A Practical Tool for Family Planning Counseling Tested in Sweden

By: Kaitlyn Eckert, DO

Director’s Note: In this research summary, Kaitlyn Eckert provides an introduction to the Reproductive Life Plan (RLP), a protocol developed to help people proactively consider their family planning goals. Fertility awareness-based methods (FABMs) are unique in that couples can use them to prevent or attempt to achieve pregnancy. FACTS recently published the second part of a study on the impact of a shared decision-making tool we developed to help women discuss FABM options for family planning and ultimately choose the method that is best for them. Eckert, a former FACTS elective student, summarized a 2016 article by Tydén et al that addresses this important topic in Swedish women: “Using the Reproductive Life Plan in contraceptive counselling.”[1] She hopes this research inspires more physicians and clinicians to engage patients in this crucial conversation, increasing patient awareness of the fertile window and family planning implications.

Introduction

The Reproductive Life Plan (RLP) is a protocol designed for women and men to help identify their reproductive goals over their lifetime as well as steps to take to achieve these goals. The RLP consists of questions intended to generate thought and create dialogue about whether parenthood is desired, and the ideal timing.[1]  A couple may discuss these questions on their own or with a medical professional to proactively address family planning. By facilitating conversations about reproductive goals, this tool helps equip patients to take appropriate steps to postpone pregnancy or begin preconception counseling to optimize a wanted pregnancy in the future. The ultimate goal is to establish pregnancy intentions to optimize birth outcomes with wanted, planned, and healthy procreation. The Reproductive Life Plan gives couples an opportunity to make autonomous decisions about their future and fertility life cycle.

“By facilitating conversations about reproductive goals, the Reproductive Life Plan tool helps equip patients to take appropriate steps to postpone pregnancy or begin preconception counseling to optimize a wanted pregnancy in the future.”

This protocol was first developed in the United States to support contraceptive counseling.[1] [2]  Limited studies exist establishing its effectiveness, with varied outcomes found.[3][4][5][6] Still, the Centers for Disease Control and Prevention (CDC) recommend the use of the RLP to decrease unintended pregnancies and adverse pregnancy outcomes with improved preconception health. With other reproductive planning tools available for both men and women,[2][5][7] it is important to assess the RLP to ensure the most effective protocol is utilized for family planning initiatives. The study summarized below was done to gain a better understanding of the replicability and utility of the RLP protocol in a healthcare facility outside the United States.

With comprehensive parental benefits and a child allowance from the state, Sweden is considered one of the most family-friendly countries in the world. Despite these benefits, various factors are thought to contribute to Sweden’s significant postponement of parenthood, including housing and financial uncertainties, increased education and career goals for women, and contraception.

Methodology

This study utilized Sweden’s free-of-charge contraceptive counseling services at a student health center to investigate the RLP’s utility. Given that midwives provide 80-90% of contraceptive counseling in Sweden, they served as the medical providers for this study. Consented female university students seeking contraception counseling completed a baseline questionnaire (n=299). All participants received standardized contraceptive counseling, with half of the women receiving the additional RLP protocol. This consisted of a semi-structured CDC-based interview and a booklet with further education about a woman’s fertile window and preconception lifestyle considerations.

Study Findings

A two-month follow-up showed participants thought midwives should routinely discuss the RLP, with 90% of them rating the tool as a “rather” or “very positive” experience. The RLP-intervention group had greater reproductive knowledge than the control group and indicated wanting to have their last child earlier in life than what they reported at baseline.[1]  Given this outcome, the RLP protocol may counteract social norms toward postponing pregnancy.[1]

“The RLP-intervention group had greater reproductive knowledge than the control group, and indicated wanting to have their last child earlier in life than what they reported at baseline.”

These results motivated a second investigation; 53 midwives were recruited to encourage RLP use with their clients. At the three-month follow-up, the midwives completed a questionnaire about RLP use. Five focus groups were also conducted. At that time, 68% of the midwives reported using the RLP protocol. Some used the informational booklet during appointments to spark discussion while others gave it to patients. Most midwives reported the booklet was an asset as an information source for their patients, especially with time constraints. The most common reason for not using the RLP was not receiving enough training.

From the focus groups, it was gathered that midwives experienced the RLP as rewarding and easy, though professionalism was needed to keep interactions positive with patients. There was disagreement on the tool’s suitability for all clients, though it was considered a motivator of healthy lifestyles to promote fertility longevity. The midwives acknowledged that their biases and their patient’s biases influenced the depth of conversation. There was disagreement about whether making the RLP mandatory would promote or impede its use; however, there was agreement that more extensive training would be beneficial.[1]

The consensus was that the current protocol needs little improvement. Both midwives and clients enjoyed the RLP booklet and found it easy to understand. The booklet encouraged non-pressured dialogue that enhanced the communication strategies and confidence of the medical professionals. Moving forward, the greatest challenge for midwives appears to be time. They share a concern that the RLP will not always fit efficiently into their visits, may be difficult to incorporate into electronic records, and will require extensive education and training to ensure unbiased, tactful engagement with patients.[1]

Discussion

Due to these initial findings, three randomized controlled trials are underway in Sweden. This outcome represents a strength of this study in stimulating further research.[6]  This study was limited by short-term follow-up and a non-representative sample. The long-term impact of RLP use in a general population remains unknown. The study authors urge future research into the RLP tool to continue to investigate its use in other countries, populations, and with other medical professionals. In the era of telemedicine, the RLP may be even more useful and afford greater flexibility, which should be explored and evaluated for its economic impact.

Since fertility awareness is valuable throughout a person’s life, not merely when attempting to conceive, the goal should be to integrate the RLP tool into standard clinical care.[8] Further research is needed to incentivize and streamline the best way to implement the RLP within our current systems.

Fertility awareness is a public health initiative that most countries could improve. In recent decades, effective initiatives have been enacted to educate and promote delaying of unwanted pregnancy, and developed countries have seen the age of first-time mothers increase steadily. In the past 40 years, Sweden’s mean age of first-time mothers has increased from 24 to 29.[1][9]  While it is well-known in medicine that advanced maternal age is associated with preterm birth, gestational diabetes, stillbirth, preeclampsia, and neonatal death, this information is not widespread in the general population.

“While the RLP provides an excellent opportunity to support delaying pregnancy when that is a couple’s goal, it also provides context to users about optimizing their fertility window and preconception health.”

While the RLP provides an excellent opportunity to support delaying pregnancy when that is a couple’s goal, it also provides context to users about optimizing their fertility window and preconception health.[8]  While striving to empower individuals and couples to understand their reproductive cycle and be intentional in their reproductive goals, it is vital to also recognize that encouraging educated, autonomous decisions is a medical professional’s responsibility. We must respect patients’ choices and optimize the circumstances that exist while remaining transparent about the risks and benefits of procreation over a lifetime. The RLP supports this relationship and facilitates open dialogue among partners, an ever-important part of reproductive health that is often not given as much consideration. The Reproductive Life Plan offers an exceptional opportunity to open the door to this crucial conversation and stimulate awareness about fertility windows and intentionality in parenthood.

Note: A self-administered worksheet is available on the CDC website for women interested in reflecting on their reproductive goals further.[1]

References