Contraception decisions rarely are consistent, especially when patients undergo a major life change, such as giving birth to their first child, new data show.1
Researchers analyzed contraceptive decision-making among 8,654 patients who delivered babies at an urban teaching hospital in Ohio between 2012 and 2014. They found that only 12% of patients wanted the same contraceptive at various points in their pregnancy journey, including at a prenatal visit; inpatient admission before or at delivery; postpartum and before hospital discharge; and at an outpatient postpartum visit.
“There’s not much variation between admission to hospital and right after delivery,” says Kavita Shah Arora, MD, MBE, MS, study co-author and associate professor and director of the division of general obstetrics and gynecology at the University of North Carolina at Chapel Hill. “Fluctuation is normal. Fewer patients wanted a highly effective contraception at the time of outpatient than at hospital delivery, and at postpartum visits, more patients wanted any type of contraception than at any other time period.”
These findings reinforce the idea that contraceptive counseling should be a dynamic and fluid process. “Paying attention to that in contraceptive counseling is very important,” Arora says. “It’s important to recognize that what is happening around them may impact a patient’s choice of contraception. Major life events, like child birth, and going from pre- to post-childbirth, can cause someone to change their planned method.”
Reproductive health providers should keep this in mind when counseling patients at all stages, from pre-pregnancy to pregnancy to post-pregnancy.
When counseling patients, it is important to acknowledge that is not all about nailing down an exact method early in the pregnancy and then not revisiting that conversation during the rest of the pregnancy. “Rather, it’s about having longitudinal contraceptive counseling postpartum that recognizes there is normalcy in fluctuation,” Arora adds.
Contraceptive decisions do not need to be static. Providers can keep in mind that patients’ interest in long-acting reversible contraception (LARC) and a permanent method may change within a short period.
For instance, Arora and colleagues found that interest in a permanent solution and LARC was greatest in the prenatal period and postpartum period before the patient left the hospital. It was lowest at the time of delivery and at the postpartum outpatient visit. But interest in injectables, pills, patch, and vaginal ring was lowest at delivery and the prenatal visit, and highest at the postpartum inpatient and postpartum outpatient times.
Since people are more drawn to LARC methods before delivery, providers should listen to patients, trust them, and uphold their autonomy by removing barriers to receiving the LARC method right after delivery.
“We also should remove barriers so that if, later, the LARC method is not what they want, we don’t pressure them to keep that method, and we trust in their autonomous decision,” Arora adds. “We should be primarily motivated by upholding patients’ autonomy when it comes to contraceptive counseling and decision-making. Take a step back and think, ‘It can’t be that doctors know more about a patient’s relationship dynamic and reproductive goals than the patient herself knows.’”
In ongoing relationships with patients, providers may find that what patients wanted in contraceptives as young adults has changed over a decade or two.
“People change their contraceptive goals with time,” she says. “This study shows that some of these fluctuations happen at a much shorter timeline.”
Patients are more likely to change contraceptive choices after a major life event. “Our goal is to open the space of conversation and letting it be a fluid, dynamic conversation throughout the pregnancy period,” Arora says.
This conversation can include updated medical information as well as information about access factors that are beyond the patient’s and provider’s control. For instance, if a provider is seeing a patient in Texas or in another state where laws have made abortion inaccessible to most people, they can let patients know that if they were to become pregnant they may not be able to access a safe and legal abortion. This information could influence their choice of contraception.
“It’s also our job to make sure patients are informed about what the law is and to make sure they’re aware of the ramifications of what those laws are,” Arora says. “It’s really important for patients to have all the information they need to make their decisions. This includes medical information or data on what we know about regret from sterilization or data about contraceptive decision-making being dynamic.”
For a physician to tell a patient who asks for a tubal ligation to wait or to think harder about an alternative would be paternalistic, Arora notes. But the doctor can give the patient relevant information, such as studies that may show similar effectiveness and better safety in the use of intrauterine devices vs. tubal ligation.
To avoid paternalism, uphold the tenets of shared decision-making.
“Ethically shared decision-making means I, as the physician, am the expert in medical information, but the patient is the expert in their own life, goals, and lived experience, and those are two equal pieces in this relationship,” she explains. “I explore what those goals are and what those desires are, and make sure I’m providing information and clarifying any misconceptions based on the data and arriving at the point of a decision.”
When Arora meets with patients, she builds trust by making it clear that it is the patient’s body and the patient gets to decide on the use of contraception.
“To me, it can’t be an algorithm process that we work through,” Arora says. “It needs to be shared decision-making, where our job is to elucidate what those choices are and remove the barriers.”
REFERENCE
- Thornton M, Ascha MS, Arora KS. Addressing fluidity in contraceptive decision-making: A key component of patient-centered contraceptive counseling. Am J Obstet Gynecol 2022;S0002-9378(22)00160-0.
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