1. Contraceptive Counseling and the Role of Shared Decision Making
Carolyn Sufrin, MD, PHd1
Kate sznajder, md, mph1
Christine Dehlendorf, MD, MAS2
Johns hopkins, dept of gyn/ob
Ucsf, depts of family & community medicine and Ob/gyn

2. What approaches do you use for contraceptive counseling?
Encourage women to choose the most highly effective methods
Give them information about all methods and let them decide for themselves
Give them whichever method they say they want or whatever they are already using
I don’t know – I just wing it every time
Let’s take a moment to think about our own approaches to counseling.

3. Objectives
Review social-historical context of contraceptive counseling and provision and how it relates to present, especially LARC provision
Give overview of approaches to contraceptive counseling, focusing on shared decision making
Review evidence for best practices in contraceptive counseling

4. What evidence is there that contraceptive counseling matters?
Positive relationship with provider associated with satisfaction with method
Satisfaction with family planning care associated with use of contraception
Counseling influences method selection
Health communication has been found to correlate with patient outcomes, including patient satisfaction and medication adherence, across a range of health conditions.
With regard to family planning, evidence shows that…
Rosenberg, Fam Plann Perspect, 1998
Forrest, Fam Plann Perspect, 1996
Harper, Patient Ed Counsel, 2010

5. Goals of contraceptive counseling visits
Provider priorities
Patient priorities
Preventing unintended pregnancy
Providing information
Helping women realize their reproductive life goals
Promoting patient and public health
Exploring women’s contraceptive priorities and concerns
Receiving information
Preventing unintended pregnancy
Side effects
Convenience/comfort
Return to fertility
Patient ability to discontinue method
Prior & friends’ experiences
Provider priorities often differ from patient priorities.
Contraception counseling is a highly preference sensitive decision.
The priorities listed here are not in order, and this is not an exhaustive list, but it highlights the fact that everyone comes to the clinician-patient relationship with different goals and priorities.

6. Common Approaches to Contraceptive Counseling
Directive Counseling
Informed choice
Informed choice
Directive Counseling
So how do we reconcile these sometimes competing provider and patient priorities? Different approaches to contraceptive counseling are described in the literature. Two common approaches are informed choice and directive counseling.
Providing information about effectiveness, side effects, and non-contraceptive benefits fits into both of these approaches, but the type of counseling has to do with how that information is provided to the patient and what is prioritized.
An informed choice model focuses on being objective and nonjudgmental. It aims to provide information and not participate in the selection of the method itself. Its goals are to educate without risk of undue influence thus preserving patient autonomy. There is also some evidence that women are more likely to continue a method if given their stated preference. One problem with this model is that when surveyed, about 50% of women expressed desire to have some degree of provider involvement in their contraceptive decision. In addition, this model fails to tailor counseling to a woman’s needs and preferences and may neglect to dispel misconceptions by not eliciting their beliefs.
On the other hand, directive counseling puts an emphasis on directing patients towards a specific method. It prioritizes efficacy and avoiding unintended pregnancy, which often includes promoting LARC. Common applications of this approach are motivational interviewing to increase LARC uptake or exclusively taking a one-size fits all tiered effectiveness counseling approach where effectiveness is the centerpiece of every counseling session. Motivational interviewing may be appropriate for women who don’t want any method but want to avoid pregnancy, but it’s less clear that it’s appropriate when counseling a woman about which method to use. Directive counseling approaches can be problematic when considering a history of reproductive coercion and when taking into account health disparities and potential for discriminatory practices. Additionally, there are data that suggest that being directive with patients can negatively influence contraceptive use, so in fact can be counter productive.
This data includes a study in the 1990s that showed that women who felt pressure to have the implant were more likely to discontinue it, and recent data from Christine Dehlendorf’s cohort study that showed that women who felt the provider had preference for which method they should use had lower satisfaction with their method.
Both informed choice and directive counseling have some good elements but also some limitations. In this talk, we take the perspective that starting from a woman’s preferences and tailoring the conversation accordingly is the best way to provide counseling. We are going to describe a model, SHARED DECISION MAKING, which incorporates the best of both these approaches and avoids their pitfalls by having a patient-centered approach.
Before we go into detail about SDM, we’re going to review data and historical examples about how contraceptive counseling intersects with health disparities. This will help us understand some of the limitations of a purely informed choice or directive counseling approach.
Promote patient autonomy
Maximize efficacy
Shared Decision Making
Pariani, Stud Fam Plann, 1991
Stern, AJPH, 2005
Dehlendorf, Clin Ob Gyn, 2014
Dehlendorf, Patient Educ Couns, 2010

7. Contraceptive Counseling and Disparities
Women of color have higher rates of unintended pregnancy…
So is directive counseling appropriate?
Need to consider ongoing repercussions of historical experiences and mistrust with health care systems
35% of Black women reported “medical and public health institutions use poor and minority people as guinea pigs to try out new birth control methods.”
Women of color have higher rates of unintended pregnancy… So is directive counseling appropriate? What about adolescents? Women with substance use disorders? Many providers either consciously or subconsciously “promote” highly effective methods for “high risk” populations. Is this ok? As medical providers we are often trained to stratify our counseling and interventions based on risk. What makes this different? Pregnancy or childbearing is not strictly a medical phenomenon but rather is an incredibly personal part of a person’s life-course. Furthermore, this reasoning projects the providers’ value system on the patients when in fact they may be different.
There is also a need to consider ongoing repercussions of historical experiences and mistrust with health care systems. For example, 35% of Black women reported “medical and public health institutions use poor and minority people as guinea pigs to try out new birth control methods.”
Thorbun and Bogart, Women’s Health, 2005
Kalmuss, Fam Plann Perspect, 1996

8. Are women of color counseled differently?
Women of color and women with lower education levels are more likely to report being dissatisfied with their family planning provider
Survey of 500 Black women, 67% reported race-based discrimination when receiving family planning care
Women of color and low-income women are more likely to report being pressured to use birth control and limit family size
In RCT of standardized patients, providers more likely to recommend IUD to low income women of color than to low income white women
So, are women of color counseled differently? Let’s look at the evidence.
The first evidence of some difference is less satisfaction: Women of color and women with lower education levels are more likely to report being dissatisfied with their family planning provider
Some women also report discrimination: in a survey of 500 Black women, 67% reported race-based discrimination when receiving family planning care
Women of color and low-income women are also more likely to report being pressured to use birth control and limit family size
To help answer whether this was just patient perception, an RCT of standardized patients was performed. Providers were more likely to recommend the IUD to low income women of color than to low income white women, showing racial differences in counseling.
Forrest and Frost, Fam Plann Perspect 1996
Thorbun and Bogart, Women’s Health, 2005
Downing et al, AJPH, 2007
Dehlendorf et al AJOG 2010

9. Case 1: Immediate Postpartum LARC
25yo G5P5005 Hispanic woman presents to your office 2 months postpartum to discuss contraception. You review options and she is leaning towards Depo-Provera. You do an exam and notice two strings protruding from her cervix.
Let’s take a moment for another case example: a 25yo G5P5005 Hispanic woman presents to your office 2 months postpartum to discuss contraception. You review options and she is leaning towards Depo-Provera. You do an exam and notice two strings protruding from her cervix – the patient has no memory of this being placed and wants it removed.
Placement of immediate postpartum LARC is increasing in availability and popularity. This is an optimal time in terms of access to care, but it can also be a vulnerable time.
We have seen patients in our clinic who were not aware that a LARC had been inserted while they were in the hospital postpartum. We presume that she was counseled and consented in some form, but clearly it did not coincide with her perceived experience. Just as Michelle reviewed, sometimes our best intentions are internalized and experienced by patients in different ways than we imagine.
This is an extreme example also, but highlights a case when directive counseling can be problematic.
In this case, we should also consider the importance of access to LARC removal. LARC removal is billed separately so women with inconsistent insurance coverage may face financial barriers to removal. Many providers may also try to talk patients out of removal. It is important to remember that although LARC is reversible, it is not patient controlled and therefore removal can be challenging for patients.
This is a good time to have a contraceptive counseling session with the patient, and if she would like the IUD removed, this should be done without creating barriers.

10. Historical Context
Disparities in contraceptive counseling and stories like the immigrant woman with an unknown IUD have an important historical legacy.

11. Well-meaning intentions: Sterilization and eugenics
Mandatory sterilization laws
Buck v Bell (1927, SC)
“Three generations of imbeciles are enough”
-Oliver Wendell Holmes
Vulnerable groups targeted for sterilization
California,
20,000 non-consensual sterilizations on institutionalized people and immigrants
California,
>100 unlawful sterilizations of women in prison
Buck v. Bell- ruled that a state statute permitting compulsory sterilization of the “unfit”, including intellectually disabled, did not violate the due process clause of 14th amendment. Endorsement of eugenics- attempt to improve the human race by eliminating those perceived to be polluting the gene pool.
Other states followed suit until 30 states and Puerto Rico had mandatory sterilization laws.
The revelation of unlawful sterilizations of women in prison, who are disproportionately poor women of color, rings all too familiar with campaigns to stop certain segments of the population from reproducing.
Stern 2005 AJPH
Johnson Center for Investigative Reporting

12. Socioeconomic engineering and contraception: Norplant
Despite the obvious legacies of eugenics with this Norplant experiment, people also thought that free birth control for poor women would be a good way to eliminate barriers to access, might give them a boost– fewer children to care for so they could focus on getting a job– and would save the welfare system money. At the time, many people genuinely thought they were helping. But tying welfare checks or giving additional money to pressure women into using an implant puts undue influence on them.
Also examples recently- in a county in NY State, women given 500 to get nexplanon

13. Case 2: LARC for Incarcerated Women
Incarcerated women are at high risk of unintended pregnancy
Limited access to care outside of jail/prison
84% prior unintended pregnancy, 85% plan to be sexually active when released, 72% not using regular birth control
Incarceration as an “opportunity” to access care
Highly effective LARC doesn’t require follow-up after release
BUT. . .
Inherently coercive environments
Disproportionately women of color
Tell story of woman in jail who consented to a Mirena and then said to me as she was getting undressed, “doc, do I have to get this?”
ASK AUDIENCE if anyone sees these women
Women internalize messages from authorities
This is an extreme example of how patients can perceive coercion even when we are not aware of it- power dynamics of clinician-patient relationship that is not as extreme as being incarcerated, but still there and affects the discussion. We can learn a lot from this extreme example.
Transition: what can we learn from this case/scenario?
Clarke et al 2006 AJPH
Sufrin et al in press PSRH

14. Approaches to Contraceptive Counseling
With this background in mind, let’s think again about approaches to counseling

15. What actually happens during contraceptive counseling?
Observational study of contraceptive counseling in the San Francisco Bay Area
80% of visits used a hands off or “informed choice” approach
Patient preference elicited in <50% of visits
Providers infrequently mentioned or elicited women’s reproductive goals
An observational study of contraceptive counseling in the San Francisco Bay Area showed that 80% of visits used a hands off or “informed choice” approach. More specifically, providers gave patients information about all methods or only the method(s) that the patient brought up. Patient preference elicited in <50% of visits. Providers infrequently mentioned or elicited women’s reproductive goals
For example, a 17-year-old patient in this study requested birth control pills and referenced previous experience using them, noting some difficulties she had experienced with the method: “I guess in the morning I probably got a little sick. I felt like a little sick, but that’s it.” Instead of investigating the extent of the patient’s discomfort or whether this discomfort contributed to her discontinuing the method in the past, the provider reflected back the patient’s minimization of the side effects and offered to prescribe the pill again, saying, “But it didn’t bother you that much? So, do you want to go ahead and start back on the pill now?
In other words, providers often do not fully engage with patients and counseling is often based on certain assumptions – on one end of the spectrum that the patient has already made a decision regarding birth control and on the other end that the provider knows best for the patient.
Since then there has been an increased move towards directive counseling, even though we didn’t see it in our study (interestingly, for my RCT we have done some audiorecordings and have actually found much more directive counseling with the same providers)
Dehlendorf et al, Persp Sex Repr Health, 2014

16. Patient preference in contraceptive decision making
Directive Counseling
Informed choice
Informed choice
Directive Counseling
Now let’s explore in more detail how an approach of shared decision making brings the best of both worlds together to honor women’s concerns and values while respecting their autonomy. This approach recognizes that avoiding pregnancy at all costs may not be a patient’s first priority! It begins with eliciting the patient’s goals and preferences, allowing providers to personalize the counseling we provide to a greater extent. Providers using A shared decision-making approach establishes rapport, regularly summarizes patient comments, and reflects an understanding of patients’ needs and concerns [from Christine’s study]
Importantly though, even if a woman says that efficacy is not as important to her as, say, side effects, counseling should still provide her with information on effectiveness. It’s just that it may not determine how she prioritizes methods and should not be the only information provided. Also, we are only talking about what is medically safe for the patient. Shared decision making starts with what is on the plate for a patient to choose from, so contraindicated methods are excluded from the discussion.
Promote patient autonomy
Maximize efficacy
Shared Decision Making

17. Shared Decision Making
“A collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences….This process provides patients with the support they need to make the best individualized care decisions.”
Informed Medical Decisions Foundation
Shared decision making (or SDM) is a collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences….This process provides patients with the support they need to make the best individualized care decisions.
Support for SDM comes both from the ethical goal of sharing responsibility as well as some evidence, including the use of decision support tools, that shows improved patient outcomes, including satisfaction and in some cases adherence.

18. Shared Decision Making in Family Planning
Evidence for improved outcomes in general medical literature
Particularly relevant for preference sensitive decisions
Qualitative and quantitative data suggest this model is consistent with women’s preferences and associated with improved outcomes
There is evidence in the general medical literature that using SDM improves outcomes. It is especially relevant for preference sensitive decisions. Qualitative and quantitative data in family planning suggest this model is more consistent with women’s preferences and is associated with improves outcomes.
SDM is an approach to counseling about WHICH contraceptive method to use, not WHETHER to use a contraceptive method at all.
Dehlendorf, Contraception, 2013

19. Shared Decision Making in Family Planning
“I just think providers should be very informative about it and non-biased…maybe not try to persuade them to go one way or the other, but maybe try to find out about their background a little bit and what their relationships are like and maybe suggest what might work best for them but ultimately leave the decision up to the patient.”
Here is an example from a qualitative study about this issue: “I just think providers should be very informative about it and non-biased…maybe not try to persuade them to go one way or the other, but maybe try to find out about their background a little bit and what their relationships are like and maybe suggest what might work best for them but ultimately leave the decision up to the patient”
in general patients wanted to make autonomous decisions, but want providers opinions within the context of engaging with the patient.

20. Shared Decision Making and LARC
Allows providers to assess preferences around relevant issues such as:
Contraceptive effectiveness
Menstrual changes
Frequency of taking method
Identify misconceptions
Tailor information and discussion to preferences and need for information
Ensure that women have all the info they need to choose a method
SDM also is ideal in many ways for addressing issues related to LARC methods and barriers to their use. It allows providers to assess preferences around relevant issues such as effectiveness, menstrual changes, and use of method. SDM helps you identify misconceptions that may be underlying why a patient might exclude certain methods from her choice. It allows the provider to tailor information and discuss to the patient’s needs and thus ensure that all women have the information and support they need to choose a method so that they can decide what method is best for them.

21. Tempering LARC enthusiasm
Recognizing patients may have different values and motivations than providers
Directing groups with highest rates of unintended pregnancy to LARC has historical legacies
Disproportionate emphasis on increasing access to LARC placement without necessarily increasing access to removal
While we are excited about LARC and think these methods are excellent options for certain patients, it is important to temper our enthusiasm and recognize that patients may have different values and motivations than providers and effectiveness is not everyone’s first priority. Tiered effectiveness counseling is an important component to counseling especially for women who prioritize avoiding unintended pregnancy at all costs but it has to be within the context of eliciting other aspects of the patient’s preferences.
Directing groups with highest rates of unintended pregnancy to LARC has historical legacies and problematic implications.
Lastly, LARC enthusiasm can lead to a disproportionate emphasis on increasing access to LARC placement without necessarily increasing access to removal, which decreases women’s control over their own bodies.
Gomez et al 2014 PSRH

22. Best Practices: Evidence and Examples
For the last segment of this talk, we are going to review evidence for best practices in contraceptive counseling to help apply positive techniques to our counseling sessions within the framework of SDM.

23. Provision of Adequate Information
Studies have found that many women report that they:
Do not receive adequate information
Feel providers dismiss concerns and overlook possible side effects
Counseling about side effects associated with method continuation
First, women want adequate information about contraceptive methods and side effects. Studies have shown many women feel they do not receive this. Conversely, when women do receive counseling about side effects, they are more likely to continue their chosen method.
Canto De Centina, Contraception, 2001
Becker, Perspect Sex Repro Health, 2007
Dehlendorf, Contraception, 2013
Yee, JHCPU, 2011

24. Establishing a Positive Personal Relationship
Women value intimacy and continuity
Trust in provider can influence perception of information
“Investing in the beginning” continuation
Greeting patient warmly
Small talk (only done in 45% of visits)
Open-ended questions (only done in 43% of visits)
In addition, women want a positive personal relationship with their provider. This can be achieved by greeting the patient warmly, partaking in small talk, using open-ended questions, and keeping continuity with patients when possible.
Establishing rapport can help to make sure patients are comfortable sharing their preferences. Starting off the visit with rapport makes it more likely women will share their preferences and values, along lines of SDM.
Dehlendorf, Contraception, 2013
Dehlendorf, unpublished data

25. Example of Facilitation
“I am hearing you say that avoiding pregnancy is the most important thing to you right now. In that case, you may want to consider either an IUD or implant. Can I tell you more about those methods?”
“You mentioned that it is really important to you to not have irregular bleeding. The pill, patch, ring and copper IUD are good options, if you want to hear more about those.”
These are two quotes that demonstrate facilitation and partnering with patients to come to joint decisions.
“I am hearing you say that avoiding pregnancy is the most important thing to you right now. In that case, you may want to consider either an IUD or implant. Can I tell you more about those methods?” In this example, the provider has elicited the patient’s priorities and asks for permission to discuss the methods that fit best, even when these are not methods that the patient brought up herself.
“You mentioned that it is really important to you to not have irregular bleeding. The pill, patch, ring and copper IUD are good options, if you want to hear more about those.” Again, the provider has started the conversation with discovering what the patient’s concerns and priorities are and tailored the recommendations accordingly.

26. Anticipate Potential Issues with Adherence and Continuation
Provide opportunity to ask questions
Only done in 47% of visits
Discuss what to do if not satisfied with method (contingency counseling)
Only done in 65% of visits
Even with excellent counseling and women receiving the method of their choice, consistent with their priorities and concerns, there are potential problems that should be addressed head on. Providers should allow patients to ask questions to see if there are any remaining concerns. In one study, this was done less at less than half of visits. They should also discuss what to do if patients are not satisfied with the method they choose – this was only done in 65% of visits.
Dehlendorf, unpublished data
Namerow, Fam Plann Perspect, 1989

27. Step by Step Approach Establish rapport
Efficacy
Frequency of use
Different ways to use
Specific side effects
Return to fertility
“There are methods you take once a day, once a week, once a month, or even less frequently. Is that something that makes a big difference to you?”
Establish rapport
Elicit patient preferences with direct questioning
“What is important to you about your method?”
“If you got pregnant on your method, how would you feel?”
Provide context about options
Provide scaffolding for decision making process (Shared Decision Making)
Include adequate information about side effects
Address potential barriers to success
Wrap-up
“Oh that’s too bad your friend had that experience, I haven’t heard of that before, and I can tell you it definitely doesn’t happen frequently. My guess is that if you were to use this method it would not happen to you.”
So let’s put this all together and review a step by step approach to shared decision making.
The first step is to establish rapport with the patient with a warm greeting and small talk at the start of the visit.
Next, the provider should elicit the patient’s preferences. For example, “what is important to you about your method?” You can use certain probes such as efficacy, frequency of use, etc. Other examples of this are “If you got pregnant on your method, how would you feel?” – this helps tease out how important it is to the patient to avoid pregnancy. You can also provide context about options – for example, “There are methods you take once a day, once a week, once a month, or even less frequently. Is that something that makes a big difference to you?”. It is also helpful to ask where they have gotten information about contraception – friends, family, other doctors, etc, to better understand their concerns.
Based on the patient’s priorities and concerns, you then provide her with information about the best methods for her, including adequate information about effectiveness, side effects, and context for fears and misconceptions. A part of providing scaffolding is actively facilitating and respectfully acknowledging things they’ve heard: “Oh that’s too bad your friend had that experience, I haven’t heard of that before, and I can tell you it definitely doesn’t happen frequently. My guess is that if you were to use this method it would not happen to you.”
[[In terms of explaining effectiveness:
Use natural frequencies:
Less than 1 in 100 women get pregnant on IUD
9 in 100 women get pregnant on pill/patch/ring
Can also emphasize relative numbers
Pill/patch/ring have 20 times greater risk of failure than IUD]]
Last, but not least it is important to acknowledge the possibility of dissatisfaction with the chosen method, and make a plan if that happens.
You should discuss potential issues with adherence such as what to do if she misses a pill.
And don’t forget to allow the opportunity for questions!

28. Summary
Historical context of contraception interventions is laden with good intentions and coercive practices directed at poor women of color.
Counseling approaches of either informed choice or directive counseling have limitations.
Shared decision making prioritizes patient preference and helps a woman choose a method that best suits her priorities.
So, in summary:
The historical context of contraception interventions is laden with good intentions and coercive practices directed at poor women of color.
Counseling approaches of either informed choice or directed counseling have limitations.
Shared decision making prioritizes patient preference and helps a woman choose a method that best suits her priorities. It brings together the best of both worlds of various counseling models, but avoids the pitfalls of having a completely hands off approach or being unwittingly coercive. Shared decision making is evidence based and hopefully it makes sense to everyone as a patient-centered approach.