Elevating the patient voice in contraceptive care quality improvement: A qualitative study of patient preferences for peripastum contraceptive care

Client Perspectives on Contraceptive Care: A Systematic Review

INTRODUCTION

Contraceptive care is an opportunity for providers to help clients achieve their reproductive health goals. Client-centeredness is a core element of quality care; however, evidence suggests that the provision of client-centered contraceptive counseling needs improvement. This systematic review summarizes recent evidence on client preferences related to contraceptive care, including how client-centered approaches inform outcomes.

METHODS

A systematic review was conducted in PubMed, Cochrane Database of Systematic Reviews, and Scopus to identify articles published between December 1, 2016 and May 1, 2023. Studies that explored client preferences related to contraceptive counseling, education, and/or care, and how client-centered approaches impact clients' perceived experiences with their care were included.

RESULTS

Thirty-nine unique studies met inclusion criteria. Clients want a range of information about contraceptive methods tailored to their preferences through a variety of formats, before, during, and after their appointment. Clients desired providers with similar demographic backgrounds (gender, race, ethnicity) and life experiences (menstruation, contraceptive use, carceral system encounters) to themselves, and who are willing to offer continuous care. Clients reported greater satisfaction when providers engaged in shared decision-making, utilized decision support tools, and supported their autonomy, including prioritizing their family-building goals. When providers shared personal preferences or pressured clients to select one method over another, clients in turn, reported feeling conflicted about which method to select and some subsequently declined using any method.

DISCUSSION

The variation in client preferences highlight the importance of offering tailored, comprehensive information that supports decision-making, prioritizes client autonomy, and recognizes positive interpersonal relationships with providers.

TRIAL REGISTRATION

Prospero: CRD42023414456 https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=414456.

Exploring adolescent-facing US clinicians' perceptions of their contraceptive counseling and use of shared decision-making: A qualitative study

BACKGROUND

Adolescent contraceptive decision-making is influenced by a number of patient and clinician-driven factors. Although the AAP continues to endorse an efficacy-based model of contraceptive counseling, many professional organizations are shifting to a shared decision-making model as the optimal approach for providing unbiased and patient-driven contraceptive counseling. While SDM is intended to reduce the influence of clinician bias, it can exacerbate inequity if a clinician tailors a conversation based on their assumptions of a patient's goals or preferences. In this qualitative study, we explored self-reported contraceptive counseling practices among US-based clinicians who see adolescent patients to assess how these practices create barriers or facilitators to SDM and person-centered contraceptive care.

METHODS

We interviewed 16 clinicians at the 2022 AAP Annual Meeting who counsel adolescent patients about contraception. We used thematic content analysis to analyze interview transcripts using Dedoose.

RESULTS

We identified six aspects of contraceptive counseling that clinicians commonly employed with adolescent patients. These were: (1) sociodemographic characteristics driving counseling, (2) reliance on tiered effectiveness counseling, (3) initiating counseling conversations using "ask then explain" or "explain then ask" approaches, (4) emphasis on teen pregnancy prevention, (5) the influence of method accessibility on counseling, and (6) parental involvement in decision-making and patient confidentiality. We describe how these themes align with or diverge from each component of the SDM framework.

CONCLUSION

Clinicians in this study frequently engaged in non-patient-centered techniques during contraceptive counseling with adolescents. These findings can inform practice recommendations to support clinicians in providing high-quality contraceptive counseling using shared decision-making.

Documentation of prenatal contraceptive counseling and fulfillment of permanent contraception: a retrospective cohort study

BACKGROUND

Barriers exist for the provision of surgery for permanent contraception in the postpartum period. Prenatal counseling has been associated with increased rates of fulfillment of desired postpartum contraception in general, although it is unclear if there is impact on permanent contraception specifically. Thus, we aimed to investigate the association between initial timing for prenatal documentation of a contraceptive plan for permanent contraception and fulfillment of postpartum contraception for those receiving counseling.

METHODS

This is a planned secondary analysis of a multi-site cohort study of patients with documented desire for permanent contraception at the time of delivery at four hospitals located in Alabama, California, Illinois, and Ohio over a two-year study period. Our primary exposure was initial timing of documented plan for contraception (first, second, or third trimester, or during delivery hospitalization). We used univariate and multivariable logistic regression to analyze fulfillment of permanent contraception before hospital discharge, within 42 days of delivery, and within 365 days of delivery between patients with a documented plan for permanent contraception in the first or second trimester compared to the third trimester. Covariates included insurance status, age, parity, gestational age, mode of delivery, adequacy of prenatal care, race, ethnicity, marital status, and body mass index.

RESULTS

Of the 3103 patients with a documented expressed desire for permanent contraception at the time of delivery, 2083 (69.1%) had a documented plan for postpartum permanent contraception prenatally. After adjusting for covariates, patients with initial documented plan for permanent contraception in the first or second trimester had a higher odds of fulfillment by discharge (aOR 1.57, 95% C.I 1.24-2.00), 42 days (aOR 1.51, 95% C.I 1.20-1.91), and 365 days (aOR 1.40, 95% C.I 1.11-1.75), compared to patients who had their first documented plan in the third trimester.

CONCLUSIONS

Patients who had a documented prenatal plan for permanent contraception in trimester one and two experienced higher likelihood of permanent contraception fulfillment compared to those with documentation in trimester three. Given the barriers to accessing permanent contraception, it is imperative that comprehensive, patient-centered counseling and documentation regarding future reproductive goals begin early prenatally.