Patient-Centered Care in Contraceptive Counseling: A Review of Research

By: Adedamola Badewa, MD

Director’s Note: Our focus at FACTS is to share the science supporting the important role of fertility awareness-based methods (FABMs) and restorative reproductive medicine to enable our colleagues to help patients achieve their family planning goals. To provide accurate information about the full spectrum of options and help medical professionals navigate these conversations with patients, FACTS offers a shared decision-making tool clinicians can use to aid patients in selecting an effective FABM. Today, we highlight research [1] published in Contraception and summarized by former FACTS elective participant, Dr. Adedamola Badewa; the study explores contraceptive counseling and emphasizes the vital role of shared decision making in comprehensive counseling.

Introduction

When it comes to patient usage and continuation of family planning methods, factors such as access to medical care, lack of insurance coverage, and patient knowledge have a significant impact on patient outcomes.[1] Clinician-patient communication is another important yet overlooked factor. It is hypothesized this may be due to a lack of research exploring what women value in their interactions with family planning clinicians.[1] Previous research supported an autonomous decision-making model. Yet, a recent study showed patients preferred shared decision making, an approach where clinicians share the best available evidence for patients to make informed decisions.[2] Additionally, a patient’s race and ethnicity should be considered an essential factor in clinician-patient communication about contraceptive usage, given the long history of racial disparities in healthcare.[1] The 2012 study by Dehlendorf et al summarized below aims to identify what women value in their interactions with family planning clinicians and decision making about contraception to improve contraceptive usage, with a sub-focus on minorities.

“A recent study showed patients preferred shared decision making, an approach where clinicians share the best available evidence for patients to make informed decisions.”

Methodology

This qualitative study recruited 42 adult women between January and May 2009 to conduct semi structured interviews.[1] Women were recruited from a total of 4 clinics in the San Francisco Bay area after receiving contraceptive counseling. Selection criteria included patients who were black, white, and Latina. Interview questions focused on basic demographics and women’s experiences and preferences around decision making in contraceptive counseling. A modified grounded theory was used to generate findings into categories.

Results

Regarding the amount of control patients prefer in their contraceptive decision-making process, most people value clinicians’ opinions as long as the final decision is in the patient’s control. Patients valued clinicians’ opinions more if they focused on the patient’s concerns, preferences, and safety, and more so if facts supported these opinions. Most respondents were not opposed to hearing a clinician’s specific preferences or suggestions, which the women generally considered helpful in making decisions. However, several women agreed the control of the conversation should be up to them, and some preferred a familial, nurturing, and long-lasting relationship with their clinician when discussing sensitive topics.

For several women, it was important for medical professionals to address concerns from social media, friends, and family members that may influence their decision. Additionally, women valued detailed discussions of side effects when addressing contraceptive options to add transparency when making a final decision. Finally, many women preferred having information delivered verbally, virtually, and/or in print prior to, during, and after meetings.

 “Women valued detailed discussions of side effects when addressing contraceptive options to add transparency when making a final decision.”

Regarding differences by race and ethnicity, more Spanish-speaking Latinas reported trouble understanding and communicating with clinicians. Some even reported restricted visit times leading to a lack of full transparency. When compared to English-speaking Latinas and white women, Black women and Spanish-speaking Latinas were more likely to decide on a method before the visit based on past experiences and the experience of family members. They were also least likely to desire clinician involvement in the decision-making process, and only if they specifically asked for their input and the clinician clearly explained their rationale.

Discussion

The study by Dehlendorf et al. assessed what women value in their family planning practitioners during contraceptive counseling to improve contraceptive usage. The study suggests that although women favor autonomy in decision making during counseling, they also desire the clinician’s involvement in their decision-making process. According to the study, several women valued more of a shared decision-making process in which clinicians’ suggestions are backed with explanations along with a nurturing, long-lasting, and non-dismissive clinician-patient relationship.

Considering race and ethnicity in individualized counseling, it is essential to value and respect a woman’s preferences. Given the (1) language and cultural barriers, (2) restricted visit times, (3) decreased desire for close relationships with clinicians, and (4) reduced involvement of clinicians in the decision-making process reported in some groups, family planning clinicians must be aware of differences between and within racial and ethnic groups to meet their patients’ needs. One way to accomplish this is to be direct; to ask patients about their preferences and goals of care from the beginning, and be mindful of the long-standing historical healthcare mistreatment of minority populations.

A notable advantage of this study is its emphasis on the importance of patient-centered care. In other words, the patient’s preferences and needs come first and should be used to guide contraceptive counseling, whether the patient wants complete involvement of their clinician or none at all. Increased support from family planning practitioners who prioritize patients’ goals will improve the usage and continuation of family planning methods by raising patients’ comfort level, thus enhancing the overall quality of contraceptive counseling.

“The patient’s preferences and needs come first and should be used to guide contraceptive counseling, whether the patient wants complete involvement of their clinician or none at all.”

One limitation of this study is the substantial variation noted within each group, including differences in age and education in the racial/ethnic/language groups, which further supports the value of individualized counseling. Within racial/ethnic/language groups, a relevant question to ask is whether religion influences one’s desire for clinician involvement. Also limiting were the subjective results of this qualitative study; it would be interesting to pursue an objective assessment of contraceptive counseling and how it impacts a patient’s decisions.

Natural or fertility awareness-based methods (FABMs) should be considered part of all contraceptive counseling, as they are effective natural ways to achieve or avoid pregnancy. With perfect use, unintended pregnancy rates have been reported to be < 5%, and < 2% with certain methods.[3][4] However, FABMs are only used by 2.2% to 3.2% of sexually active women.[5] The low usage rate may be due to a lack of both medical professional and patient knowledge about these methods. Natural family planning (NFP) methods should be discussed at counseling sessions alongside other options, given their effectiveness with proper usage and their multiple benefits, such as minimal or no financial investment, the lack of side effects, and a higher likelihood of acceptance based on religious and cultural beliefs about family planning.

Considering these facts, FABMs should also be included in the education of medical professionals, especially those working in women’s health. In the end, patients should be able to decide on the best form of family planning based on their values, beliefs, and preferences as well as safety considerations. The role of a practitioner should be to inform patients of their contraceptive options, including safety profiles and concerns, and to support a patient’s decision and adherence to their chosen method of family planning.

[1] Dehlendorf C, Levy K, Kelley A, Grumbach K, Steinauer J. Women’s preferences for contraceptive counseling and decision making. Contraception. 2013 Aug;88(2):250-6. doi: 10.1016/j.contraception.2012.10.012. Epub 2012 Nov 21. PMID: 23177265; PMCID: PMC4026257.
[2] Elwyn G, Frosch D, Thomson R, Joseph-Williams N, Lloyd A, Kinnersley P, Cording E, Tomson D, Dodd C, Rollnick S, Edwards A, Barry M. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012 Oct;27(10):1361-7. doi: 10.1007/s11606-012-2077-6. Epub 2012 May 23. PMID: 22618581; PMCID: PMC3445676.
[3] Review of FABM effectiveness published in high profile OB/GYN medical journal. FACTS About Fertility. Published August 21, 2018. https://www.factsaboutfertility.org/review-of-fabm-effectiveness-published-in-high-profile-ob-gyn-medical-journal/
[4] Duane M, Stanford JB, Porucznik CA, Vigil P. Fertility Awareness-Based Methods for Women’s Health and Family Planning. Front Med (Lausanne). 2022;9:858977. Published 2022 May 24. doi:10.3389/fmed.2022.858977.
[5] Charisse Loder MD, Villavicencio MD. Familiarizing yourself with fertility awareness as a birth control option. Contemporary Obgyn. 2020;65. https://www.contemporaryobgyn.net/view/familiarizing-yourself-fertility-awareness-birth-control-option.

ABOUT THE AUTHOR

Adedamola Badewa, MD

Dr. Adedamola Badewa is currently serving as an intern within the UT Southwestern Pediatric Residency Program at Children’s Health. Prior to this, she attended Georgetown University School of Medicine in Washington, DC. She took the FACTS elective to enhance her understanding of natural family planning methods and women’s reproductive health, and hopes to share this knowledge with friends, family, and patients. Dr. Badewa plans to become certified as a lactation consultant to support mothers. This aligns with her goal of empowering women by fostering an understanding of their bodies and ensuring optimal care for mother and child.