Evidence-based Contraceptive Counseling

Jacki Witt, MSN, WHNP-BC, SANE-A

Disclosures

Advisory Board Member:Agile Therapeutics, Watson Pharmaceuticals and Afaxys Pharmaceuticals

Objectives Discuss counseling vs education in a

family planning context

Compare three methods/frameworks for effective contraceptive counseling (RLP, MI and Tiered Counseling)

Delineate at least three evidence-based principles for counseling in a family planning setting

Counseling Guidance of the individual by use of

standard psychological methods. The counselor's goal is generally to

orient the individual toward opportunities that can best guarantee fulfillment of his personal needs and aspirations. The counselor usually attempts to clarify the client's own thinking rather than to solve his problems.

(Merriam-Webster)

Educating

To instruct or provide with information

(Merriam-Webster)

Counseling in the family planning setting

Patient-centered, shared decision making and patient engagement in a nonjudgmental manner

Reproductive Life Plan (RLP)

RLP: What is it? A self-assessment of life goals

Goals in several broad categories (based on the social determinants of health)

Education Work/Career Family Planning

We assist or guide as needed

RLP: Purpose To reveal patient’s genuine

intentions regarding reproduction Individual absorbs what is most

important to her/him So that she/he can:

obtain necessary information make choices adhere to her plan fulfill her own goals.

Ambivalence is expected

RLP: How does it help? It shows how motivated someone

is to become pregnant or prevent pregnancy

Once this is clarified we can begin the process of offering appropriate interventions

Contraception or not Highly effective or not Preconception Care Life goals prior to planned

pregnancy

Sample RLP questions:

Do you want to have (more) children? (Someday?) If so: When? (Or how old would you like to

be?) How many children would you like to

have? How long do you want to wait between

pregnancies? How would you feel if you were to

become pregnant over the next few months?

What are you hoping to accomplish before then?

Discovering clients’ true motivations

The point of a RLP is to get substantive information from our clients about what is motivating them so we can help them make better choices

The client is the one who will make the choices

Motivational Interviewing(MI)

Motivational Interviewing with contraception counseling

Saves time

Effective

Client centered

When is MI not needed?

A patient says:“Give me the most

effective method you’ve

got!”

MI has been used for

Addiction counseling and treatment

Contraception counselingBehavior changeDiabetes self managementWeight lossMedication adherence

MI: the approach

Start from a place of respect Guiding not directing Not “me vs. you” rather…“us together on

the same side” Help patients feel motivated by having

them verbalize their own reproductive and life goals

Identify what is personally meaningful or of value to the patient rather than those things that we think are most important

MI: the benefitReduces frustration with the patient

and subsequently ourselves Removes our ego…

“I need to make this patient do what’s good for her.”

“I want to protect her from an unnecessary unplanned pregnancy!”

“If I can’t get through to my patient, I fail.” Our morale will be exhausted without

success

Ineffective strategies

Taking sides in the patients ambivalence Threatening bad outcomes;

“You’ll get pregnant if you don’t ...” This gets their attention but doesn’t

work for behavior change Giving advice assumes this person

simply doesn’t know enough. To offer one idea after another =

exhaustion

Accept ambivalence

MI elicits behavior change by helping clients explore and resolve ambivalence.

Expect, find, accept and show ambivalence

Also called developing discrepancy

Just showing the discrepancy is a powerful way to help patients make better choices

AmbivalenceWe want to accomplish our goals

There may be many obstacles

REWARDS

OBSTACLES

Motivation for contraceptive useWith PERFECT use of

contraception 1 year, 3 years, 5-10 years, 20+ years…what will happen??

The best case scenario...

NOTHING!

Obstacles

All contraceptive methods have potential side effects

Fear of negative health effects

Risk for unplanned pregnancy is theoretical

Perception of risk is not fully rational and is based on past life experience---ask

Obstacles

Contraceptive sabotage by a partner

Logistical constraints Cost Wait times Work schedule Transportation Childcare

ObstaclesIntermittent/inconsistent sexual partnering

Believes she doesn’t need contraception (today)

Ask specific details of what she did and when

Ask if she intends or would like to be sexual with someone in the next month, year… two years

Tiered effectiveness Counseling

Case Studies

Sandy 16 yr old G1 P0 TAB 1

RLP: Wants to get pregnant now

Ask about her life goals

Find something about her behavior that is “mature” and refer to it

Review PCC (insert reality)

Demonstrate that you believe she is in charge of her own life

Rather than tell her she’s too young:

“You will be a wonderful mother some day…and to be an even better mother, what would you like to accomplish before you have a baby? (or in addition) ”

“Sounds like you’ve given this some thought (or “you are obviously smart”), what are some ways you see yourself handling this?”

Maria BMI 3122 year old G2 P0 TAB 2 student

RLP: Wants children one day. At least 3

years from now. Wants to be married, finish school. She’s clear that she is not willing to have another abortion

Prior DMPA (gained weight), very concerned that hormones cause weight gain. Mostly has used withdrawal and doesn’t believe she has ever gotten pregnant that way

Maria

“You said that you are using the pull out method now. And on the one hand you feel that if you get pregnant you would continue the pregnancy, yet you also are pretty sure you don’t want to have a baby right now. Do I have that right?”

“What would you like to accomplish before you have a baby? And what else?” (Refer to RLP life goals)

Maria

“If delaying pregnancy until you finish school is very important to you, would you be interested in using one of the top tier methods?”

“Since a lot of women who rely on their partner to “pull out” get pregnant, would you like to talk about pre-natal vitamins and other things that are important to do to prepare for pregnancy?”

Understanding objections

If we listen well enough to where the resistance has come from we can develop discrepancy (describe the ambivalence)

0 2 4 6 8 10Least Most

Confidence Ruler

Melanie Gold DO

“Think of how you feel about getting pregnant right now and then see if you can tell me where you fall on a scale of 1-10. 1 being that it would be the worst thing you can imagine, and 10 being that it would make you the happiest you could possibly be.”

QUANTITATIVE APPROACH: ‘the ruler’

Demonstrate Ambivalence in Maria

“a 2” “Why would you say you aren’t you a

lower #?” “I’m not ready for a baby but I know that I

won’t have another abortion because I am an adult and having a baby wouldn’t be the absolute worst thing in the world”

“Why do you think the # might not be higher?”

“I really want to wait a few more years!”

Or qualitative questions:

“How would you feel if you got pregnant now?”

“How ready are you for pregnancy?”

“How important is it to you to avoid pregnancy?”

Repeat or rephrase examples

….”Let me make sure I understand….”

“So on one hand you don’t want to get pregnant…do I have this right? Yet, you are not using birth control. How does this fit in with your not wanting to get pregnant?”

Her reply uncovers the ambivalence

Make it real

“On one hand you really want to get pregnant in the future, but not right now, and on the other hand, it sounds like a part of you would like to have a baby now? Do I have that right?”

“Have you discussed this with your partner? Do you plan to tell him? How do you think he would react?”

What now? Open ended…

What do you think you will do? What birth control are you thinking

can help you... (fill in with her stated goal)?

What do you see as your options? Where do we go from here? What happens next?Rather than: Do you have any questions? Do you understand?

Final steps Plan for obstacles; they have great

intentions but they return to their lives once they leave the office (it’s a long way from the exam room to the bedroom)

Close the deal Operationalize same day LARC placement

Ask “How do you feel about this” Plan concrete next steps

Take home messages (Jaccard & Levitz, 2013)

Based on Jaccard and Levitz – Adolescent Counseling

Principle 1: Demonstrate the “key three” attributes of effective counselors -- expertise, trustworthiness, and accessibility

Principle 2: Address issues of confidentiality and the role of parents in contraceptive decision-making

Principle 3: Use skills-based strategies to actively engage the client in learning and remembering important points and provide them with easily accessible and reliable information sources

Principle 4: Address all four facets of contraception – method choice, correct use, consistent use, and method switching

Principle 5: Make choosing a method manageable and give priority to more effective methods

Principle 6: Consider how the method fits the lifestyle of the client by raising other key social-behavioral factors

Principle 7: If the client is at risk of contracting a STI, which is almost always the case for adolescents, recommend dual protection--condoms plus a more effective contraceptive

method

Principle 8: Give the client practical strategies to ensure accurate and consistent use of the chosen method of contraception

Principle 9: Address the issue of side effects ahead of time

Principle 10: If a client decides to change her method of birth control, encourage her to switch to an equally or more effective method and try to ensure that there are no gaps in protection

Principle 11: Be sure a staff member follows up with the client to see how things are going

Principle 12: Use quick-start options for any method that has such an option unless it is medically inappropriate to do so

References

ACOG Committee Opinion: Motivational Interviewing: A Tool for behavior Change; 423; Jan 2009.

Barnet B et al. Cost-effectiveness of a Motivational Intervention to Reduce Rapid Repeated Childbearing in High-Risk Adolescent Mothers Arch Pediatr Adolesc Med. 2010;164(4):370-376

Barnet B et al. Motivational Intervention to Reduce Rapid Subsequent Births to Adolescent Mothers: A Community-Based Randomized Trial Ann Fam Med 2009;7:436-445.

Dehlendorf, C et al. Women’s preferences for contraceptive counseling and decision making Contraception 88 (2013) 250-256.

Egarter, C et al. Contraceptive counselling and factors affecting women’s contraceptive choices: results of the CHOICE study in Austria Repro Biomed Online (2012 (24): 692- 697

References Gold Melanie et al. Motivational Interviewing Strategies to

facilitate Adolescent Behavior Change. Adoles Health Update; 20(1):1-7, Oct 2007.

Hecht J et al. Motivational Interviewing in Community-Based Research: Experiences From the Field. Annu Behav Med. 2005.

Hettema, Steele, Miller. Motivational Interviewing. Annu Rev. Clin Pychol. 2005. 1:91-111.

Hodgson, EJ et al. Family planning and contraceptive decisiion-makinbg by economically disadvantaged, African-American women Contraception (2013) 88: 289-296

Jaccard, J and Levitz, N. Counseling adolescents about contraception: towards the development of an evidenced-based protocol for contraceptive counselors Jour of Adol Health 52 (2013) S6- S13

Julius et al. Medication adherence: a review of the literature and implications for clinical practice. J Psychiatr Pract. 2009 Jan;15(1):34-44

References

Lopez et al. Theory-based interventions for contraception. 2009 Jan, Cochrane Database.

Merki-Feld, GS & Gruber, IML. Broad counseling for adolescents about combined hormonal contraceptive methods: the CHOICE study Jour of Adol Health (2013) 1 - 6

Petersen et al. Applying motivational interviewing to contraceptive counseling: ESP for clinicians. Contraception; 69(3):213-17. Mar 2004.

Rollnick S, et al. Motivational Interviewing in Health Care. New York: Guilford Press; 2008

Rubak et al. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005 Apr;55(513):305-12.

Schillinger, “Closing the Loop” Teach-back is supported by research. Arch Intern Med/Vol 163, Jan 13, 2003