Over half of the US population – that is over 166,000,000 people – can become pregnant within their lives. This is important to understand because in conversations with health care leadership, I regularly hear, “contraceptive care isn’t a priority”. I challenge that statement as a woman and as a physician. Contraceptive care is important to a person’s long-term health and wellbeing. Yet many patients lack access to their preferred birth control due to barriers such as high costs, availability of appointments, or pressure from health care staff to choose a different method.
Much has been advanced in recent years to better understand how social determinants of health impact a person’s overall health outcomes. These barriers are disproportionately experienced by people of color, people with low incomes, members of the LGBTQIA+ and other communities who have historically faced systemic and institutional discriminatory barriers to care. Many of these populations also have a history of reproductive coercion or forced sterilization. This history, in addition to the stress of an unplanned pregnancy, can have a broader impact on a person’s health and wellbeing.
These facts lead me to wonder why contraceptive care isn’t a priority – our patients are a priority, reducing impacts of social determinants of health is a priority, therefore; contraceptive care has to be a priority too. I think our Hippocratic Oath calls us to consider preventive measures such as family planning and contraceptive care in our commitment to do no harm. The harm reduction lens also calls us to lead with an equity lens.
Our ability to gain a patient’s trust relies on the ability to communicate in a manner free from bias, with plain language, so that we can ensure a patient understands their options and can make an informed decision. A shared-decision making approach leads to patients feeling respected and satisfied that their health needs were met; this can apply to family planning too. My commitment to health equity and removing barriers for patients led me to Upstream USA.
Upstream strives for a world where there is “no wrong door” for access to contraceptive care. This means that everyone, regardless of where they access healthcare, is being asked about their pregnancy intentions and have the ability to choose from a full range of options, if they have interest in birth control. The model provides health centers with training, funding, and identifies opportunities to improve contraceptive care. Based on our work with health centers, we have a few patient-centered recommendations for delivering contraceptive care, free from coercion:
1. Raising awareness on the unintentional impact bias and coercion could have on patients in your practice. Your team can take an Implicit Association Test to examine what kinds of implicit biases might be showing up in clinical care.
At Upstream, we offer foundational e-Learning modules that address the history of reproductive coercion in the U.S.; and how history, contemporary factors, and systems impact contraceptive care. Our virtual instructor-led training discussions on how our values and implicit biases can impact patient care and access, and sharing strategies for recognizing and addressing one’s own unconscious biases (e.g., “The pill works just fine, why change”). Many of our partners have shared that this portion of our training was the most impactful to their work. You can view a sample of our instructor-led training here.
2. Asking a patient a Pregnancy Intention Screening Question (PISQ) creates an opportunity for valuable dialogue and supports a patient making an informed decision. Here are two examples:
“Do you want to become pregnant in the next year?” or “Are you planning a pregnancy?”
A “yes” creates the moment for providers to discuss preconception care and planning to support a healthy pregnancy. If the answer is “no” or does not fit into a binary response, this question can create a conversation about the patient’s reproductive goals and providers have an opportunity to deliver excellent, patient-centered counseling. Contraception and family planning is not “one size fits all”.
3. Ensure patients have plain-language access to educational materials. Today, just 30% of women report receiving all the information they need before making a birth control decision.
To better understand what patients need to make informed birth control decisions, Upstream held focus groups and conducted research on best practices and prototype testing with patients. This research confirmed that educational contraception materials can facilitate trusting conversations between patients and health care staff. One patient who engaged with our materials shared:
The whole approach is asking a lot of questions versus just giving you statements. I like that format better. Makes it more personal. It makes me think.”
Contraceptive Care is Preventative Care
The above recommendations are just a few of the program elements we bring to health centers wanting to improve contraceptive care at their health center If you want to provide more patient-centered contraceptive care consider these questions:
- What training/discussions do you provide on reducing bias and coercion?
- Do you ask patients about their reproductive goals at every visit? Who is responsible for asking this question?
- Do you have inclusive, plain-language educational materials for patients that are easy to understand?
- What types of birth control are available at your center? How do you keep them in stock to optimize access to the full range of options?
- Do you have a referral plan for when a type of birth control is not available?
- Similarly, do you have a supportive process if a patient is planning for a pregnancy?
Upstream USA is a nonprofit that partners with health centers to improve access to contraceptive care. Our program is available at no cost and begins with a baseline assessment, identifying opportunities for refinement. If you would like to know more about prioritizing contraceptive care for your patients and the funding available to help in that effort, please reach out to me at SAbernethy@upstream.org or visit Upstream.org/Join-Us.
This article first appeared on Northwest Regional Primary Care Association’s website.
About the Author
Dr. Susan Abernethy is the National Director of Partnerships & Community Engagement at Upstream USA.
