takes in information at different times.”
If a patient prefers written information about contraception, then they will respond best if the provider hands it to them with a comment, such as, “I think this is important information. Could you take look at it, and we can talk about it when you’re ready?” she says.
Be open-ended in contraceptive discussions. “Are you ready to have this conversation right now, or should we schedule another time?”
Patients may have other priorities and things on their mind at the doctor’s appointment when their doctor first brings up contraception. So, it is best to ask them if they are ready for the discussion.
Make no assumptions about which method they may prefer. Even if the patient had been using an intrauterine device (IUD) for years, providers should not assume that she will prefer to return to the IUD after giving birth. The same is true of patients using other forms of birth control — or even no birth control.
“I always bring up different options of contraception to everybody,” Karlin says.
This includes mentioning permanent contraception and not reserving this for older patients.
“There are some young patients who have three kids and don’t want to be pregnant anymore. There are some that want permanent contraception earlier than age 30 and maybe they’re done with their family planning,” she explains. “Don’t assume certain options are off the table because you as a provider have some biases or stereotypes in the back of your head.”
Patients who feel they are heard and understood believe their provider cares about them.
Ask if they have any questions and probe into their experiences and preferences. “I ask people for their narrative about how they started certain contraception, and I go back to how their mom when they were 14 of 15 brought them to the doctor and started them on oral contraception pills, and maybe they are afraid of other options,” Karlin offers as an example.
“Encourage patients to advocate for their own bodies and create an open enough environment that people can ask us questions that they might be scared to ask other people in their lives,” she says.
Go over side effects, pros, and cons of various methods. “I ask them if they have any ideas of what works for them or which methods they want to hear about,” Karlin says. “If they have ideas, I ask what they know about the method and what are its positives and negatives.”
If a patient has never been on a particular contraceptive, Karlin tells them what the literature says about the contraceptive’s side effects and what they will need to do if they choose this method.
“It varies from taking a pill every day to having a method placed in your body that you don’t have to think about up to 12 years or having permanent contraception where you don’t have to think about it again,” she says.
Karlin also asks these questions:
- Are side effects important to you?
- Is how often you take it important to you?
- How important is the contraceptive’s effectiveness?
Individualize each contraception counseling conversation. “If someone says, ‘I never want to put something artificial in my body,’ I would say, ‘Have you considered a diaphragm?’ or ‘Let’s talk about the rhythm method or natural family planning,’” Karlin says. “We could dive into that, teaching patients about cycles and keeping a calendar of their menses.”
While physicians primarily think of contraception in terms of pharmaceuticals and devices, natural family planning as contraception also can be effective, she notes.
One effective method is breastfeeding, and patients who plan to breastfeed may have questions about how this may affect their ability to get pregnant.
Karlin would tell these patients that breastfeeding correctly could be 98% effective at preventing pregnancy before the baby is 6 months of age. But it would need to be done every three hours, day and night, and pumping breast milk does not count.
Women who breastfeed every three hours until after midnight when their partner takes over for the 3 a.m. feeding will not have the full benefits of pregnancy protection, for instance.
“We push women to exclusively breastfeed now, but if my patient says, ‘I need sleep, and this is affecting my mental health,’ I tell her the whole picture is most important,” Karlin explains. “Breastfeeding is important, but so is your mental health and getting sleep.”
Even if someone says they plan to use only condoms, which physicians know is not that effective for most people, they should tell the patient, “I’m so excited you want to use condoms. Let’s figure out how we can make this work the best for you,” she says.
“Language is very important in these situations,” Karlin says. “You could say, ‘Condoms work really well for a lot of people, and they prevent sexually transmitted infections, so let’s figure out how they work for you.’”
