Today I’m sharing the contraception tool I created for my Doctorate of Nursing Practice program. I worked to edit and perfect this tool for months in my program and it was the center of my quality improvement initiative. When I was creating and planning my initiative, I couldn’t find a current tool that included all the components of shared decision making. And believe me, I looked at ALL OF THE CURRENT TOOLS (see below) but none of the tools had all the components that women need to make a solid decision about contraception. Quick disclaimer: contraception doesn’t just include hormonal methods – it absolutely includes methods like natural family planning, lactation amenorrhea method, condoms…you get the idea! Here’s an idea of the tools out there…
Some of these tools were easy to read and some were not. Some tools were too many pages (these are informative but no one wants to read 25 pages to figure out which contraception tool is best for them). Some tools were colorful and beautifully designed but offered no information about side effects (one of the main reasons women discontinue contraception is that they don’t understand the side effects and what to do if they occur). Some tools were terribly designed. Some tools included cost and some did not. Some were clear on the effectiveness of the method – some were not! Some were made to be on paper and some were made to be on a screen.
(Anyone else feel like they’re in a contraception Dr. Seuss book?).
In short, I created a tool that encompassed everything that evidence stated should be included in counseling and could be used on paper or on a screen!
Before we get to the tool, a little background on why a new tool is needed to offer counseling about contraception and family planning.
Why is contraception important and how does contraception benefit women and their family?
First, 50% of all pregnancies are unplanned and unplanned pregnancies cost the United States $21 billion annually (Centers for Disease Control and Prevention, 2015). Contraception helps to reduce unplanned pregnancies and offers women the opportunity to prevent or plan their pregnancies. Evidence also supports that contraception counseling during pregnancy increases contraception use during the postpartum period (Bhatt, Oluvadi & Amico, 2020).
One of my favorite reports I came across working on my initiative was The Benefits of Birth Control in America: Getting the Facts Straight (Kaye, Appleton Gootman, Stewart Ng & Finley, 2014). The report highlights some amazing and often overlooked benefits of contraception:
- When women can plan and space their pregnancies, there are HUGE benefits for the woman, her children, her family and taxpayers. Also, optimal birth spacing is four times more common when a woman is using her contraception method effectively.
- Postpartum depression is twice as common in women with an unplanned pregnancy when compared to women with a planned pregnancy.
- “83% of children born following a planned pregnancy are living with two married parents at age two, compared to only 46% of children born following an unplanned pregnancy” (p.25).
- “Pregnancy timing matters: There is a 3% increase in weekly wages and a 9% increase in career earnings for each year of delayed childbearing” (Kaye, Appleton Gootman, Stewart Ng & Finley, 2014, p.31).
What do national organizations say about contraception counseling?
The American College of Obstetricians and Gynecologists (ACOG) recommend that a discussion about a woman’s reproductive plan begin in pregnancy and continue throughout the postpartum time period – but no specific time period to offer this guidance and counseling has been recommended or studied. The “reproductive life plan discussion” should include the woman’s desire for and timing of pregnancies; a review of all 18 methods of contraception and each method’s risks and benefits (to include methods without hormones such as barrier methods, abstinence, lactational amenorrhea method, natural family planning); possible side effects of the method and strategies to manage possible side effects, and a plan for continuation (ACOG, 2018; Dehlendorf, Krajewski & Borrero, 2014).
The American College of Nurse-Midwives (2016) support the right to access factual, evidence-based and unbiased information about sexual and reproductive health care services so that women can make informed decisions.
That all sounds great, right? But how many women actually receive counseling and how effective is that counseling? Ah, that is the meat of the discussion. Here’s what women think!
What do women think about current contraception counseling?
Based on a family planning survey conducted by the American College of Nurse-Midwives (2013) :
- Women do not feel like they know enough information about the types of contraception available to them.
- Many healthcare providers are not adequately educating and counseling women on how to use the method that they are prescribed.
- 40% of women reported they were not given information on how to use the contraception method they were prescribed by their provider.
- Women reported barriers such as long wait times to schedule appointments or difficulty talking with their provider that made it difficult to manage side effects or ask about changing their method.
- Women has misconceptions about which method of contraception may be harmful to them.
- Many women are not using the contraception methods that are the most effective at preventing pregnancy (Johnson, Kane Low, Kaplan et al., 2013).
Other than surveys and recommendations, what does the evidence say?
- Shared decision making is associated with higher patient satisfaction when utilized in contraception counseling (Dehlendorf, Krajewski & Borrero, 2014)
- Contraception counseling should include a needs assessment (also known as a screening), support in the decision making process (i.e. shared decision making) and a decision for a method with appropriate follow up (Holt, Dehlendorf, & Langer, 2017)
- ***In short, more evidence is needed. Studying contraception counseling, especially with shared decision making, is a new focus of this decade.***
Hopefully that provides a little background on where the United States currently stands on contraception counseling and highlights the benefits exceptional contraception counseling can offer a woman and her family.
And without further adieu, here’s the tool!
Now, here’s why is this tool so awesome?
- First, the tool starts with a screening in Step 1! Does the woman already have a contraception plan? If so, what is it? If she doesn’t have a plan, she’s telling you that clearly with the screen.
- Secondly, the questions in Step 2 are essentially a family planning activity! As a provider, it’s important to ask these questions in order to provide adequate, comprehensive, shared decision making for a woman!
- Third, the option grid is color coded in green-yellow-red based on how effective the contraception method is. This makes it easier for the patient to grasp the differences between the method’s while also seeing the wide range of options that are available to the woman.
- Lastly, the shared decision making tool! It’s colored coded the same way as the option grid. My favorite thing is the checklist. In line with shared decision making and The Checklist Manifesto by Atul Gwande, it ensures that all components of counseling are completed by the provider and that the woman understands her chosen plan and is without questions. Even on the busiest clinic day, the checklist will ensure all the components were addressed.
I explain how to use the tool in this video (cute baby included for entertainment):
Or you can read about how to use the tool here…
The tool is a 3 page packet that is a screening on the first page, an option grid on the second page and a shared decision making tool on the third page. Ideally, the patient is handed the packet at check-in for their appointment and completes the first two pages of the packet while they are waiting. If anyone has every completed contraception counseling, a review of all the methods and their risks or side effects can be time consuming. After the patient completes the first two pages, the provider reviews the patient’s answers and family plan, then reviews which methods the patient is most interested in. The shared decision making tool is utilized during this discussion to help the patient come to a decision. A SURE test is completed after the patient makes a decision to ensure that all components of counseling were addressed. And a list of websites is available at the bottom of the tool for the patient to read more on contraception should they desire. Lastly, and most important, the entire packet leaves with the patient! By taking the packet home, the patient leaves with their completed family plan, an option grid for future use, their completed tool, and resources to use in the future as needed. That’s how contraception counseling should be!
I hope you guys like the tool! It was such a learning experience making it. Remember, the tool is free for sharing but please credit the source. It’s pending a copyright too!
Access the tool anytime on the new TOOLS & HANDOUTS page!
Have a great day 🙂
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American College of Nurse-Midwives. (2013). Family planning and birth control survey key findings. Our Moment of Truth: A New Understanding of Midwifery Care. http://www.midwife.org/acnm/files/ccLibraryFiles/Filename/000000003464/2013%20ACNM%20Contraception%20Survey%20-%20Key%20Findings.pdf
American College of Nurse-Midwives. (2016). Position statement: Access to comprehensive sexual and reproductive health care services, 1-4. http://www.midwife.org/acnm/files/ACNMLibraryData/UPLOADFILENAME/000000000087/Access-to-Comprehensive-Sexual-and-Reproductive-Health-Care-Services-FINAL-04-12-17.pdf
American College of Obstetricians & Gynecologists. (2018). ACOG committee opinion No. 736: Optimizing postpartum care. Obstetrics & Gynecology, 131(5), e140-e150. https://doi.org/10.1097/AOG.0000000000002633ACOG
Bhatt, K., Oluyadi, F., & Amico, J. (2020). Does contraceptive counseling increase self-reported use of hormonal, intrauterine, or permanent contraception in the first six months postpartum? Evidence-Based Practice, 23(3), 40. doi: 10.1097/EBP.0000000000000567
Centers for Disease Control and Prevention. (2015). Evidence summary: Prevent unintended pregnancy. https://www.cdc.gov/sixeighteen/docs/6-18-evidence-summary-pregnancy.pdf
Contraceptive action plan. (2020). Contraceptive counseling model: A 5-step client-centered approach. https://www.contraceptiveactionplan.org/index.php/tools-and-resources-menu-item/cap-birth-control-options-grid
Dehlendorf, C., Krajewski, C., & Borrero, S. (2014). Contraceptive counseling: Best practices to ensure quality communication and enable effective contraceptive use. Clinical Obstetrics and Gynecology, 57(4), 659-673. doi:10.1097/GRF.0000000000000059
Holt, K., Dehlendorf, C., & Langer, A. (2017). Defining quality in contraceptive counseling to improve measuresure of individuals’ experiences and enable service delivery improvement. Contraception, 96, 133-137. doi: 10.1016/j.contraception.2017.06.005
Kaye, K., Appleton Gootman, J., Stewart Ng, A. & Finley, C. (2014). The benefits of birth control in America: Getting the facts straight. Washington, DC: The National Campaign to Prevent Teen and Unplanned Pregnancy, 1-44. https://powertodecide.org/sites/default/files/resources/primary-download/benefits-of-birth-control-in-america.pdf
Johnson, C., Kane Low, L., Kline Kaplan, L., Romano, A., & Tillman, S. (2013). Our moment of truth 2013 survey of women’s health care experiences and perceptions: Spotlight on family planning and contraception, 1-6.
Pathfinder international. (2016). Cue cards for counseling adults on contraception. https://toolkits.knowledgesuccess.org/toolkits/oral-contraceptives/counseling-tools-job-aids
Planned Parenthood Federation of America Inc. (2020). Birth control. http://www.plannedparenthood.org/learn/birth-control
Quality family planning. (2016). Activity 3.1: Birth control information – simple and accurate. http://www.cardeaservices.org/documents/resources/QFPtoolkit/3.1_BirthControlInfo-SimpleAccurate.pdf
University of California San Francisco, & Bedsider. (2019). How well does birth control work? https://beyondthepill.ucsf.edu/sites/beyondthepill.ucsf.edu/files/Tiers%20of%20Effectiveness_English-043019.pdf
U.S. Department of Health and Human Services, & Centers for Disease Control and Prevention. (2011). Effectiveness of family planning methods. https://www.cdc.gov/reproductivehealth/UnintendedPregnancy/PDF/Contraceptive_methods_508.pdf