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The history of tiered-effectiveness contraceptive counseling and the importance of patient-centered family planning care
Journal Pre-proof The History of Tiered-Effectiveness Contraceptive Counseling and its Effects on Patient-Centered Family Planning Care Kristyn Brandi, MD, MPH, Liza Fuentes, DrPH, MPH PII:
S0002-9378(19)32692-4
DOI:
https://doi.org/10.1016/j.ajog.2019.11.1271
Reference:
YMOB 12988
To appear in:
American Journal of Obstetrics and Gynecology
Received Date: 16 August 2019 Revised Date:
4 November 2019
Accepted Date: 6 November 2019
Please cite this article as: Brandi K, Fuentes L, The History of Tiered-Effectiveness Contraceptive Counseling and its Effects on Patient-Centered Family Planning Care, American Journal of Obstetrics and Gynecology (2019), doi: https://doi.org/10.1016/j.ajog.2019.11.1271. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
1
The History of Tiered-Effectiveness Contraceptive Counseling and its Effects on Patient-Centered
2
Family Planning Care
3
Kristyn Brandi, MD, MPH, [email protected] a
4
Liza Fuentes, DrPH, MPH, [email protected] b
5 6
a
7
Newark, NJ, USA 07103
8
b
Department of Obstetrics, Gynecology and Women’s Health, Rutgers - New Jersey Medical School,
Guttmacher Institute, New York, NY, USA 10038
9 10
Clinical Opinion
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The authors report no conflict of interest.
12 13
Key Words:
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Contraception, LARC, IUD, implant, coercion, shared decision making, reproductive justice, choice, tiered
15
counseling
16
17
Abstract
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Public health workers, clinicians, and researchers have tried to increase long- acting reversible
19
contraceptives (LARC) use by changing contraceptive counseling between patients and providers.
20
Several major health organizations now recommend tiered-effectiveness counseling, in which the most
21
effective methods are explained first so that patients can use information about the relative efficacy of
22
contraceptive methods to make an informed choice. Some scholars and practitioners have raised
23
concerns that given histories of inequitable treatment and coercion in reproductive health care, tiered-
24
effectiveness counseling may undermine patient autonomy and choice. This Clinical Opinion examines
25
the development of tiered-effectiveness contraceptive counseling, how its rise mirrored the focus on
26
promoting LARCs to decrease the unintended pregnancy rate, and key considerations and the potential
27
conflicts of a LARC-first model with patient-centered care. Lastly, we discuss how reproductive justice
28
and shared-decision making can guide efforts to provide patient-centered contraceptive care.
29
Introduction
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A main strategy that has emerged in the United States for reducing the proportion of
31
pregnancies that are unintended is to increase the use of long-acting reversible contraception (LARC)
32
due to their high efficacy.1 In the past decade policies and programs such as the Affordable Care Act
33
contraceptive mandate and privately and publicly funded state-based program have made considerable
34
progress in eliminating barriers to contraception, and to LARCs in particular. One such effort is the
35
adoption of the tiered-effectiveness contraceptive counseling model, in which patients receive
36
information about the most effective methods of contraception first. This model was developed to
37
ensure that both providers and patients have accurate information about LARCs. Studies have shown
38
that tiered-effectiveness counseling is associated with an increase in patient knowledge about
39
contraception2 and of LARC use.1
40
Tiered-effectiveness contraceptive counseling is now recommended by several professional
41
organizations3. However, clinicians, researchers, and advocates have raised concerns about whether
42
LARC promotion, and tiered effectiveness counseling in particular, conflicts with the central goal of
43
family planning care: to ensure that patients have the resources and information they need to decide if,
44
when, and how to have children. In order to understand this tension, we review the history of tiered-
45
effectiveness counseling and introduce how the reproductive justice and patient-centered models of
46
care are aligned with the goals of contraceptive counseling.
47 48 49
A Brief Recent History of Contraceptive Counseling The initial theory around using LARC to decrease unintended pregnancy rates stemmed from
50
evidence that LARC use was overall low in the general population and despite patients valuing efficacy in
51
their contraceptive method, many barriers prevented their use. The Mirena® and Paragard® intrauterine
52
devices (IUDs) and contraceptive implant Implanon® (now Nexplanon®) were available in the United
53
States in the early 2000’s but total use comprised only about 2.4% of all women using contraception in
54
2002.4,5 In the early 2000’s, research found that misinformation among both providers and
55
contraceptive users about associated risks, upfront cost of devices, lack of provider training, and
56
backlash from the failures of the Dalkon Shield® likely contributed to the low prevalence of LARCs.6,7
57
These articles described the benefits for individual patients including low failure rates and cost-
58
effectiveness. 6,7 Several studies of women’s preferences in birth control characteristics found that
59
efficacy is highly valued, with some studies demonstrating that it is the most important part of
60
contraception to women.8,9 Articles increasingly motivated their work by proposing the idea that
61
increasing LARC use could have a meaningful effect on lowering the unintended pregnancy rate and
62
abortion rate.7
63
The renewed enthusiasm for LARC gave rise to a shift from general contraceptive education and
64
counseling to using a tiered-effectiveness approach.10-12 This method of counseling focuses on efficacy of
65
contraceptive methods, with the most effective methods discussed first followed by less effective
66
methods. In visual aids using this counseling method, LARC methods are placed at the top of the chart
67
and less effective contraceptives listed further down,13 thereby prioritizing LARC methods. The purpose
68
of tiered-effectiveness contraceptive counseling is to allow patients can compare relative efficacy of
69
methods and use this information to make an informed choice about their birth control. As Jenny
70
Higgins noted in 2014: “the field has witnessed a distinct shift from options-based counseling, in which a
71
wide array of contraceptive methods are presented to potential contraception users, to directive and/or
72
first-line counseling in which one or two LARC methods are recommended over all others”.14
73
The tiered-effectiveness model has been increasingly studied and recommended over the past
74
15 years. The first study on tiered-effectiveness counseling was in 2005 and To address the gap between
75
patients’ valuing method efficacy and low LARC use theycompared three contraception decision tools
76
with varying emphases on efficacy, including one tool that is the predecessor to the tiered-effectiveness
77
charts used today.2 The study found that while all three charts improved patient’s knowledge about
78
contraceptives, the tiered-effectiveness chart was easiest to understand.2 The WHO Expert Working
79
Group Meeting on the Global Handbook for Family Planning Providers relied on this study’s results in
80
their endorsement of the tiered-effectiveness chart for contraceptive decision-making.2 The first
81
version of the Global Handbook was published in early 2007 and encouraged physicians to incorporate
82
this model when counseling patients about contraceptive options.2,16
83
The largest test of this tiered-effectiveness contraceptive counseling came from the
84
Contraceptive CHOICE Project, which aimed to “provide no-cost contraception to a large number of
85
women…and to promote the use of long-acting reversible contraception” in hopes to reduce the
86
unintended pregnancy rates in St. Louis.19 While the Steiner study and the WHO Global Handbook
87
helped introduce the tiered -effectiveness model to clinicians, the Contraceptive CHOICE project
88
provided the first data on its use in a large sample of contraceptive users.1,19 The Contraceptive CHOICE
89
Project studied the effects of removing barriers to patients’ LARC use that had been identified in
90
previous studies, in particular: cost, provider bias, provider training, facility availability, and finally,
91
patient information.19 The latter was addressed using tiered-effectiveness counseling for all study
92
participants.
93
The Contraceptive CHOICE Project’s methods describe using the GATHER process (Greet, Ask,
94
Tell, Help, Explain, and Return) to model their counseling, which uses a “client-centered process focused
95
on the woman, her expressed needs, situation, problems, issues and concerns”.12 The way they describe
96
the process, though, is more streamlined. When a woman presented for contraceptive counseling, she
97
was read a script by the counselor that outlines each type of contraception according to tiered-
98
effectiveness contraceptive model.20 Methods are explained in detail starting with LARCs, with
99
diaphragm and natural family planning only discussed if the patient brought them up.12,20,21 After the
100
script, patients were asked a series of questions like “What questions do you have about any of these
101
methods?” or “What birth control method sounds like a good choice for you?”.12,20,21 This model of
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counseling focuses more on efficacy and other facts about contraception instead of asking about
103
patients’ preferences and individualizing counseling. 22 Dehlendorf describes this as using “task-oriented
104
communication” to provide information rather than “relational communication”. 22She notes in her best
105
practices recommendations for counseling that both are needed to achieve a patient-centered
106
contraceptive counseling experience.22
107
The Contraceptive CHOICE Project first published analysis showed an unprecedented result–
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67% of study participants chose a LARC compared to the 2.4% national average.1,19 The study raised
109
awareness, discussion, and contributed to the adoption of tiered-effectiveness contraceptive counseling
110
among US-based providers.1,3 Other interventions have modeled aspects of the Contraceptive CHOICE
111
Project, including-tiered effectiveness. Perhaps the most famous was the foundation-funded effort to
112
provide LARCs to low-income teens in Colorado, which sought to “make LARC placement the default
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clinic visit outcome”23, and was found to have led to a modest decrease teen birth rate.24
114
The Contraceptive CHOICE Project led to the adoption of tiered-effectiveness counseling
115
recommendations among major professional organizations, since 2012 from the World Health
116
Organization (WHO), Centers for Disease Control and Prevention (CDC), and American College of
117
Obstetricians and Gynecologists (ACOG).2,3,15-17 ACOG’s most recent guidance on contraceptive
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counseling recommends that “LARC methods should be first-line recommendations for all women and
119
adolescents”.15 Likewise, the American Academy of Pediatrics’ (AAP) most recent guidance on
120
contraceptive care for adolescents states that “pediatricians are encouraged to counsel adolescents…
121
discussing the most effective contraceptive methods first”.18 These recommendations underscore that
122
patient choice and preference is a priority, but say little about how to square that with a LARC first-
123
approach, especially when a patient does not want a LARC or wants a LARC removed. Our concern is
124
even though the centrality of patient preferences and the call to encourage LARC use are both found in
125
the same guidelines and committee recommendations, clinicians are left without guidance when patient
126
choice and LARC-first recommendations come into conflict.
127 128 129
Where Are We Now? Access and use of LARC has expanded considerably in the United States since 2002. The
130
proportion of women using contraception who use a LARC method more than doubled from 2008 to
131
2014 and this is reflected among women in all age and race/ethnicity groups.25 ACA has decreased out
132
of pocket costs for contraception.26 Changes in Medicaid covered including increased reimbursement
133
and post-partum coverage.27 Some states or communities have had privately funded interventions to
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provide free LARCs28 and clinical training and billing streamlining.29 In the same time period, many
135
training and education initiatives have been started to train OB/GYN providers and family medicine
136
physicians on how to place these devices.
137
This current landscape focused on increasing LARC access and use raises a question of whether
138
the tiered-effectiveness counseling approach is consonant or in conflict with contraceptive counseling
139
guidelines that state that patients may choose to use the contraceptive method they prefer. It also
140
raises the question more broadly about, if efficacy is not right focus, what counseling approaches
141
clinicians should use to help patients prevent and plan for pregnancy, including ensuring the ability to
142
choose their preferred method of contraceptive without barriers, judgement, or coercion?
143
Indeed, other models of contraceptive counseling have emerged since tiered-effectiveness,
144
some that center patient preferences in guiding the clinical encounter before efficacy and others that
145
focus on effecting behavior change. One example is reproductive life plan screening using the “One Key
146
Question” (OKQ).30,31 OKQ encourages providers to ask reproductive-age women if they want to become
147
pregnant in the next year. This screening question helps to triage patients into pre-pregnancy planning
148
like starting prenatal vitamins or discussing contraception if they are not interested in pregnancy at this
149
time. 30,31 OKQ is now required by some departments of health and has been incorporated into several
150
electronic health records.30 Another model is motivational interviewing, where similar to other health
151
interventions like smoking cessation, patients are encouraged to initiate a behavior change—in this
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case, move towards using contraception.32 Lastly, some have argued for a shared decision-making model
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in which clinicians focused on “building partnerships with patients, where patients function as experts
154
on their preferences and needs and providers function as experts on the medical evidence”.31,33 Indeed,
155
the latest edition of Contraceptive Technology (21st Edition, Managing Contraception, LLC, 2018)
156
included an entire chapter on patient-centered contraception counseling, whereas the previous version
157
only had separate treatments of considerations of safety, efficacy, and “personal considerations”.34,35
158
Potential Conflict Between Tiered-Effectiveness Counseling and Patient Preferences
159
There are several concerns that have been raised about the “LARC first” approach exemplified
160
by tiered effectiveness. One is that the provider-controlled nature of LARCs means that they are
161
inherently more capable of being used coercively compared to methods that patients can stop on their
162
own. Another is that the ways providers are educated to provide and promote LARCs may lead them to
163
prioritize their preferences for what they think patients should use over the preferences of patients.14,36
164
This is reflected in training and practice, where clinicians are taught their job is to “get” patients to use a
165
LARC, and do not have good guidance on patient-centered approaches on how to honor requests for
166
removal.36,37 That LARCs are recommended “first-line” methods generates a provider bias that LARCs are
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the “best” contraception and the belief that women do not choose LARCs primarily because they are not
168
educated enough about them or must justify their reasons for not doing so.37,38 Additionally, rhetoric
169
regarding the use of the clinical encounter to reduce the unintended pregnancy rate on a population
170
level is a misapplication of a population level indicator. This rhetoric can cause providers to feel that
171
whenever a patients does not choose a LARC their clinical goals are in direct conflict with the goals of
172
the family planning clinical encounter – to ensure the patient can use the birth control method they feel
173
is best for them. Moreover, racism and sexism that shapes broader society necessarily create implicit
174
biases within providers and therefore influences the clinical encounter. Therefore, overly directly or
175
coercive contexts for the use of LARC may be more likely among low-income patients, young patients,
176
Black and Brown patients, and patients with certain co-morbidities such as substance use disorders.44
177
These concerns are justified, since physician bias towards LARC can be perceived by patients as a
178
form of contraceptive coercion.39-41 While patients may value efficacy, they also value other features of
179
contraceptive methods and there is no method that has all of the features that are important them.43
180
Patients seeking contraceptives must weigh their options all against their individual preferences, values,
181
needs, and priorities. A tiered-effectiveness approach alone cannot provide space and guidance for
182
patients to do that. While some patients may express frustration around this bias, others feel guilt and
183
shame in their choices which further perpetuates issues around contraception choice, parenthood, and
184
abortion stigma.10,39,40,42
185
There is an opportunity to use Reproductive Justice within reproductive health care, and
186
specifically when counseling patients on contraceptive options, to develop practices that do not risk
187
undermining patients’ autonomy. Originally coined by a collective of Black women, reproductive justice
188
is the human right to have a child, not have a child, and to parent in a safe, sustainable environment to
189
allow families to thrive.45 The Reproductive Justice framework explicitly recognizes historic and current
190
forms of racialized and gendered reproductive oppression, and therefore provides a lens for
191
understanding how the way in which targeting interventions to promote LARC towards groups that are
192
systematically discriminated against, such as by race/ethnicity, immigration status, wealth, or health,
193
such as substance use disorder, may perpetuate bias and can result in harm.14,46
194
Some may argue that a more pressing concern is that many barriers still exist between a patient
195
and their preferred contraceptive method, especially LARCs. Though there is still progress to be made in
196
ensuring that patients have the information, resources, and services they need to use their preferred
197
method of contraception44,47, this can coexist with coercive clinical encounters and in fact may
198
exacerbate them. We must create training and practice guidelines and advocate for policies that address
199
both. In order to mitigate the conflict between a patient’s autonomous choice and provider bias, we
200
must recognize that our goals must be our patient’s goals. The tiered-effectiveness approach was
201
developed in response to specific contraceptive landscape in the early 2000’s, when LARCs where not
202
widely available. In maintaining the tiered-effectiveness approach as a standard of care, we are deciding
203
what all patients need hear to make that choice. This can lead to patients feeling overly directed or
204
coerced into choosing a certain methods, cause dissatisfaction with their care and their method, and
205
create skepticism around providers intentions.39-41 And these potential “pitfalls”31 are not random.
206
When providers and patients’ preferences align, a tiered-effectiveness approach may not unduly
207
pressure a patient or miss their needs regarding contraception. However, when patients have differing
208
preferences from their providers’ or circumstances that providers feel should influence contraceptive
209
choice, providers who think LARC is the “best” method may feel that patients are not making decisions
210
they agree with.36 It is in these circumstances in which providers must ensure they are taking a patient-
211
centered approach, so that they can be self-aware not to put their preferences over the patients.
212
Patient-centered counseling “aims to provide education to patients that integrates evidence-based
213
recommendations with patient preferences, recognizing that patients’ individual values and preferences
214
should be an integral factor in decisions made about their health care”31 and ensures that “patients
215
function as experts on their preferences and needs and providers function as experts on the medical
216
evidence.”31
217
As efforts continue to improve access to LARCs, providers and contraceptive counselors should
218
use contraceptive counseling approaches that center the goal of ensuring patients preferences are met
219
regarding contraceptive choice. The individual clinical encounter should not be considered a mechanism
220
by which to “reduce the unintended pregnancy rate” because it is not patients’ responsibility to choose
221
a LARC or any method in service of moving a national level indicator. Rather, family planning care exists
222
to ensure all people can plan for and prevent pregnancies, including using contraceptives that meet
223
their lifestyle, and sexual health and pleasure needs. Efficacy is an important factor in many patients’
224
choices’, but it is not the only or even primary factor for all patients; even those that value efficacy may
225
still not choose to use a LARC for other reasons.48 Any family planning program should “put the
226
priorities, needs and preferences of individual women—not the promotion of specific technologies—
227
first”.11
228
Recommendations for Patient-Centered Counseling to Minimize Conflict
229
•
Before providing information on contraceptive options, it is important to determine what values and
230
preferences the patient has regarding contraception and, more broadly, their reproductive life
231
goals.
232
•
233 234
Providers must find a balance between correcting misinformation about contraceptives and dismissing negative experiences around prior use.
•
Patients are allowed to have conflicting views between their pregnancy intention and use of
235
contraception. Pregnancy is not always a negative outcome for those experiencing an unplanned
236
pregnancy and pregnancy ambivalence can be factored into contraceptive counseling.
237
•
Programs that help improve access to LARC devices should recognize the coercive situations they
238
may create. For example, having access to a free LARC device versus paying per pill pack per year
239
creates a non-choice for those in lower socioeconomic groups.
240
•
241 242
disorder patients or prisoners can perpetuate judgments on who should be parents. •
243 244
Screening for contraceptive use with programs like One Key Question help to start the conversation but should be used an initiator to a conversation about deeper values around reproductive goals.
•
245 246
Programs that target improvement in access to LARC in certain populations like substance use
It is important for providers to use tools like Implicit Bias Training to learn about their own biases and how they may factor into contraceptive counseling.
•
247
Providers should incorporate reproductive justice tenants into their provision of health care and use shared decision making as a model for counseling versus one-fits-all scripts on counseling.
248 249
References
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1. 2.
3. 4. 5. 6. 7. 8. 9.
10. 11.
E. BN, Qiuhong Z, M. SG, Tessa M, F. PJ. Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review. Journal of Women's Health. 2015;24(5):349-353. Steiner MJ, Trussell J, Mehta N, Condon S, Subramaniam S, Bourne D. Communicating contraceptive effectiveness: A randomized controlled trial to inform a World Health Organization family planning handbook. American journal of obstetrics and gynecology. 2006;195(1):85-91. Obstetricians ACo, Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstetrics and gynecology. 2011;118(1):184. Branum AM, Jones J. Trends in long-acting reversible contraception use among US women aged 15-44. US Department of Health and Human Services, Centers for Disease Control and …; 2015. Mosher WD, Moreau C, Lantos H. Trends and determinants of IUD use in the USA, 2002–2012. Human Reproduction. 2016;31(8):1696-1702. Arias RD. Compelling reasons for recommending IUDs to any woman of reproductive age. International journal of fertility and women's medicine. 2002;47(2):87-95. Morgan KW. The intrauterine device: rethinking old paradigms. Journal of midwifery & women's health. 2006;51(6):464-470. Grady WR, Klepinger DH, Nelson-Wally A. Contraceptive characteristics: the perceptions and priorities of men and women. Family planning perspectives. 1999:168-175. Edwards JE, Oldman A, Smith L, McQuay HJ, Moore RA. Women's knowledge of, and attitudes to, contraceptive effectiveness and adverse health effects. BMJ Sexual & Reproductive Health. 2000;26(2):73-80. Gold RB. Guarding against coercion while ensuring access: a delicate balance. Guttmacher Policy Review. 2014;17(3):8-14. Gomez AM, Fuentes L, Allina A. Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods. Perspectives on sexual and reproductive health. 2014;46(3):171-175.
276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322
12. 13. 14. 15. 16. 17. 18. 19.
20.
21. 22.
23.
24. 25. 26.
27.
28.
29. 30. 31.
Madden T, Mullersman JL, Omvig KJ, Secura GM, Peipert JF. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception. 2013;88(2):243-249. Curtis KM, Jatlaoui TC, Tepper NK, et al. US selected practice recommendations for contraceptive use, 2016. 2016. Higgins JA. Celebration meets caution: LARC's boons, potential busts, and the benefits of a reproductive justice approach. Contraception. 2014;89(4):237-241. Obstetricians ACo, Gynecologists. Committee opinion number 539: Adolescents and long-acting reversible contracep tion: implants and intrauterine devices. 2012. In:2014. Health WHOR. Family planning: a global handbook for providers: evidence-based guidance developed through worldwide collaboration. Johns Hopkins Ccp-Info; 2007. Klein DA, Arnold JJ, Reese ES. Provision of Contraception: Key Recommendations from the CDC. American family physician. 2015;91(9). Ott MA, Sucato GS. Contraception for adolescents. Pediatrics. 2014;134(4):e1257-e1281. Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. American journal of obstetrics and gynecology. 2010;203(2):115. e111-115. e117. First L. Client-Centered Counseling: Contraceptive Counseling Module (English). https://web.archive.org/web/20160322225117/http://larcfirst.com/resources/counseling/coun seling_script/Contraceptive_Counseling_Script_in_English.pdf. Published 2016. Accessed. Stanback J, Steiner M, Dorflinger L, Solo J, Cates W. WHO tiered-effectiveness counseling is rights-based family planning. Global health: science and practice. 2015;3(3):352-357. Dehlendorf C, Krajewski C, Borrero S. Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use. Clinical obstetrics and gynecology. 2014;57(4):659. Romer S, Teal S. The BC4U service model: achieving astronomical LARC uptake in adolescents. Paper presented at: annual meeting of the Association of Reproductive Health Professionals2013. Lindo JM, Packham A. How much can expanding access to long-acting reversible contraceptives reduce teen birth rates? American Economic Journal: Economic Policy. 2017;9(3):348-376. Kavanaugh ML, Jerman J. Contraceptive method use in the United States: trends and characteristics between 2008, 2012 and 2014. Contraception. 2018;97(1):14-21. Bearak JM, Finer LB, Jerman J, Kavanaugh ML. Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: an analysis of insurance benefit inquiries. Contraception. 2016;93(2):139-144. Evans MG, Broyles S, Frederiksen B, et al. Long-Acting Reversible Contraceptive (LARC) Utilization After Policy Change Increasing Device Reimbursement to Wholesale Acquisition Cost in Louisiana. American journal of obstetrics and gynecology. 2019. Goyal V, Aiken A, Dermish A, Potter J. Comparing contraceptive choices among postabortion patients with and without free access to long-acting reversible contraceptive (LARC) methods. Contraception. 2015;92(4):385-386. USA U. Upstream USA: Delaware Contraceptive Access Now (CAN). https://www.upstream.org/campaigns/delaware-can/. Published 2019. Accessed 8/15/19. Allen D, Hunter MS, Wood S, Beeson T. One Key Question®: first things first in reproductive health. Maternal and child health journal. 2017;21(3):387-392. Callegari LS, Aiken AR, Dehlendorf C, Cason P, Borrero S. Addressing potential pitfalls of reproductive life planning with patient-centered counseling. American journal of obstetrics and gynecology. 2017;216(2):129-134.
323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359
32.
33. 34. 35. 36. 37.
38. 39. 40.
41. 42. 43. 44. 45. 46. 47.
48.
Whitaker AK, Quinn MT, Munroe E, Martins SL, Mistretta SQ, Gilliam ML. A motivational interviewing-based counseling intervention to increase postabortion uptake of contraception: a pilot randomized controlled trial. Patient education and counseling. 2016;99(10):1663-1669. Dehlendorf C, Fox E, Sobel L, Borrero S. Patient-centered contraceptive counseling: evidence to inform practice. Current Obstetrics and Gynecology Reports. 2016;5(1):55-63. Kowal D, Hatcher RA, Nelson AL, et al. Contraceptive Technology 21st Edition. Managing Contraception, LLC; 2018. Hatcher RA. Contraceptive Technology: 20th Edition. Bridging the Gap Communications; 2011. Amico JR, Bennett AH, Karasz A, Gold M. “I wish they could hold on a little longer”: physicians' experiences with requests for early IUD removal. Contraception. 2017;96(2):106-110. Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: perceptions of young adult women. American journal of public health. 2016;106(11):1932-1937. Gilliam ML. Beyond coercion: let us grapple with bias. Obstetrics & Gynecology. 2015;126(5):915-916. Brandi K, Woodhams E, White KO, Mehta PK. An exploration of perceived contraceptive coercion at the time of abortion. Contraception. 2018;97(4):329-334. Yee LM, Simon MA. Perceptions of coercion, discrimination and other negative experiences in postpartum contraceptive counseling for low-income minority women. Journal of Health Care for the Poor and Underserved. 2011;22(4):1387-1400. Amico JR, Bennett AH, Karasz A, Gold M. “She just told me to leave it”: Women's experiences discussing early elective IUD removal. Contraception. 2016;94(4):357-361. Dehlendorf C, Levy K, Kelley A, Grumbach K, Steinauer J. Women's preferences for contraceptive counseling and decision making. Contraception. 2013;88(2):250-256. Lessard LN, Karasek D, Ma S, et al. Contraceptive features preferred by women at high risk of unintended pregnancy. Perspectives on sexual and reproductive health. 2012;44(3):194-200. Harris LH, Wolfe T. Stratified reproduction, family planning care and the double edge of history. Current Opinion in Obstetrics and Gynecology. 2014;26(6):539-544. Ross L, Solinger R. Reproductive justice: An introduction. Vol 1: Univ of California Press; 2017. Gilliam ML, Neustadt A, Gordon R. A call to incorporate a reproductive justice agenda into reproductive health clinical practice and policy. Contraception. 2009;79(4):243-246. Hall KS, Ela E, Zochowski MK, et al. “I don't know enough to feel comfortable using them:” Women's knowledge of and perceived barriers to long-acting reversible contraceptives on a college campus. Contraception. 2016;93(6):556-564. Jackson AV, Karasek D, Dehlendorf C, Foster DG. Racial and ethnic differences in women's preferences for features of contraceptive methods. Contraception. 2016;93(5):406-411.
S0002-9378(19)32692-4
DOI:
https://doi.org/10.1016/j.ajog.2019.11.1271
Reference:
YMOB 12988
To appear in:
American Journal of Obstetrics and Gynecology
Received Date: 16 August 2019 Revised Date:
4 November 2019
Accepted Date: 6 November 2019
Please cite this article as: Brandi K, Fuentes L, The History of Tiered-Effectiveness Contraceptive Counseling and its Effects on Patient-Centered Family Planning Care, American Journal of Obstetrics and Gynecology (2019), doi: https://doi.org/10.1016/j.ajog.2019.11.1271. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
1
The History of Tiered-Effectiveness Contraceptive Counseling and its Effects on Patient-Centered
2
Family Planning Care
3
Kristyn Brandi, MD, MPH, [email protected] a
4
Liza Fuentes, DrPH, MPH, [email protected] b
5 6
a
7
Newark, NJ, USA 07103
8
b
Department of Obstetrics, Gynecology and Women’s Health, Rutgers - New Jersey Medical School,
Guttmacher Institute, New York, NY, USA 10038
9 10
Clinical Opinion
11
The authors report no conflict of interest.
12 13
Key Words:
14
Contraception, LARC, IUD, implant, coercion, shared decision making, reproductive justice, choice, tiered
15
counseling
16
17
Abstract
18
Public health workers, clinicians, and researchers have tried to increase long- acting reversible
19
contraceptives (LARC) use by changing contraceptive counseling between patients and providers.
20
Several major health organizations now recommend tiered-effectiveness counseling, in which the most
21
effective methods are explained first so that patients can use information about the relative efficacy of
22
contraceptive methods to make an informed choice. Some scholars and practitioners have raised
23
concerns that given histories of inequitable treatment and coercion in reproductive health care, tiered-
24
effectiveness counseling may undermine patient autonomy and choice. This Clinical Opinion examines
25
the development of tiered-effectiveness contraceptive counseling, how its rise mirrored the focus on
26
promoting LARCs to decrease the unintended pregnancy rate, and key considerations and the potential
27
conflicts of a LARC-first model with patient-centered care. Lastly, we discuss how reproductive justice
28
and shared-decision making can guide efforts to provide patient-centered contraceptive care.
29
Introduction
30
A main strategy that has emerged in the United States for reducing the proportion of
31
pregnancies that are unintended is to increase the use of long-acting reversible contraception (LARC)
32
due to their high efficacy.1 In the past decade policies and programs such as the Affordable Care Act
33
contraceptive mandate and privately and publicly funded state-based program have made considerable
34
progress in eliminating barriers to contraception, and to LARCs in particular. One such effort is the
35
adoption of the tiered-effectiveness contraceptive counseling model, in which patients receive
36
information about the most effective methods of contraception first. This model was developed to
37
ensure that both providers and patients have accurate information about LARCs. Studies have shown
38
that tiered-effectiveness counseling is associated with an increase in patient knowledge about
39
contraception2 and of LARC use.1
40
Tiered-effectiveness contraceptive counseling is now recommended by several professional
41
organizations3. However, clinicians, researchers, and advocates have raised concerns about whether
42
LARC promotion, and tiered effectiveness counseling in particular, conflicts with the central goal of
43
family planning care: to ensure that patients have the resources and information they need to decide if,
44
when, and how to have children. In order to understand this tension, we review the history of tiered-
45
effectiveness counseling and introduce how the reproductive justice and patient-centered models of
46
care are aligned with the goals of contraceptive counseling.
47 48 49
A Brief Recent History of Contraceptive Counseling The initial theory around using LARC to decrease unintended pregnancy rates stemmed from
50
evidence that LARC use was overall low in the general population and despite patients valuing efficacy in
51
their contraceptive method, many barriers prevented their use. The Mirena® and Paragard® intrauterine
52
devices (IUDs) and contraceptive implant Implanon® (now Nexplanon®) were available in the United
53
States in the early 2000’s but total use comprised only about 2.4% of all women using contraception in
54
2002.4,5 In the early 2000’s, research found that misinformation among both providers and
55
contraceptive users about associated risks, upfront cost of devices, lack of provider training, and
56
backlash from the failures of the Dalkon Shield® likely contributed to the low prevalence of LARCs.6,7
57
These articles described the benefits for individual patients including low failure rates and cost-
58
effectiveness. 6,7 Several studies of women’s preferences in birth control characteristics found that
59
efficacy is highly valued, with some studies demonstrating that it is the most important part of
60
contraception to women.8,9 Articles increasingly motivated their work by proposing the idea that
61
increasing LARC use could have a meaningful effect on lowering the unintended pregnancy rate and
62
abortion rate.7
63
The renewed enthusiasm for LARC gave rise to a shift from general contraceptive education and
64
counseling to using a tiered-effectiveness approach.10-12 This method of counseling focuses on efficacy of
65
contraceptive methods, with the most effective methods discussed first followed by less effective
66
methods. In visual aids using this counseling method, LARC methods are placed at the top of the chart
67
and less effective contraceptives listed further down,13 thereby prioritizing LARC methods. The purpose
68
of tiered-effectiveness contraceptive counseling is to allow patients can compare relative efficacy of
69
methods and use this information to make an informed choice about their birth control. As Jenny
70
Higgins noted in 2014: “the field has witnessed a distinct shift from options-based counseling, in which a
71
wide array of contraceptive methods are presented to potential contraception users, to directive and/or
72
first-line counseling in which one or two LARC methods are recommended over all others”.14
73
The tiered-effectiveness model has been increasingly studied and recommended over the past
74
15 years. The first study on tiered-effectiveness counseling was in 2005 and To address the gap between
75
patients’ valuing method efficacy and low LARC use theycompared three contraception decision tools
76
with varying emphases on efficacy, including one tool that is the predecessor to the tiered-effectiveness
77
charts used today.2 The study found that while all three charts improved patient’s knowledge about
78
contraceptives, the tiered-effectiveness chart was easiest to understand.2 The WHO Expert Working
79
Group Meeting on the Global Handbook for Family Planning Providers relied on this study’s results in
80
their endorsement of the tiered-effectiveness chart for contraceptive decision-making.2 The first
81
version of the Global Handbook was published in early 2007 and encouraged physicians to incorporate
82
this model when counseling patients about contraceptive options.2,16
83
The largest test of this tiered-effectiveness contraceptive counseling came from the
84
Contraceptive CHOICE Project, which aimed to “provide no-cost contraception to a large number of
85
women…and to promote the use of long-acting reversible contraception” in hopes to reduce the
86
unintended pregnancy rates in St. Louis.19 While the Steiner study and the WHO Global Handbook
87
helped introduce the tiered -effectiveness model to clinicians, the Contraceptive CHOICE project
88
provided the first data on its use in a large sample of contraceptive users.1,19 The Contraceptive CHOICE
89
Project studied the effects of removing barriers to patients’ LARC use that had been identified in
90
previous studies, in particular: cost, provider bias, provider training, facility availability, and finally,
91
patient information.19 The latter was addressed using tiered-effectiveness counseling for all study
92
participants.
93
The Contraceptive CHOICE Project’s methods describe using the GATHER process (Greet, Ask,
94
Tell, Help, Explain, and Return) to model their counseling, which uses a “client-centered process focused
95
on the woman, her expressed needs, situation, problems, issues and concerns”.12 The way they describe
96
the process, though, is more streamlined. When a woman presented for contraceptive counseling, she
97
was read a script by the counselor that outlines each type of contraception according to tiered-
98
effectiveness contraceptive model.20 Methods are explained in detail starting with LARCs, with
99
diaphragm and natural family planning only discussed if the patient brought them up.12,20,21 After the
100
script, patients were asked a series of questions like “What questions do you have about any of these
101
methods?” or “What birth control method sounds like a good choice for you?”.12,20,21 This model of
102
counseling focuses more on efficacy and other facts about contraception instead of asking about
103
patients’ preferences and individualizing counseling. 22 Dehlendorf describes this as using “task-oriented
104
communication” to provide information rather than “relational communication”. 22She notes in her best
105
practices recommendations for counseling that both are needed to achieve a patient-centered
106
contraceptive counseling experience.22
107
The Contraceptive CHOICE Project first published analysis showed an unprecedented result–
108
67% of study participants chose a LARC compared to the 2.4% national average.1,19 The study raised
109
awareness, discussion, and contributed to the adoption of tiered-effectiveness contraceptive counseling
110
among US-based providers.1,3 Other interventions have modeled aspects of the Contraceptive CHOICE
111
Project, including-tiered effectiveness. Perhaps the most famous was the foundation-funded effort to
112
provide LARCs to low-income teens in Colorado, which sought to “make LARC placement the default
113
clinic visit outcome”23, and was found to have led to a modest decrease teen birth rate.24
114
The Contraceptive CHOICE Project led to the adoption of tiered-effectiveness counseling
115
recommendations among major professional organizations, since 2012 from the World Health
116
Organization (WHO), Centers for Disease Control and Prevention (CDC), and American College of
117
Obstetricians and Gynecologists (ACOG).2,3,15-17 ACOG’s most recent guidance on contraceptive
118
counseling recommends that “LARC methods should be first-line recommendations for all women and
119
adolescents”.15 Likewise, the American Academy of Pediatrics’ (AAP) most recent guidance on
120
contraceptive care for adolescents states that “pediatricians are encouraged to counsel adolescents…
121
discussing the most effective contraceptive methods first”.18 These recommendations underscore that
122
patient choice and preference is a priority, but say little about how to square that with a LARC first-
123
approach, especially when a patient does not want a LARC or wants a LARC removed. Our concern is
124
even though the centrality of patient preferences and the call to encourage LARC use are both found in
125
the same guidelines and committee recommendations, clinicians are left without guidance when patient
126
choice and LARC-first recommendations come into conflict.
127 128 129
Where Are We Now? Access and use of LARC has expanded considerably in the United States since 2002. The
130
proportion of women using contraception who use a LARC method more than doubled from 2008 to
131
2014 and this is reflected among women in all age and race/ethnicity groups.25 ACA has decreased out
132
of pocket costs for contraception.26 Changes in Medicaid covered including increased reimbursement
133
and post-partum coverage.27 Some states or communities have had privately funded interventions to
134
provide free LARCs28 and clinical training and billing streamlining.29 In the same time period, many
135
training and education initiatives have been started to train OB/GYN providers and family medicine
136
physicians on how to place these devices.
137
This current landscape focused on increasing LARC access and use raises a question of whether
138
the tiered-effectiveness counseling approach is consonant or in conflict with contraceptive counseling
139
guidelines that state that patients may choose to use the contraceptive method they prefer. It also
140
raises the question more broadly about, if efficacy is not right focus, what counseling approaches
141
clinicians should use to help patients prevent and plan for pregnancy, including ensuring the ability to
142
choose their preferred method of contraceptive without barriers, judgement, or coercion?
143
Indeed, other models of contraceptive counseling have emerged since tiered-effectiveness,
144
some that center patient preferences in guiding the clinical encounter before efficacy and others that
145
focus on effecting behavior change. One example is reproductive life plan screening using the “One Key
146
Question” (OKQ).30,31 OKQ encourages providers to ask reproductive-age women if they want to become
147
pregnant in the next year. This screening question helps to triage patients into pre-pregnancy planning
148
like starting prenatal vitamins or discussing contraception if they are not interested in pregnancy at this
149
time. 30,31 OKQ is now required by some departments of health and has been incorporated into several
150
electronic health records.30 Another model is motivational interviewing, where similar to other health
151
interventions like smoking cessation, patients are encouraged to initiate a behavior change—in this
152
case, move towards using contraception.32 Lastly, some have argued for a shared decision-making model
153
in which clinicians focused on “building partnerships with patients, where patients function as experts
154
on their preferences and needs and providers function as experts on the medical evidence”.31,33 Indeed,
155
the latest edition of Contraceptive Technology (21st Edition, Managing Contraception, LLC, 2018)
156
included an entire chapter on patient-centered contraception counseling, whereas the previous version
157
only had separate treatments of considerations of safety, efficacy, and “personal considerations”.34,35
158
Potential Conflict Between Tiered-Effectiveness Counseling and Patient Preferences
159
There are several concerns that have been raised about the “LARC first” approach exemplified
160
by tiered effectiveness. One is that the provider-controlled nature of LARCs means that they are
161
inherently more capable of being used coercively compared to methods that patients can stop on their
162
own. Another is that the ways providers are educated to provide and promote LARCs may lead them to
163
prioritize their preferences for what they think patients should use over the preferences of patients.14,36
164
This is reflected in training and practice, where clinicians are taught their job is to “get” patients to use a
165
LARC, and do not have good guidance on patient-centered approaches on how to honor requests for
166
removal.36,37 That LARCs are recommended “first-line” methods generates a provider bias that LARCs are
167
the “best” contraception and the belief that women do not choose LARCs primarily because they are not
168
educated enough about them or must justify their reasons for not doing so.37,38 Additionally, rhetoric
169
regarding the use of the clinical encounter to reduce the unintended pregnancy rate on a population
170
level is a misapplication of a population level indicator. This rhetoric can cause providers to feel that
171
whenever a patients does not choose a LARC their clinical goals are in direct conflict with the goals of
172
the family planning clinical encounter – to ensure the patient can use the birth control method they feel
173
is best for them. Moreover, racism and sexism that shapes broader society necessarily create implicit
174
biases within providers and therefore influences the clinical encounter. Therefore, overly directly or
175
coercive contexts for the use of LARC may be more likely among low-income patients, young patients,
176
Black and Brown patients, and patients with certain co-morbidities such as substance use disorders.44
177
These concerns are justified, since physician bias towards LARC can be perceived by patients as a
178
form of contraceptive coercion.39-41 While patients may value efficacy, they also value other features of
179
contraceptive methods and there is no method that has all of the features that are important them.43
180
Patients seeking contraceptives must weigh their options all against their individual preferences, values,
181
needs, and priorities. A tiered-effectiveness approach alone cannot provide space and guidance for
182
patients to do that. While some patients may express frustration around this bias, others feel guilt and
183
shame in their choices which further perpetuates issues around contraception choice, parenthood, and
184
abortion stigma.10,39,40,42
185
There is an opportunity to use Reproductive Justice within reproductive health care, and
186
specifically when counseling patients on contraceptive options, to develop practices that do not risk
187
undermining patients’ autonomy. Originally coined by a collective of Black women, reproductive justice
188
is the human right to have a child, not have a child, and to parent in a safe, sustainable environment to
189
allow families to thrive.45 The Reproductive Justice framework explicitly recognizes historic and current
190
forms of racialized and gendered reproductive oppression, and therefore provides a lens for
191
understanding how the way in which targeting interventions to promote LARC towards groups that are
192
systematically discriminated against, such as by race/ethnicity, immigration status, wealth, or health,
193
such as substance use disorder, may perpetuate bias and can result in harm.14,46
194
Some may argue that a more pressing concern is that many barriers still exist between a patient
195
and their preferred contraceptive method, especially LARCs. Though there is still progress to be made in
196
ensuring that patients have the information, resources, and services they need to use their preferred
197
method of contraception44,47, this can coexist with coercive clinical encounters and in fact may
198
exacerbate them. We must create training and practice guidelines and advocate for policies that address
199
both. In order to mitigate the conflict between a patient’s autonomous choice and provider bias, we
200
must recognize that our goals must be our patient’s goals. The tiered-effectiveness approach was
201
developed in response to specific contraceptive landscape in the early 2000’s, when LARCs where not
202
widely available. In maintaining the tiered-effectiveness approach as a standard of care, we are deciding
203
what all patients need hear to make that choice. This can lead to patients feeling overly directed or
204
coerced into choosing a certain methods, cause dissatisfaction with their care and their method, and
205
create skepticism around providers intentions.39-41 And these potential “pitfalls”31 are not random.
206
When providers and patients’ preferences align, a tiered-effectiveness approach may not unduly
207
pressure a patient or miss their needs regarding contraception. However, when patients have differing
208
preferences from their providers’ or circumstances that providers feel should influence contraceptive
209
choice, providers who think LARC is the “best” method may feel that patients are not making decisions
210
they agree with.36 It is in these circumstances in which providers must ensure they are taking a patient-
211
centered approach, so that they can be self-aware not to put their preferences over the patients.
212
Patient-centered counseling “aims to provide education to patients that integrates evidence-based
213
recommendations with patient preferences, recognizing that patients’ individual values and preferences
214
should be an integral factor in decisions made about their health care”31 and ensures that “patients
215
function as experts on their preferences and needs and providers function as experts on the medical
216
evidence.”31
217
As efforts continue to improve access to LARCs, providers and contraceptive counselors should
218
use contraceptive counseling approaches that center the goal of ensuring patients preferences are met
219
regarding contraceptive choice. The individual clinical encounter should not be considered a mechanism
220
by which to “reduce the unintended pregnancy rate” because it is not patients’ responsibility to choose
221
a LARC or any method in service of moving a national level indicator. Rather, family planning care exists
222
to ensure all people can plan for and prevent pregnancies, including using contraceptives that meet
223
their lifestyle, and sexual health and pleasure needs. Efficacy is an important factor in many patients’
224
choices’, but it is not the only or even primary factor for all patients; even those that value efficacy may
225
still not choose to use a LARC for other reasons.48 Any family planning program should “put the
226
priorities, needs and preferences of individual women—not the promotion of specific technologies—
227
first”.11
228
Recommendations for Patient-Centered Counseling to Minimize Conflict
229
•
Before providing information on contraceptive options, it is important to determine what values and
230
preferences the patient has regarding contraception and, more broadly, their reproductive life
231
goals.
232
•
233 234
Providers must find a balance between correcting misinformation about contraceptives and dismissing negative experiences around prior use.
•
Patients are allowed to have conflicting views between their pregnancy intention and use of
235
contraception. Pregnancy is not always a negative outcome for those experiencing an unplanned
236
pregnancy and pregnancy ambivalence can be factored into contraceptive counseling.
237
•
Programs that help improve access to LARC devices should recognize the coercive situations they
238
may create. For example, having access to a free LARC device versus paying per pill pack per year
239
creates a non-choice for those in lower socioeconomic groups.
240
•
241 242
disorder patients or prisoners can perpetuate judgments on who should be parents. •
243 244
Screening for contraceptive use with programs like One Key Question help to start the conversation but should be used an initiator to a conversation about deeper values around reproductive goals.
•
245 246
Programs that target improvement in access to LARC in certain populations like substance use
It is important for providers to use tools like Implicit Bias Training to learn about their own biases and how they may factor into contraceptive counseling.
•
247
Providers should incorporate reproductive justice tenants into their provision of health care and use shared decision making as a model for counseling versus one-fits-all scripts on counseling.
248 249
References
250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275
1. 2.
3. 4. 5. 6. 7. 8. 9.
10. 11.
E. BN, Qiuhong Z, M. SG, Tessa M, F. PJ. Preventing Unintended Pregnancy: The Contraceptive CHOICE Project in Review. Journal of Women's Health. 2015;24(5):349-353. Steiner MJ, Trussell J, Mehta N, Condon S, Subramaniam S, Bourne D. Communicating contraceptive effectiveness: A randomized controlled trial to inform a World Health Organization family planning handbook. American journal of obstetrics and gynecology. 2006;195(1):85-91. Obstetricians ACo, Gynecologists. ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstetrics and gynecology. 2011;118(1):184. Branum AM, Jones J. Trends in long-acting reversible contraception use among US women aged 15-44. US Department of Health and Human Services, Centers for Disease Control and …; 2015. Mosher WD, Moreau C, Lantos H. Trends and determinants of IUD use in the USA, 2002–2012. Human Reproduction. 2016;31(8):1696-1702. Arias RD. Compelling reasons for recommending IUDs to any woman of reproductive age. International journal of fertility and women's medicine. 2002;47(2):87-95. Morgan KW. The intrauterine device: rethinking old paradigms. Journal of midwifery & women's health. 2006;51(6):464-470. Grady WR, Klepinger DH, Nelson-Wally A. Contraceptive characteristics: the perceptions and priorities of men and women. Family planning perspectives. 1999:168-175. Edwards JE, Oldman A, Smith L, McQuay HJ, Moore RA. Women's knowledge of, and attitudes to, contraceptive effectiveness and adverse health effects. BMJ Sexual & Reproductive Health. 2000;26(2):73-80. Gold RB. Guarding against coercion while ensuring access: a delicate balance. Guttmacher Policy Review. 2014;17(3):8-14. Gomez AM, Fuentes L, Allina A. Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods. Perspectives on sexual and reproductive health. 2014;46(3):171-175.
276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322
12. 13. 14. 15. 16. 17. 18. 19.
20.
21. 22.
23.
24. 25. 26.
27.
28.
29. 30. 31.
Madden T, Mullersman JL, Omvig KJ, Secura GM, Peipert JF. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception. 2013;88(2):243-249. Curtis KM, Jatlaoui TC, Tepper NK, et al. US selected practice recommendations for contraceptive use, 2016. 2016. Higgins JA. Celebration meets caution: LARC's boons, potential busts, and the benefits of a reproductive justice approach. Contraception. 2014;89(4):237-241. Obstetricians ACo, Gynecologists. Committee opinion number 539: Adolescents and long-acting reversible contracep tion: implants and intrauterine devices. 2012. In:2014. Health WHOR. Family planning: a global handbook for providers: evidence-based guidance developed through worldwide collaboration. Johns Hopkins Ccp-Info; 2007. Klein DA, Arnold JJ, Reese ES. Provision of Contraception: Key Recommendations from the CDC. American family physician. 2015;91(9). Ott MA, Sucato GS. Contraception for adolescents. Pediatrics. 2014;134(4):e1257-e1281. Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. American journal of obstetrics and gynecology. 2010;203(2):115. e111-115. e117. First L. Client-Centered Counseling: Contraceptive Counseling Module (English). https://web.archive.org/web/20160322225117/http://larcfirst.com/resources/counseling/coun seling_script/Contraceptive_Counseling_Script_in_English.pdf. Published 2016. Accessed. Stanback J, Steiner M, Dorflinger L, Solo J, Cates W. WHO tiered-effectiveness counseling is rights-based family planning. Global health: science and practice. 2015;3(3):352-357. Dehlendorf C, Krajewski C, Borrero S. Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use. Clinical obstetrics and gynecology. 2014;57(4):659. Romer S, Teal S. The BC4U service model: achieving astronomical LARC uptake in adolescents. Paper presented at: annual meeting of the Association of Reproductive Health Professionals2013. Lindo JM, Packham A. How much can expanding access to long-acting reversible contraceptives reduce teen birth rates? American Economic Journal: Economic Policy. 2017;9(3):348-376. Kavanaugh ML, Jerman J. Contraceptive method use in the United States: trends and characteristics between 2008, 2012 and 2014. Contraception. 2018;97(1):14-21. Bearak JM, Finer LB, Jerman J, Kavanaugh ML. Changes in out-of-pocket costs for hormonal IUDs after implementation of the Affordable Care Act: an analysis of insurance benefit inquiries. Contraception. 2016;93(2):139-144. Evans MG, Broyles S, Frederiksen B, et al. Long-Acting Reversible Contraceptive (LARC) Utilization After Policy Change Increasing Device Reimbursement to Wholesale Acquisition Cost in Louisiana. American journal of obstetrics and gynecology. 2019. Goyal V, Aiken A, Dermish A, Potter J. Comparing contraceptive choices among postabortion patients with and without free access to long-acting reversible contraceptive (LARC) methods. Contraception. 2015;92(4):385-386. USA U. Upstream USA: Delaware Contraceptive Access Now (CAN). https://www.upstream.org/campaigns/delaware-can/. Published 2019. Accessed 8/15/19. Allen D, Hunter MS, Wood S, Beeson T. One Key Question®: first things first in reproductive health. Maternal and child health journal. 2017;21(3):387-392. Callegari LS, Aiken AR, Dehlendorf C, Cason P, Borrero S. Addressing potential pitfalls of reproductive life planning with patient-centered counseling. American journal of obstetrics and gynecology. 2017;216(2):129-134.
323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359
32.
33. 34. 35. 36. 37.
38. 39. 40.
41. 42. 43. 44. 45. 46. 47.
48.
Whitaker AK, Quinn MT, Munroe E, Martins SL, Mistretta SQ, Gilliam ML. A motivational interviewing-based counseling intervention to increase postabortion uptake of contraception: a pilot randomized controlled trial. Patient education and counseling. 2016;99(10):1663-1669. Dehlendorf C, Fox E, Sobel L, Borrero S. Patient-centered contraceptive counseling: evidence to inform practice. Current Obstetrics and Gynecology Reports. 2016;5(1):55-63. Kowal D, Hatcher RA, Nelson AL, et al. Contraceptive Technology 21st Edition. Managing Contraception, LLC; 2018. Hatcher RA. Contraceptive Technology: 20th Edition. Bridging the Gap Communications; 2011. Amico JR, Bennett AH, Karasz A, Gold M. “I wish they could hold on a little longer”: physicians' experiences with requests for early IUD removal. Contraception. 2017;96(2):106-110. Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: perceptions of young adult women. American journal of public health. 2016;106(11):1932-1937. Gilliam ML. Beyond coercion: let us grapple with bias. Obstetrics & Gynecology. 2015;126(5):915-916. Brandi K, Woodhams E, White KO, Mehta PK. An exploration of perceived contraceptive coercion at the time of abortion. Contraception. 2018;97(4):329-334. Yee LM, Simon MA. Perceptions of coercion, discrimination and other negative experiences in postpartum contraceptive counseling for low-income minority women. Journal of Health Care for the Poor and Underserved. 2011;22(4):1387-1400. Amico JR, Bennett AH, Karasz A, Gold M. “She just told me to leave it”: Women's experiences discussing early elective IUD removal. Contraception. 2016;94(4):357-361. Dehlendorf C, Levy K, Kelley A, Grumbach K, Steinauer J. Women's preferences for contraceptive counseling and decision making. Contraception. 2013;88(2):250-256. Lessard LN, Karasek D, Ma S, et al. Contraceptive features preferred by women at high risk of unintended pregnancy. Perspectives on sexual and reproductive health. 2012;44(3):194-200. Harris LH, Wolfe T. Stratified reproduction, family planning care and the double edge of history. Current Opinion in Obstetrics and Gynecology. 2014;26(6):539-544. Ross L, Solinger R. Reproductive justice: An introduction. Vol 1: Univ of California Press; 2017. Gilliam ML, Neustadt A, Gordon R. A call to incorporate a reproductive justice agenda into reproductive health clinical practice and policy. Contraception. 2009;79(4):243-246. Hall KS, Ela E, Zochowski MK, et al. “I don't know enough to feel comfortable using them:” Women's knowledge of and perceived barriers to long-acting reversible contraceptives on a college campus. Contraception. 2016;93(6):556-564. Jackson AV, Karasek D, Dehlendorf C, Foster DG. Racial and ethnic differences in women's preferences for features of contraceptive methods. Contraception. 2016;93(5):406-411.