Addressing fluidity in contraceptive decision-making: a key component of patient-centered contraceptive counseling

Abstract

Contraceptive decision-making is an inherently personal process that is influenced by a multitude of factors both internal and external to the patient.1Paul R. Huysman B.C. Maddipati R. Madden T. Familiarity and acceptability of long-acting reversible contraception and contraceptive choice.Am J Obstet Gynecol. 2020; 222: S884.e1-S884.e9Abstract Full Text Full Text PDF Scopus (15) Google Scholar The American College of Obstetricians and Gynecologists recently reviewed these factors and recommended provision of contraceptive counseling in a manner that is patient centered and evidence based.2American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women, Contraceptive Equity Expert Work Group, and Committee on EthicsPatient-centered contraceptive counseling: ACOG Committee Statement Number 1.Obstet Gynecol. 2022; 139: 350-353Crossref PubMed Scopus (8) Google Scholar Yet, although the document acknowledges that contraceptive “goals and needs change over time,” the existing literature has largely focused on contraceptive counseling and decision-making at one single point in time. However, major life events such as pregnancy can impact contraceptive choice.3Kokanalı D. Kuntay Kokanalı M. Ayhan S. Cengaver N. Özakşit G. Engin-Üstün Y. Contraceptive choices of adolescents before and after the voluntary termination of pregnancy.J Obstet Gynaecol. 2019; 39: 822-826Crossref PubMed Scopus (4) Google Scholar We sought to better understand the fluidity of contraceptive decision-making throughout pregnancy and the postpartum period. This is a planned secondary analysis of a retrospective chart review of 8654 patients who delivered at or beyond 20 weeks of gestation at a single, urban, teaching hospital in Ohio, between January 1, 2012 through December 31, 2014.4Bhide S. Ascha M. Wilkinson B. et al.Variation in effectiveness of planned postpartum contraception at two time points from prenatal to postpartum care.Contraception. 2020; 102: 246-250Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Although the primary analysis focused on fulfillment of the desired permanent contraception, data abstracted from all deliveries form the basis of this analysis. Planned postpartum contraceptive method was recorded at 4 points during the obstetrical period—last plan documented in outpatient prenatal care, inpatient admission before or at delivery, last plan documented before hospital discharge postpartum, and plan at the outpatient postpartum visit. We analyzed contraceptive methods within the Center for Disease Control and Prevention–defined tiers of efficacy including tier 1 (permanent and long-acting reversible contraception), tier 2 (short-acting reversible methods including injectables, pills, patch, and vaginal ring), tier 3 (barrier methods, fertility awareness, withdrawal, and abstinence), none, and missing. A total of 12% of patients planned to use a contraceptive method postpartum with the same efficacy at each of these time points (Figure). Fewer patients desired highly effective methods of contraception at the time of outpatient postpartum visit when compared with the time of hospital discharge after delivery, although, overall, more patients wanted any contraceptive method at the postpartum visit than at other time points. A major life event like childbirth may impact how a patient considers their choice of contraceptive methods. Given that more than two-thirds of patients in this study desired a postpartum contraceptive method with a different level of effectiveness than initially planned before delivery, there is likely even more fluidity in contraceptive method choice if we analyze methods individually rather than grouped within tiers of efficacy. Clinicians should incorporate this concept of fluidity in contraceptive decision-making into their contraceptive counseling.4Bhide S. Ascha M. Wilkinson B. et al.Variation in effectiveness of planned postpartum contraception at two time points from prenatal to postpartum care.Contraception. 2020; 102: 246-250Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Although it is important to provide counseling based on the patient preferences and goals at the time of the encounter, clinicians should specifically be attentive to this normalcy in fluctuation and be aware that contraceptive decisions do not need to be static. Instead, as demonstrated by qualitative data, contraceptive decision-making is a dynamic process; thus, attention to fluidity in counseling is a crucial expression of reproductive justice.5Downey M.M. Arteaga S. Villaseñor E. Gomez A.M. More than a destination: contraceptive decision making as a journey.Womens Health Issues. 2017; 27: 539-545Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar