Commentary Contraception

Improving Contraceptive Counseling by Listening to Women’s Voices

Dr. Kristyn Brandi & Dr. Pooja Mehta

Could the benefits of long-acting reversible contraceptives—and the way we as providers emphasize these benefits—be paradoxically limiting choices for women seeking to space or prevent pregnancy?

As obstetricians and gynecologists, we often talk to our patients about the benefits of long-acting reversible contraception (LARC) such as intrauterine devices (IUDs) and implants. They are safe and effective, easy for patients with busy schedules and lives to use, and can be used to space wanted pregnancies or protect from unwanted pregnancies for up to years at a time.

But could the benefits of LARC devices—and specifically the way we as providers emphasize these benefits—be paradoxically limiting choices for women seeking to space or prevent pregnancy? Leaders in the reproductive justice movement might argue yes, citing a time in the not-so-distant history of U.S. medicine when doctors had full license to sterilize anyone whom they felt should be done reproducing, as well as the existence of coercive programs such as one that tied shorter jail sentences to LARC use.

To explore the question of whether unintended coercion by providers takes place during critical health-care moments, we turned to the greatest experts of all—our patients. We interviewed 31 women soon after they received care for an undesired pregnancy, to better understand any conversations about contraception they had with providers over the course of their care. These interviews were then analyzed using rigorous methods to ensure balanced interpretation, recognizing the limitations of such a small study. For example, we knew we would not learn about how applicable the perspectives we obtained in such a small, specific group would be to larger or different populations in other parts of the country.

Some of our findings disappointed us. While most of our participants described feeling very satisfied with their care overall, about half told us they had experienced some form of pressure from a provider to choose a contraceptive method, most commonly a LARC method. When these women described the specific moment they felt pressure, it often manifested as a feeling that they were not being told about all of their contraceptive method options, or a feeling that they had to choose an option right away.

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“[I felt] kind of, like, pressured to get it. Which made me not want to get it. Because if I feel pressured in doing something I’m just not going to do it,” one participant told us.

On the other hand, many women felt empowered and supported by their providers. The most satisfied participants described having been presented all of their options equally in a comfortable and open environment, with thorough discussion of risks and benefits and often with decision aids like charts and pamphlets to help them see a range of options at once. They also described appreciating being given opportunities to deliberate on their decision and not feeling pressure to choose that day.

In sharing their stories, these participants also told us something that other studies have reinforced, and that many providers who are women themselves likely already know: effectiveness of a birth control method is often not the primary reason that individuals make a decision about how to space or prevent a pregnancy. Rather, our participants prioritized factors such as side effects, physician or friend recommendation, cost, and convenience.

Perhaps the most startling result of our study was that some women perceived that their providers wanted their patients to use contraception chiefly because providers themselves may have been biased against abortion. “[They try] to prevent another abortion,” one participant reflected. “It’s their jobs, but I feel like some people have their own beliefs that [abortion] is not something that should be done.”

In fact, a growing body of evidence explores potential stigma faced and felt by abortion providers in today’s polarized cultural and political conversation around abortion. It should not surprise us at all that challenges to accessing safe abortion care may also affect abortion providers—disproportionately women themselves—in ways that potentially affect care. The research of Dr. Lisa Harris and others tells us that abortion providers overall are very satisfied in their work, but those who have experienced abortion stigma have lower job satisfaction rates, higher job burnout, and higher compassion fatigue.

Our study participants spoke out during a critical moment in their lives to tell us what works and doesn’t work for them in conversations around contraception. When we take the lessons these women shared and place them into context with our collective history, it seems more important than ever that we do not let prevailing political narratives enter into the counseling we offer our patients. Indeed, we have been down that path before, during some of the most shameful moments in the history of American medicine.

New tools and strategies offer a path forward for finding innovative and efficient ways to make offering a menu of options the default, for trusting our patients to choose what is right for them, and for measuring quality of care by the range of choices offered or explained. Let’s hear what our patients are telling us—and resist a subtle rhetoric of restriction and judgment that may trickle down from politics into clinical care and facilitate unintentional coercion.

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