Reproductive healthcare is moving toward a more holistic understanding of reproductive autonomy. It is no longer just about pregnancy intention.
“Framing pregnancy as the only question and goal limits the conversation,” says Saskia Shuman, MHS, a doctoral candidate and assistant vice president of research operations at the Institute for Family Health in New York City.
As a new study shows, a better goal is to provide a nondirective conversation about the patient’s desire to parent and to assess how important it is for them to prevent pregnancy.1
“As a provider, what is it I need to know about my patient’s reproductive desires, and what is the timeline?” Shuman asks. “What information do they need, and vice versa?”
PATH Questions
One way to assess these needs is through the framework of Parenting/Pregnancy Attitudes, Timing, and How Important (PATH) and PATH questions. These provide a holistic approach that frames contraceptive counseling as a bigger conversation about reproductive autonomy.1
“As we noted in this publication, the PATH questions are listed by important source documents as being a good thing to use, but there hasn’t been much done on the patient and user side,” Shuman says. “The goal was to draw from the field of cognitive interviewing, used more typically in survey development. We wanted to make sure when you ask a question, and they give you an answer, it makes sense.”
PATH questions are not narrowly focused on pregnancy, intentionality, and contraception. For example, a patient is meeting with a provider, and the provider asks, “Are you satisfied with your contraceptive method?” The patient’s answer could be, “Yeah, I’m satisfied,” and that would be the end of the conversation, Shuman explains.
But taking the PATH and a holistic approach, the conversation might go like this:
Provider: “Tell me about your contraceptive desires.”
Patient: “I have an IUD, but it may need to come out in a year or two. I haven’t discussed with my partner if we’re ready or not.”
The provider then makes a quick note to ask the patient about IUD removal at the next annual visit. When the patient returns a year later, the conversation could be as follows:
Provider: “Last time we spoke, I noted that you wanted to explore your options. Tell me what you want now.”
This type of patient-centered contraceptive discussion leads to an open exploration of a patient’s thoughts and needs, rather than simply a yes-or-no answer, Shuman explains.
The PATH framework involves training. Providers who want to use the PATH will learn how to ask open-ended questions. They may take notes to follow up with the patient.
“The documentation is not the most critical piece in the moment,” Shuman notes. “That’s a lot to expect of a provider, and this research project was focused on the use of the questions — not on the best-case scenario.”
Shuman and colleagues found that participants who answered specific prompts for PATH questions demonstrated clear comprehension and were largely comfortable with the conversations. For example, one 20-year-old participant said about the PATH questions’ wording, “I think, like, it’s a pretty simple and basic question. It’s a question that’s understandable.”
Nine out of 10 participants said they would feel comfortable with their provider starting a conversation using the first PATH questions.
Shuman and colleagues used cognitive interviewing, a methodological approach, to ask people to tell them what they were thinking about when they heard the PATH questions. “We wanted to make sure they understood the questions and they could answer them in the context of a clinical visit,” she explains.
At first, there was one concern from participants. “They had some questions about why a provider would ask me these questions,” Shuman notes. “I work at an FQHC [Federally Qualified Health Center] network, which is one of the biggest FQHCs in New York state. It has primary care, mental healthcare, and dental care integrated. Because of that, and that this is qualitative, I recruited patients from within the existing network.”
The first four respondents said they had no problem answering the questions but were a little curious about why their primary care provider (PCP) would be asking them about this. “They said, ‘I don’t mind that they’re asking, but I’m a little confused,’” Shuman says. “They felt like the questions were a little far afield from primary care, which is not necessarily the case because PCPs are full-spectrum providers. But some patients have a PCP and an OB/GYN doctor, and they’re used to separating those tasks.”
For instance, one 21-year-old participant said their provider could say in an encouraging tone something like, “OK, maybe at your age we should focus a little more on birth control or other methods.”
The researchers added a preamble explaining that a patient’s physician might ask them reproductive healthcare questions to better understand and address their health needs. “Once I did that, no one brought up the same concerns,” Shuman says.
The point of person-centered healthcare is that some patients’ contraceptive needs may be met by their PCP, and others may not desire this. “It suggests that providers need to understand the needs of their patients and then adjust to them to provide what they need,” Shuman says.
REFERENCE
- Shuman S, Cason P, Manze M. Assessing comprehension of the PATH questions through cognitive interviewing. Contraception 2023 Jul 31;110135. doi: 10.1016/j.contraception.2023.110135. [Online ahead of print].
Reproductive healthcare is moving toward a more holistic understanding of reproductive autonomy. It is no longer just about pregnancy intention. As a new study shows, a better goal is to provide a nondirective conversation about the patient’s desire to parent and to assess how important it is for them to prevent pregnancy.
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