Contraceptive Technology Update asked a Veterans Affairs researcher about her new study involving data on women veterans and contraceptive counseling.1 Lisa Callegari, MD, MPH, a core investigator at the Veterans Affairs (VA) Health Services Research and Development Center of Innovation at VA Puget Sound Health Care System and an associate professor in the department of obstetrics and gynecology at the University of Washington, responded to questions via email.
CTU: Please describe your study and why it is important to measure the quality of contraceptive counseling.
Callegari: We used data from a national survey of women veterans seen in the VA healthcare system to report on veterans’ perceptions of contraceptive counseling. Before now, there were data from small, qualitative studies on contraceptive counseling quality within VA, but ours is the first to provide quantitative data from a large national sample of veterans.
The questions in our survey get at a few dimensions of counseling quality. First, they ask about person-centeredness of care, including whether a provider listened carefully to a person’s questions or concerns about birth control and whether a provider asked which birth control a person thought was best for them. Both of these questions assess whether clinicians incorporated individuals’ preferences and concerns in the conversation, which is really at the heart of a person-centered approach.2
The survey also asked whether providers talked about more than one option and the pros and cons of multiple options. Generally, guidelines recommend that clinicians offer information about a range of options so that patients have full information to develop informed preferences and make informed decisions.3 That said, there also can be cases where individuals only want information about one method. In those cases, it could still be person-centered care to discuss only one option.
Measuring contraceptive counseling quality, including whether counseling is person-centered, is critical for health systems like VA to ensure that they are meeting the reproductive health needs of the population they are serving. VA serves a highly diverse population, with complex medical and psychosocial needs. Data clearly shows that people in marginalized groups, including BIPOC [Black, indigenous, and people of color] and low-income individuals, often receive worse quality counseling, which can include pressure to use contraception or pressure to use certain methods.4-7
This ultimately leads to poor outcomes, including broken trust with providers and method discontinuation. High-quality, person-centered counseling is essential to protect reproductive autonomy and ensure that all individuals can choose the methods they prefer.
CTU: You found that only 62% of participants strongly agreed that their provider asked them which method they thought was best. What can reproductive health providers and clinics do to ensure that every patient feels their perspectives are heard and valued?
Callegari: Identifying what matters most to patients about their contraceptive method and identifying their preferences for different attributes of methods is necessary for a person-centered approach. We saw in our study that a large proportion of patients didn’t feel their provider assessed what they thought was best for them, which is concerning. Simple questions such as, “Do you have a sense of what is important to you about your birth control method?” or “Do you have a sense of what you are looking for in a birth control method?” can really help providers elicit patient preferences and focus the conversation on helping patients best identify the methods that align with those preferences.
CTU: In your research, what did you identify as some of the most important opportunities to improve the quality of contraceptive counseling with VA primary care settings?
Callegari: Clearly, we saw opportunities for providers to do a better job of finding out what matters to patients and what [methods they think] are best for them. We also saw that only 44% of veterans strongly agreed that their providers talked to them about the pros and cons of different methods.
While some people may have only preferred to hear about one method, many people will want a broader conversation about their options and side effects. VA providers may have room to improve here. Person-centered job aids or charts, such as the ones provided by the Reproductive Health National Training Center, can be really helpful for walking patients through pros and cons and possible side effects.
CTU: Is there anything else about the study and its findings that you would like to express?
Callegari: This study is an important first step in understanding counseling quality in the VA, but there’s more work to be done. Since this survey was fielded, some exciting new measures have been developed and validated to assess person-centered contraceptive counseling quality. For example, the four-item Person-Centered Contraceptive Counseling (PCCC) measure has been endorsed by the National Quality Forum and added to the National Survey of Family Growth to measure trends in counseling quality over time.8 I’d really like to see the VA incorporate the PCCC measure on a systems level to capture veterans’ perspectives as it continues to work on improving contraceptive care quality and equity.
REFERENCES
- Callegari LS, Mahorter SS, Benson SK, et al. Perceived contraceptive counseling quality among veterans using VA primary care: Data from the ECUUN study. J Gen Intern Med 2022;37:698-705.
- Dehlendorf C, Fox E, Sobel L, Borrero S. Patient-centered contraceptive counseling: Evidence to inform practice. Curr Obstet Gynecol Rep 2016;5:55-63.
- Gavin L, Moskosky S, Carter M, et al. Providing quality family planning services: Recommendations of CDC and the U.S. Office of Population Affairs. MMWR Recomm Rep 2014;63:1-54.
- Gomez AM, Wapman M. Under (implicit) pressure: Young Black and Latina women’s perceptions of contraceptive care. Contraception 2017;96:221-226.
- Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: Perceptions of young adult women. Am J Public Health 2016;106:1932-1937.
- Gubrium AC, Mann ES, Borrero S, et al. Realizing reproductive health equity needs more than long-acting reversible contraception (LARC). Am J Public Health 2016;106:18-19.
- Thorburn S, Bogart LM. African American women and family planning services: Perceptions of discrimination. Women Health 2005;42:23-39.
- Dehlendorf C, Fox E, Silverstein IA, et al. Development of the Person-Centered Contraceptive Counseling scale (PCCC), a short form of the Interpersonal Quality of Family Planning care scale. Contraception 2021;103:310-315.
Contraceptive Technology Update asked a Veterans Affairs researcher about her new study involving data on women veterans and contraceptive counseling.
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