Asking patients about their pregnancy intention might not be the best barometer for whether they want contraception.
New research revealed that women who had not had sex with a man in the last month or longer, women who said they wanted to become pregnant in the next year, and women who were ambivalent about preventing pregnancy also said they wanted contraception now.1
“It was not surprising to me that some people will be interested in pregnancy in a year even while desiring pregnancy prevention now,” says Christine Dehlendorf, MD, MAS, study co-author and a professor and vice chair for research, family, and community medicine at the University of California, San Francisco (UCSF). Dehlendorf also is the director of the Person-Centered Reproductive Health Program at UCSF. “A year is a while in the future. Today, they have different needs and desires. Maybe they’re starting a new job or planning for a life transition, like marriage.”
There are people who want pregnancy prevention now, even while planning a near-term pregnancy. Looking into patients’ future pregnancy desires does not necessarily help providers meet their immediate needs, Dehlendorf says. Clinicians should not discount a patient’s desire for a long-acting reversible contraceptive (LARC), such as an intrauterine device (IUD), even when the patient plans a pregnancy in a year.
“We have moved away from counseling based on the fact that people will have to have an IUD removed in a year or that it’s not cost-effective,” Dehlendorf says. “If they want it, we should give it to them, even if it’s going to be removed in a shorter period of time.”
For some patients, an IUD is a good option for contraception before they plan to attempt pregnancy because an IUD allows a quick return to fertility, Dehlendorf notes.
The results also highlight the responsibility of providers to counsel all patients on contraception, even if they are talking about pregnancy planning.
“We’re missing people who want pregnancy prevention now,” Dehlendorf says. “We have to recognize that taking that future-oriented perspective about what they might need may not be patient-centered care.”
Instead, clinicians should ask patients about their thoughts and feelings about pregnancy. The traditional pregnancy planning framework is dated and was not based on how people think about reproduction and the possibility of pregnancy, Dehlendorf says. “For some people, an unexpected pregnancy is a happy accident,” she notes. “By treating all unplanned pregnancies as bad and all planned pregnancies as good does not acknowledge the different ways people think about pregnancy in their lives.”
Asking patients whether they want to become pregnant within the next year implies they should have a “yes” or “no” answer, and they often do not have one, she says.
Dehlendorf and colleagues found that 70% of patients said they did not want to become pregnant within the next year. Ten percent said they did want to become pregnant, and 20% were ambivalent. Among the respondents who said they wanted to become pregnant in the next year, 30% reported they wanted to prevent pregnancy now, and 6% were ambivalent.
Respondents to the study’s survey were asked the key question, “Do you want to get pregnant in the next year?” They could answer “yes,” “no,” or “unsure.”
Researchers also asked respondents “Do you want to prevent pregnancy now?” with the following answer choices:
- “Yes, I am already doing something to prevent pregnancy.”
- “Yes, I want to start preventing pregnancy.”
- “No, I don’t want to prevent pregnancy.”
- “I am unsure whether I want to prevent pregnancy.”
Quick questions like these play a role in contraceptive discussions but should not be substituted for contraception counseling. “The screening questions have a different role than in-depth conversation,” Dehlendorf says. “Screening questions are designed to help figure out what conversation you should be having to meet people’s needs. Absolutely, they are not the end of the conversation, but entry to the conversation.”
Providers should follow up on patients’ affirmative answers with a conversation about what they would like for contraception. “Patients want to have their needs met. They want to be asked what their service needs are,” Dehlendorf says. “Asking direct questions is valuable. Some patients want to talk about their future desires around pregnancy and reproduction, and others do not.”
Clinicians should meet patients where they are regarding privacy and sharing information. “Our job is to meet their needs with medication, contraceptives, and treatment but not to expect them to share their inner lives with us,” Dehlendorf says.
Contraceptive counseling is particularly sensitive after the Dobbs decision. The potentially greater need for contraception does not diminish the need for providers to understand and counsel according to the principles of reproductive justice and patient-centered care.
“We’ve definitely seen nationwide indications that patients are aware of restrictions on their reproductive autonomy where abortion is not available, and that influences people’s decisions on reproduction, including increases in sterilization in earlier ages,” Dehlendorf notes. “It’s important we be very careful to not provide directive counseling for patients around highly effective methods or sterilization when people don’t have access to abortion.”
The clinician’s role is to provide patients with information about their options and to prevent contraceptive coercion in the post-Roe era. “We need to move toward patient-centered models of care that recognize the range of different ways in which people experience their reproductive lives, and we need to meet their needs accordingly,” Dehlendorf says.
REFERENCE
- Wingo E, Dehlendorf C. Lack of pregnancy intention or interest in pregnancy prevention now? How best to screen for desire for contraceptive care. Contraception 2023:110303. doi: 10.1016/j.contraception.2023.110303.
[Online ahead of print].
Asking patients about their pregnancy intention might not be the best barometer for whether they want contraception. New research revealed that women who had not had sex with a man in the last month or longer, women who said they wanted to become pregnant in the next year, and women who were ambivalent about preventing pregnancy also said they wanted contraception now.
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