Bias-Free Reproductive Health Counseling Can Improve Patient Autonomy
Contraceptive Agency Scale helps
November 1, 2022 6 minutes read
Counseling patients on their contraception choices has always been difficult, but the stakes are higher now in the post-Roe era. New research about provider bias and empowering women to make their own decisions suggests ways to improve contraception counseling.
“These ideas of reproductive autonomy and patient agency and trying to diminish provider bias have been increasingly under focus in the past few years,” says Cynthia Harper, PhD, professor in the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco (UCSF).
Contraceptive counseling is trickier since the Dobbs v. Jackson Women’s Health decision because of the state abortion bans that are affecting millions of reproductive-age people across the United States. Healthcare providers may feel even more compelled to steer women toward the most effective forms of contraceptives, even if those are not the methods patients initially had in mind. But they need to resist this temptation.
“What it ultimately comes back to is the same thing: We need to provide care that is consistent with the patient’s values and preferences,” says Connie Folse, MPH, CHES, training and education manager for Beyond the Pill at the Bixby Center for Global Reproductive Health at UCSF. “Even in restrictive or hostile environments, our understanding of the realities that may face a patient who ends up with an undesired pregnancy and who is seeking to terminate, we still have to remember that our job is not to try to persuade the patient to see things differently. Any information we provide to the patient should be fact-based and neutral.”
The Contraceptive Agency Scale
A good way to assess whether providers and clinicians are eliminating bias from their contraceptive counseling is to use an evidence-based tool. For example, the seven-item Contraceptive Agency Scale (CAS) can be used to reinforce non-coercive contraceptive care.1
CAS was developed by researchers who were looking for a rigorous standardized measure to evaluate the effect of an intervention or to monitor care in a clinical setting. The goal was to ensure patients are making their own decisions about which contraceptive to use, says Corinne Rocca, PhD, MPH, a professor in the department of obstetrics, gynecology, and reproductive sciences at UCSF School of Medicine. Rocca also participates in the research group Advancing New Standards of Reproductive Health.
“I’m trained as a psychometrician,” Rocca says. “I partnered with Cynthia Harper, who was interested in improving contraceptive access.” A notable element on their study of a psychometric measure of contraceptive decision-making was that they made sure the items on the scale came from patients, she adds.
CAS is built on patients’ voices about their experiences in clinical encounters. “It asks seven simple questions about their decision making,” Harper notes.
CAS includes these seven items:
- “My provider would be open to me trying different birth control methods.”
- “I feel that my provider would support me if I wanted to stop using birth control.”
- “My provider helped me choose a birth control method that could work for me.”
- “I felt that my provider made me use a specific birth control method.”
- “My provider made me feel like I had to use birth control.”
- “My provider wanted to make my birth control decisions for me.”
- “I felt that my provider judged me for my birth control decisions.”
Each item is followed by a scale of strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree.
“Everyone agrees it’s important for patients to have agency to make their own decisions. It’s their health and life, and they’re the ones using the methods,” Harper says. “Before this scale, there was not a way to measure that in clinical practice to see if patients were indeed making their own decisions or exercising agency — or whether the provider was making decisions for them or using undue influence.”
Family planning providers could administer CAS each year during a certain week or month to assess how well their patients exercised their choices. “All providers are trying their hardest, and now we’re in this extended pandemic and might be tired, burned out, or have too high a patient load,” Harper says. “This scale can give real-time data on the patient experience, and that could help providers who might be falling short for very real reasons because of pandemic burnout or things like that.”
Providers can include patient-centered care and bias awareness in their staff training. It is more than cultural awareness. “We encourage folks to practice cultural humility as opposed to implementing a cultural competency model,” Folse says. “Cultural humility focuses on strategies to approach each person as a unique individual. Cultural competency implies you can learn about a culture and provide care based on that learning.”
Training in cultural humility includes practices of self-reflection and activities that help participants reflect on their own values around contraception and abortion, Folse explains. (For more information, see story on cultural humility training in this issue.)
“I realized midway through my career that a lot of people who work in family planning do that for the desire to prevent abortion,” Folse says. “That can influence — whether or not consciously — how they talk about different contraception options, particularly with regard to contraceptive failure.”
If a provider is highly motivated to prevent abortions, then they may feel less comfortable talking about contraceptive options with higher failure rates. They might want to promote intrauterine devices (IUDs) and implants because there is less room for user error.
“Patients don’t receive neutral counseling or receive the information they feel is important,” Folse says. “Maybe a patient is OK with less effective contraception because they know abortion is an option for them. Other patients may say effectiveness is most important to them.”
It is critical to provide care that is consistent with the patient’s priorities rather than the provider’s priorities. “That’s why we engage in self-reflection about our own values, so that we can begin to recognize how our own values could infect the counseling process,” Folse says.
Demand is increasing for provider training that improves patient care and respects patients’ preferences. “We want to meet patients where they are and serve a diverse patient population with high-quality services,” Harper says. “We use training techniques and try to raise awareness. It’s an ongoing process.”
The interactive training includes role-play. “We use expert trainers,” Harper says. “Our first request came from a public health department in Georgia. That’s when we started to develop this module.”
Researchers worked with Georgia public health officials to conduct contraceptive training in patient-centered care. One of the concerns was using limited resources efficiently.
“What happens if you’re training in how to remove IUDs or other devices, and you have a clinic that can’t afford many devices, so if someone gets it in, they need to really want it?” Harper asks. “There was training on what the patient wants is always most important.”
All training sessions are based in reproductive justice principles that center around the patient and help providers focus on the patient as the expert on their own body. Qualitative research showed that most people reported positive experiences with reproductive and contraceptive care.
“But the negative ones had a really big impact and [affected] how they seek care in the future,” Harper says. “They’re particularly harmful when connected to larger societal inequities, like racism or discrimination.”
If patients visit a clinic and do not feel respected, the impact is even greater. “We have asked people about their experiences, and most people are able to come up with an experience that was negative over their lives,” Harper says. “Throughout the reproductive life course, most people have had an experience that wasn’t optimal.”
The changes made in reproductive health and contraceptive counseling provide hope for a future in which patients’ desires are placed front and center of all counseling sessions.
“We’ve seen this big movement to respect reproductive autonomy, and now we have a way to measure this and our research interventions to make sure that is happening,” Harper explains. “We have a gauge that shows us what’s really happening in our clinical care.”
It is all part of a broader movement within the field of contraception and sexual and reproductive health to establish new ways to assess care. “We have a lot of measures, such as contraceptive use and contraceptive uptake, and they didn’t fully capture how the patient felt about their care or their experience,” Harper says. “They didn’t explain why someone might want to use another method.”
With CAS, clinicians and researchers can capture patients’ agency and other necessary aspects of care, Harper adds.
REFERENCE
- Harper CC, Rao L, Muñoz I, et al. Agency in contraceptive decision-making in patient care: A psychometric measure. J Gen Intern Med 2022 Sep 7. doi: 10.1007/s11606-022-07774-0. [Online ahead of print].
Counseling patients on their contraception choices has always been difficult, but the stakes are higher now in the post-Roe era. New research about provider bias and empowering women to make their own decisions suggests ways to improve contraception counseling.
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