Updates in Contraception: Advances in Technical and None to report - PDF document

5/23/17 Disclosures Updates in Contraception: Advances in Technical and • None to report Interpersonal Care Christine Dehlendorf, MD MAS Department of Family and Community Medicine and Obstetrics, Gynecology and Reproductive Sciences Contraceptive Counseling: What is the best approach to LARC First? contraceptive decision making? • Increasing emphasis on/promotion of LARC methods in family planning a. Encourage women to choose the most highly effective methods • Examples : b. Give them information about all methods and let § Tiered effectiveness: Present methods in order of them decide for themselves effectiveness • Motivational interviewing: Patient-centered approach c. Give them whichever method they say they want to achieving behavior change d. None of these 1

5/23/17 Is “LARC First” counseling How do women think about patient-centered? pregnancy? • Intentions : Timing-based ideas about if/when to get • Women have strong and varied preferences for pregnant contraceptive features • Plans: Decisions about when to get pregnant and • Relate to different assessments of potential formulation of actions outcomes, such as side effects • Desires: Strength of inclination to get pregnant or avoid • Also relates to different assessments of the pregnancy importance of avoiding an unintended pregnancy • Feelings: Emotional orientations towards pregnancy Aiken, PSRH, 2016 Lessard: PSRH, 2012 Madden: AJOG , 2015 A Multidimensional Concept Planning May Not Be Desirable “I guess one of the reasons that I haven’t Plans ≠ Intentions ≠ Desires ≠ Feelings gotten an IUD yet is like, I don’t know, having one kid already and being in a long-term committed relationship, it takes the element of surprise out of when we would have our next All different concepts • kid, which I kind of want. I’m in that weird Women may find all or only some meaningful • position. I just don’t want to put too much thought and planning into when I have my next Often appear inconsistent with each other • kid.” Higgins et al . In Preparation 2016 2

5/23/17 Ambivalent and Indifferent Unintended May be Welcome Desires “Another pregnancy is definitely not the right path for me and I’m being “Sometimes I probably want to get very careful with birth control. But If I pregnant when I’m 22 or 27… or somehow ended up pregnant would probably soon. Who knows? I embrace it and think it’s for the Probably when my daughter starts best? Absolutely.” “I don’t want more kids and was walking, maybe.” “I already got a kid so you know I’m hoping to get my tubes tied. We not opposed to having children. If it can’t afford another one. But if it happens, it happens…. I’d prefer happened I’d still be happy. I’d be we don’t have children right now really excited. We’d rise to the occasion…nothing would really but if it happens, okay.” change.” Gomez et al . Young Couples Study Aiken, Dillaway & Mevs-Korff. 2015 Social Science & Medicine 2016 Concerns with directive counseling But shouldn’t we get women to approaches plan “for their own good”? • Is an unintended pregnancy a universally negative • Assuming women should want to use certain health outcome? methods: § Ignores variability in preferences, including around • Little data to support this assumption importance of avoiding unintended pregnancy § Many studies show no association with social or health § Does not prioritize autonomy outcomes § Some studies show associations with low birth weight and • Pressure to use specific methods can be preterm birth counterproductive § However, generally not well-designed and well-controlled § Perceived pressure increases risk of method discontinuation § Most examine only retrospective intentions § Perceiving provider as having a preference associated with lower satisfaction with method Kalmuss: Fam Plann Perspect , 1996 Gipson et al. Studies in Family Planning, 2008 Dehlendorf: Contraception , 2017 3

5/23/17 Shared Decision Making in Contraceptive decision making Family Planning “I just think providers should be very informative about it and non- Consumerist Directive Consumerist Directive biased…maybe not try to persuade Counseling Counseling Counseling Counseling them to go one way or the other, but maybe try to find out about their background a little bit and what their relationships are like and maybe suggest what might work best for them but ultimately leave the decision up to the patient.” Quality decision based on Shared decision making patient preferences Dehlendorf, Contraception, 2013 Shared decision-making in family planning Shared Decision Making and • “Investing in the beginning” and “Eliciting the patient perspective” both associated with Disparities in Family Planning contraceptive continuation (p<0.05) Care • Patients who report sharing their decision with their provider had higher satisfaction with their family planning experience § Compared to both patient- and provider-driven decisions • May not be best for everyone, but provides starting point for counseling Dehlendorf, AJOG, 2016 Dehlendorf, Contraception, 2017 4

5/23/17 History of reproductive injustices Race and trust in family planning services • Nonconsensual sterilization of poor women and women of color throughout the • 35% of Black women reported “medical and public 1900s health institutions use poor and minority people as guinea pigs to try out new birth control methods.” • Unethical testing of oral • Greater than 40% of Blacks and Latinas think contraceptives in Puerto government promotes birth control to limit minorities Rico • Black women more likely to prefer a method over • 150 incarcerated women in which they have control California were coercively sterilized from 2006-2010 Jackson, Contraception, 2015 Rocca, PSRH, 2015 Thorbun and Bogart, Women’s Health, 2005 Provider bias in family planning Are women of color counseled differently? • Low-income women of color more likely to report • Family planning providers have lower levels of trust in being advised to limit their childbearing than their Black patients middle-class white women • Providers are more likely to agree to sterilize women of color and poor women • Blacks were more likely than whites to report having been pressured by a clinician to use contraception • Are there also disparities in counseling about the IUD? • 67% of black women reported race-based § RCT using videos of standardized patients presenting for discrimination when receiving family planning care contraceptive advice § Shown to participants at national meetings of ACOG and AAFP Jackson, unpublished data Downing: Am J Public Health , 2007 Harrison, Obstet Gynecol 1988 Becker: Perspect Sex Reprod Health , 2008 Dehlendorf, American Journal of Obstetrics and Gynecology, 2010 Thorburn: Women Health , 2005 5

5/23/17 Are providers more or less likely to The “Patients” recommend IUDs to Black and Latina women? 1. Providers are MORE likely to recommend IUDs to Black and Latina women than to White women 2. Providers are LESS likely to recommend IUDs to Black and Latina women than to White women 3. There are no differences by race/ethnicity in recommendations for IUDs Counseling and Family Planning Percent of Providers Recommending IUC to Low SES Women, by Race/Ethnicity (n=173) Disparities 90 67% 63% 80 • Providers need to be aware of both historical context and documented disparities in counseling 70 42% 60 % Recommending IUC • Essential to ensure that providers focus on individual 50 preferences when caring for women of color 40 30 • Shared decision making provides explicit framework for doing this, without swinging too far to other side 20 10 P<0.05 0 Whites Blacks Latinas Dehlendorf, et al. AJOG, 2010 6

5/23/17 The process of shared decision Counseling about side effects making • Focus on menstrual side effects • Establish rapport • Inquire about particular other areas of interest or • Elicit informed preferences for method concern to patient “I think that they hide the fact of the characteristics: § Previous experiences? complications or the defects, the things that § Effectiveness § Things she has heard from friends? might happen if you take that. They don’t § Side effects give you that information and I don’t think § Frequency of using method • Respond to client concerns about side effects in a any provider has given me that information.” § Different ways of taking methods respectful manner • Facilitate decision grounded in patient preferences • Consider benefits (e.g., acne) as well Dehlendorf: Contraception , 2013 Examples of facilitation Are you familiar with the US Medical Eligibility Criteria for Contraception? “I am hearing you say that avoiding pregnancy is the most important thing to you right now. In that case, you may want to consider either an IUD or a. Yes implant. Can I tell you more about those methods?” b. No “You mentioned that it is really important to you to not have irregular bleeding. The pill, patch, ring and copper IUD are good options, if you want to hear more about those.” 7