Original research articleWomen's preferences for contraceptive counseling and decision making
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.
Section snippets
Methods
We conducted semistructured, in-depth interviews with adult women between January and May 2009. Women were recruited at five clinics in the San Francisco Bay Area after receiving contraceptive counseling. Four of these clinics provide primary care services, while the remaining clinic is a general obstetrics and gynecology clinic. Participation rates were not formally tracked. Selection criteria for patients were that they were black, white or Latina; over the age of 18 years; and English or
Population
Table 1 presents the characteristics of the 42 participants. White and English-speaking Latina participants were older and reported higher levels of education than blacks and Spanish-speaking Latinas; they also had the fewest number of children.
Control over contraceptive decision making
The vast majority of patients felt it was appropriate that they make the final decision about which birth control method they would use. However, most women did want providers to actively assist them in deliberating about their options and determining
Discussion
The goal of this study was to gather women's input about contraceptive counseling in order to help shape future research and programs designed to meet women's needs for quality family planning care. Our results provide guidance for contraceptive counseling research and practice regarding contraceptive decision making, interpersonal relationships and information provision.
While our results regarding decision making agree with the overall desire for autonomy found in other studies [17], [19],
Conclusion
Many patients desire active involvement of their family planning provider during the process of choosing a contraceptive method, and value intimacy and adequate information provision during the contraceptive counseling encounter. In order to accommodate a range of patient experience and desires, it is valuable for providers to adopt a patient-centered approach to counseling in which patient preferences are explicitly discussed and attended to.
Acknowledgments
This publication was supported by the Fellowship in Family Planning and by the National Center for Research Resources, the National Center for Advancing Translational Sciences, and the Office of the Director, National Institutes of Health (NIH), through UCSF-CTSI Grant Number KL2 RR024130. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. These results were presented in preliminary form at the International Conference on
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