Women's preferences for contraceptive counseling and decision making

Abstract

Background

Little is known about what women value in their interactions with family planning providers and in decision making about contraception.

Study Design

We conducted semistructured interviews with 42 black, white and Latina patients. Transcripts were coded using modified grounded theory.

Results

While women wanted control over the ultimate selection of a method, most also wanted their provider to participate in the decision-making process in a way that emphasized the women's values and preferences. Women desired an intimate, friend-like relationship with their providers and also wanted to receive comprehensive information about options, particularly about side effects. More black and Spanish-speaking Latinas, as compared to whites and English-speaking Latinas, felt that providers should only share their opinion if it is elicited by a patient or if they make their rationale clear to the patient.

Conclusion

While, in the absence of medical contraindications, decision making about contraception has often been conceptualized as a woman's autonomous decision, our data indicate that providers of contraceptive counseling can participate in the decision-making process within limits. Differences in preferences seen by race/ethnicity illustrate one example of the importance of individualizing counseling to match women's preferences.

Introduction

Underuse of effective contraception is one factor which contributes to high rates of unintended pregnancy in the United States [1], [2]. While contraceptive use is affected by a complex network of factors including access to medical care, lack of insurance coverage and patient knowledge, patient–provider communication is another important factor to consider. Health communication is regarded as an important marker of quality of care by the Institute of Medicine [3] and is associated with patient outcomes [4], [5].

Observational studies support the importance of the provider–patient relationship in family planning care, with associations between satisfaction with interpersonal aspects of care and contraceptive use and continuation [6], [7], [8]. Despite the importance of the provider–patient relationship, attempts to improve contraceptive use through counseling interventions have had limited success [9]. One possible reason is a lack of research regarding what women value in their interactions with family planning providers.

One area of communication with relevance to family planning is control over the decision making process. In the health communication literature, studies have found that many patients prefer shared decision making, in which both the provider and the patient contribute to the choice of medical treatments [10]. There are variations in preferences, however, with some patients preferring to make decisions autonomously and others to have the health care provider make decisions for them [10], [11]. Furthermore, there appears to be intraindividual variation in decision-making preferences depending on the specific health care decision [12]. Regardless of the specific preference, studies have suggested that providers who facilitate the patient's preferred model of decision making may improve patient outcomes [13].

In the field of family planning, there has been an emphasis on the autonomous, or “informed choice,” model of decision making [14], [15], [16], in which the provider's role is to provide objective information to the patient in order to facilitate her choice of a contraceptive method after assessing for medical contraindications to specific methods. While the provider may personalize the information in order to be most relevant to the needs of the patient, he or she does not participate in the process of selecting the method, which is seen as solely the responsibility of the patient. It is unknown whether this autonomous model of decision making meets women's needs in choosing a contraceptive method. Previous qualitative studies have indicated that women value autonomy in contraceptive decision making, but have not investigated the details of the decision making process and the appropriate level of provider involvement [17], [18]. A recent study about decision making around contraception in the United States found that women were significantly more likely to prefer autonomous decision making about birth control than other medical issues [19]. However, there was substantial variation in preferences, with 50% of women desiring some input from their provider.

This study aims to assess patients’ preferences about birth control counseling, with a focus on the decision-making process, with the goal of informing future efforts to devise counseling interventions aimed at improving contraceptive use.

In considering provider–patient communication about contraception, an additional factor to take into account is the race and ethnicity of the patient. African–Americans and Latinas may be more distrustful than whites of the health care system [20], and given the historical connection of some coercive family planning programs with racist beliefs [21], these concerns could be amplified in the context of contraception. Given the significant racial and ethnic disparities in unintended pregnancy in the United States [22], any differences in how minority patients experience contraceptive counseling and contraceptive decision making are of particular interest in studies of provider–patient communication.