This article originally appeared as an editorial in the September 2009 volume of the journal Contraception.
Create a compelling image that represents a promising concept, and people are more likely to discover it, understand it, identify with it and support it. Add context with an obvious and compelling strategy, some significant resources and a pressing need — reducing unintended pregnancy rates in the US as soon as possible, for example — and you have great potential for rapid and sustainable success.
Picture a highly educated, well-trained, exceedingly competent and empathetic clinician who is steeped in knowledge about the nuances of family planning and effective patient care. This positive image represents an obtainable goal for primary care clinicians.
Even better, it directly links to a deceptively simple idea we can all support: Commit the required resources — right now — to dramatically expand reproductive health education for all clinicians during their academic training and throughout their careers.
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This concept provides a crucial, immediate pathway toward healthy, planned families in the US and around the globe while building on the growing body of published research in the field. Bottom line: a tightly knit, highly trained, culturally sensitive cadre of health care professionals can make a real difference in the health and safety of the general public and can have a major impact on unintended pregnancy rates.
Unfortunately, the majority of primary care clinicians are not getting the training in reproductive health and family planning they need in order to provide the best possible patient care. This education should include the linked issues of contraception, sexuality, abortion, HIV and sexually transmitted infections, pregnancy, and maternal and child health, among others. Our challenge is to make the image of the well-trained clinician a reality for all members of the reproductive health care team.
The time is right to transform provider education in reproductive health and family planning. A perfect storm of societal, political, economic and health care-related issues has converged in the US in particular, reinforcing the need to invest in education for all members of the health care team, including physicians, advanced practice clinicians, pharmacists, nurses, educators, counselors and other professionals.
The president has challenged all Americans to work together to help reduce the need for abortion by, among other complementary goals, reducing unintended pregnancies in the US. Those of us who work in family planning and reproductive health have heard this call before, and it will be a true challenge to loosen the very deeply planted ideological heels of pro- and antichoice advocates. The administration is on solid ground with a long, thoughtful list of goals and a challenge to focus on realistic steps that can be taken quickly. The answer will likely involve a number of comprehensive new initiatives that build on and enhance some of the excellent work already being done in the reproductive health field, while retaining an individual woman’s right to choose when, where and how to have children. With notable exceptions, most of that work involves bringing evidence-based, comprehensive reproductive health care to the patients who can benefit most.
For clinicians to play their part in reducing unintended pregnancies, we must rapidly expand our efforts to combine the best clinical and behavioral science available and to creatively translate this data into innovative provider education. Much of the foundational research we rely on for effective clinical practice is funded by the federal government through the National Institutes of Health and other US health agencies. We must continue to support investment in new research and innovative programs that address gaps in reproductive health practice. But we cannot stop there. We miss the point of scientific data collection and analysis if it is not effectively, assertively and widely translated into clinical practice on the ground with the ultimate goal of improving patient care. With a bold investment of resources into clinician education during their academic training years and throughout their careers, we can improve reproductive health care — including family planning — and contribute significantly to the reduction of unintended pregnancy rates in the US.
Of course, this work will not exist in a vacuum. The investment in provider education will only work in concert with an equivalent surge in new research, health care reform, patient education and advocacy, and a healthier economy. The concept of ramping up family planning education is only one of a handful of linked efforts that, when combined, can help reduce US unintended pregnancy rates.
This idea is not new to the core reproductive health community. For example, in 2006, the United Nations Population Fund (UNFPA) and the Program on Appropriate Technologies in Health (PATH) developed a report to help guide family planning professionals, called Meeting the Need: Strengthening Family Planning Programs.
In 1999, during his Guttmacher Award lecture at the annual clinical conference of the Association of Reproductive Health Professionals (ARHP), Dr. Daniel Mishell focused on the pressing need to expand family planning curricula at US medical schools. More recently, the National Campaign to Prevent Teen and Unintended Pregnancy and ARHP jointly convened a panel of experts to review and discuss barriers to effective contraception among young adults. After a thorough literature review and two intensive meetings, the panel concluded that there is not a clear picture in the US of the amount of contraceptive education health care providers receive at all levels of their training. Worse, it appears that much education is minimal or nonexistent, in spite of family planning training requirements in various specialties and disciplines.5 The panel recommended expanding “broadly based, well-balanced and unbiased continuing education activities where practitioners could be exposed to evidence-based information in addition to practical hands-on experiences”.
A 2007 editorial published in Contraception reports that lack of training is the number one reason cited by health care practitioners for not taking a sexual health history from patients on a routine basis, followed by clinician embarrassment and a belief that sexual health is not relevant to the patient’s visit. Reasons for the small amount of time spent on contraceptive counseling, abortion care and sexuality during training are listed as lack of time, competing curricular priorities, lack of trained faculty or appropriate training sites, and the belief that these issues are less important than training in other areas.
A review published in the Journal of Sexual Medicine reinforces these conclusions, stating that “in all countries, medical students, house staff, and practicing physicians currently receive variable, nonstandardized, or inadequate training in sexual history taking and sexual medicine assessment and treatment. There remain significant physician–patient barriers to discussing sexual issues; and patients feel that their physicians are reluctant, disinterested, or unskilled in sexual problem management. There is a knowledge gap between developments in sexual medicine and the clinical skills of practicing physicians.”
The Association of American Medical Colleges reports that only 76 of 142 medical schools in the US and Canada claim that contraception and abortion education are part of their curriculum for medical students (with about two-thirds of schools reporting).
A study of contraceptive knowledge and attitudes among residents confirms that physician knowledge about contraceptives may not be optimal and is inconsistent across primary care specialties.10 Study authors recommend that “health care providers need ongoing education about new and effective methods of contraception, including long-acting methods. Support should be given to higher education institutions to provide students in the health and medical field with evidence-based information on the latest contraceptive methods. Grants should be available so that health care providers can pursue ongoing continuing medical education on the latest contraceptive methods.”
Health professions students have been strong advocates for these changes and are asking for more reproductive health training. For example, a 2006 study published in Contraception reported that “students requested that more time be devoted to teaching contraception.” And these students could benefit from this additional training. For example, a study published in Obstetrics and Gynecology in 2008 concludes that “about half of US medical students believed that counseling their patients about safe sex will not be highly relevant to their practice.”
Our priority should be to expand research and invest heavily into its translation into academic and continuing education for all members of the health care team. For the reproductive health and family planning field, this means increasing provider knowledge, skills and understanding of contraception, family planning, sexuality, prepregnancy health, HIV and sexually transmitted infections, maternal and child health, and other issues associated with reproductive health. But it also means incorporating key research about human behavior to improve patient consultation skills, develop cultural competence and increase awareness of and sensitivity to the potential impacts of provider and patient biases on reproductive health care.
In addition to learning about family planning essentials, clinicians need to improve their communication skills with their patients. Discomfort about discussing sexuality can interfere with effective reproductive health care. A 2003 ARHP survey of women and primary care providers in the US concludes that providers can be as uncomfortable as patients when discussing specific issues such as sexuality, vaginal health, sexually transmitted infections and other related issues. Sex and sexuality must be addressed in any discussion about pregnancy prevention. An analysis published in the Journal of the National Medical Association in 2006 on sexually transmitted disease prevention programs also addresses this point, concluding that “it is essential to train all healthcare providers to lead discussions, educate patients and provide treatment in hopes that sexual health promotion will become as important as other socially accepted healthcare concerns.”
And reproductive health care, including patient counseling, can be time intensive. A 2000 report focusing on contraceptive counseling for teens concludes that “prescribing and reviewing contraceptive methods with adolescents involves a significant amount of time and resources. Health care providers need to be familiar with how teens think about sex and birth control, what their beliefs are, and how individual teens may make different choices based on their lifestyles.” It is clear that an investment in provider education on family planning and reproductive health is in order to meet these needs.
From the patient’s perspective, an untrained or unavailable health care provider can negatively impact their contraceptive care. In analysis of contraceptive use and nonuse published in Perspectives in Sexual and Reproductive Health, the authors found that many women experiencing problems with their contraceptive methods believe that contraceptive service providers are not readily available to answer method-related questions. Another study completed by Motivational Educational Entertainment Corporation in 2004 found that among a group of urban, African-American teens in the United States, experiences with the health system (including family planning services) were among the most distressing encounters they experienced with any human services system at all.
In a 2007 article on the state of US family planning published in Obstetrics and Gynecology, the authors conclude that “a comprehensive approach requires policy change to improve funding for and access to family planning…” To help lower unintended pregnancy rates in the US, we must make the image of the well-trained clinician a reality. To accomplish this goal, the time is right for significant federal investment in provider training and continuing education on reproductive health and family planning.
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