Assess for Pregnancy Intentions
Pregnancy intention screening may take different forms depending on the patient’s needs and the relationship between the patient and her/his clinician. Regardless of the format, pregnancy intention screening should be patient-centered.
- Screen for pregnancy intention as part of initial continuing health assessments. Pregnancy intention screening/counseling should assess the patient’s current desire to become pregnant.1-4
- Routinely ask patients about satisfaction with their current method and extent to which current method aligns with pregnancy intention. Method satisfaction is a key factor associated with continuation/discontinuation.2-4
- Recognize that pregnancy intentions are often complex and multi-dimensional.
- Many patients experience ambivalence regarding pregnancy and parenting desires.
- Facets of pregnancy intention may include the strength of patient’s motivations in avoiding pregnancy, their expected emotional reaction if s/he were to become or cause their partner to become pregnant, and the perceived support of the partner.1-4
- Provide preconception and/or contraception services, based on the patient’s pregnancy intention, during the current visit, in subsequent visit(s), or through coordinated referral.1-6
- Some populations, such as males, adolescents, and LGBT patients, may be less likely to receive pregnancy and parenting intention screening in a typical clinic setting.
- Research on the effectiveness of existing pregnancy intention screening tools and methods among special populations is ongoing but limited. Some adaptation may be necessary to ensure that screening is culturally appropriate and patient-centered.
Several pregnancy intention screening tools are used in different clinical and non-clinical settings. Numbers one and two below are the most commonly-recommended tools.
- One Key Question®, developed by the Oregon Foundation for Reproductive Health and strongly supported by the Oregon Health Authority: http://www.onekeyquestion.org
- Reproductive life plan resources, Centers for Disease Control and Prevention, Preconception Health and Health Care: http://www.cdc.gov/preconception/reproductiveplan.html
- Motivational Interviewing (MI) can be applied to contraception counseling. https://www.arhp.org/uploaddocs/Client%20Centered%20Contraception%20Counseling%20.pdf
- Providing Quality Family Planning Services (QFP), Recommendations of CDC and U.S. Office of Population Affairs, 2014, pages 5-7: http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
- Before, Between and Beyond Pregnancy, The National Preconception Curriculum and Resources Guide for Clinicians: http://beforeandbeyond.org/toolkit
- Preconception health and health care, resources from the Centers for Disease Control and Prevention: http://www.cdc.gov/preconception/index.html
Counseling and Education
Counseling that is respectful of, and responsive to, individual patient preferences, needs and values. This approach saves time and encourages patient decision-making and responsibility.
Effective contraceptive counseling and education is a two-way process. By asking questions and listening to what patients
say, we experience bi-directional learning. Patient-centered counseling benefits patients because it addresses their concerns, focuses on their needs and results in positive health outcomes. It benefits clinicians by saving time, decreasing stress and frustration, and increasing effectiveness and professional engagement.
A range of factors can influence a patient’s choice of a contraceptive method. Personal preferences, relationship characteristics, social influences, pregnancy intentions, and cultural considerations may affect the decision-making process. The contraception care provider has an important role in assisting patients with their decisions. First, by listening to the patient—eliciting concerns, interests and goals related to pregnancy prevention. Then, by providing clear and accurate information about the full range of contraceptive options, emphasizing those most aligned with patient-expressed desires.
- Ensure clinical proficiency with one or more evidence-based or nationally endorsed patient-centered counseling techniques and approaches. Examples include:
- The Five Principles for Providing Quality Counseling, as laid out by the Center for Disease Control and the Office of Population A airs in Providing Quality Family Planning Services.1
- Teach-Back Method: a practice based on the health literacy principles of plain language that confirms patient understanding and improves patient outcome. This method is also effective in ensuring the clinician can explain back to the patient what the clinician heard regarding the patient’s preferences.2
- O.A.R.S.: a skills-based model of interactive techniques adapted from a patient-centered approach, using motivational interviewing principles.3
- PC2 You Decide: a five-step approach to guide clinicians in helping patients choose a new contraceptive method, understand cardiovascular risks associated with combined hormonal methods, and address patient concerns.4
- Offer annual training and resources that maintain clinician knowledge and understanding of all FDA-approved contraceptive methods. Ensure contraceptive counseling reflects current practice standards.5,6,7
- Ensure clinicians have access to the most current versions (print and/or electronic) of the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 and the U.S. Selected Practice Recommendations for Contraceptive Use, 2013 for all contraceptive counseling and education providers.5,6
- Consider training on the tiered approach to counseling. In this approach, the most effective, reversible long-acting methods are presented before less effective methods, and include methods that may not be available on-site. Tiered counseling should start at the patient’s experience level and be based on their stated preferences and goals. It is particularly important to be mindful of historic experiences of coercion and forced sterilization among communities of color and other vulnerable populations.
- As a result of counseling and education training and resources offered, clinicians should be able to demonstrate the following skills.8
- Establish rapport: The ability to establish rapport and gain insight into the patient’s personal circumstances and challenges can help the clinician to individualize information and guidance.
- Engage patients as partners in their own care: The ability to engage the patient in developing a plan that includes setting goals, discussing possible difficulties and challenging situations, and considering backup plans and follow-up (see Component 2.8: Patient Support for Contraceptive Management).
- Use education and decision aids: Appropriate use of decision aids (paper or computer-based) during the counseling visit to help patients self-assess, learn about methods, and develop questions for the clinician.
- Build trust: Competent interpersonal skills that build trust allow for greater insight into the patient’s cultural and personal context.
- Interpersonal communication skills: Nonjudgmental listening and empathy can be especially important in sexual health discussions.
- Offer training in Implicit Bias in addition to Cultural Competency. Consider innovative approaches to understanding implicit biases of clinicians, such as videotaping encounters to analyze for patterns and examining relevant data (e.g., examining contraceptive methods used by patients of different racial and ethnic backgrounds across individual clinicians to see whether there are differences in method provision).
- Competencies 1.3 Special Populations/Diversity and 1.4 Language/Health Literacy/Communication include strategies and resources related to the provision of culturally and linguistically appropriate counseling and education services.
- Providing Quality Family Planning Services (QFP), Recommendations of CDC and U.S. Office of Population Affairs, 2014, Appendix C – Five Principles for Providing Quality Counseling and Appendix E – Strategies for Providing Information to Clients: www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
- Teach-Back Method: http://www.teachbacktraining.org
- The OARS Model, Essential Communication Skills, Center for Health Training, 2010: http://www.oregon.gov/oha/ph/HealthyPeopleFamilies/ReproductiveSexualHealth/Documents/edmat/OARSEssentialCommunicationTechniques.pdf
- PC2 You Decide: A Five-Step Approach to the personal choice interview, risk assessment, and patient education with regards to cardiovascular risks associated with hormonal contraception: https://www.uchoosebaltimore.org/clientproviderguides
- Centers for Disease Control and Prevention, Reproductive Health, US Selected Practice Recommendations (US SPR) for Contraceptive Use, 2013: http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usspr.htm
- Centers for Disease Control and Prevention, Reproductive Health, US Medical Eligibility Criteria (US MEC) for Contraceptive Use, 2016: https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html
- Dehlendorf C, Krajewski C, Borrero S. Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use. Clin Obstet Gynecol 2014 Dec; 57(4):659-73.
- Oregon Health Authority, Public Health Division, Reproductive Health Program, Client-Centered Counseling Models and Re- sources, 2013: http://www.oregon.gov/oha/ph/HealthyPeopleFamilies/ReproductiveSexualHealth/Documents/edmat/Client-CenterCounselingModelsandResources.pdf
- Rachel L. Johnson, Debra Roter, Neil R. Powe, Lisa A. Cooper. Patient Race/Ethnicity and Quality of Patient–Physician Communication During Medical Visits. Am J Public Health. 2004 December; 94(12): 2084–2090.
Condoms and Vasectomy Services
in this context, refers to patients assigned male at birth who are having sex with women.
Males are increasingly recognized as a key part of preventing unintended pregnancies, as well as planning and supporting healthy pregnancies. Several strategies can be used to increase their involvement in the spacing and timing of pregnancies.
- Order condoms in bulk to receive price discounts.
- Make condoms available in restrooms and at the front desk. This allows patients access at no cost to them and without an appointment or use of clinic staff.
- Offer condoms to males and females at a variety of visit types.
- Make available various types of condoms (latex and non-latex; lubricated and non-lubricated; different sizes).
- Demonstrate to patients the best techniques for applying and removing condoms using a penile model.
- Discuss dual protection of methods (condoms provide excellent back-up to other contraceptive methods and are the only contraceptive method that also protects against the transmission of STIs).
Strategies specific to Vasectomy Services
- Obtain a memorandum of understanding (MOU) or formal contract with a partner organization to accept referrals for vasectomy.
- Ensure the MOU/contract addresses the provision of services across payer sources. Ensure the MOU/contract addresses who will perform the pre-procedure counseling; post-procedure semen analysis; and deal with any complications/emergencies.
- Provide patient with counseling on vasectomy, including the permanent nature of the method, to ensure appropriate referral is made.
- To prevent delays, obtain patient consent for sterilization using the federal sterilization consent form.
- Fax or email the signed consent form and relevant medical information to the referred clinician.
- At the time the patient requests the service, offer to call and schedule an appointment with the referred clinician.
- Follow-up on referral as described in Component 3.3: Linkages to Primary Care and/or Chronic Disease Care Management Services.
- Accept referrals for vasectomies from outside agencies and across payer sources.
- Ensure that patient instructions after the procedure include direction for after hours’ emergencies, interim contraception and post-procedure semen analysis.
- Have a system in place to obtain and follow up as needed on post-procedure semen analysis.
- Follow nationally-recognized recommendations for all aspects of the procedure.
- Ensure that referrals received are tracked. As appropriate, share information with the referring provider.
- Providing Quality Family Planning Services (QFP), Recommendations of CDC and U.S. Office of Population Affairs, 2014, pages 15 and 23: http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
- American Urology Association (AUA) vasectomy guidelines: http://www.auanet.org/education/guidelines/vasectomy.cfm
Services for Youth
a person in a period of human growth and development that occurs after childhood and before adulthood, from ages 10 to 19.
a person under the age of 18.
a person under the age of 24.
- When serving adolescents, special considerations are essential for high quality services.
- Mandatory Reporting
- Cost and Billing Transparency
- Quality adolescent services are patient-centered, respectful and developmentally appropriate.
- Youth-friendly Services
- Parent/Guardian Involvement.6
Ensure that all patients, particularly youth, are aware of the Oregon Confidential Communication Request law. This law gives patients enrolled in a private health insurance policy the right to request that protected health information is sent directly to them instead of the person who pays for health insurance.3
– Use billing procedures to maintain patient confidentiality. If this is not possible, advise the patient about the potential breach of confidentiality. Provide alternative billing options such as self-pay on a sliding fee scale.5
- Minor Rights: Access and Consent to Health Care, developed by the Oregon Health Authority Adolescent Health Program: https://public.health.oregon.gov/HealthyPeopleFamilies/Youth/Documents/minor-rights.pdf
- Advocates for Youth, Best Practices for Youth Friendly Clinical Services: http://www.advocatesforyouth.org/publications/publica-%20tions-a-z/1347–best-practices-for-youth-friendly-clinical-services
- Information regarding the Oregon Confidential Communication Request law: https://public.health.oregon.gov/HealthyPeopleFam- ilies/ReproductiveSexualHealth/Pages/Reproductive-Health-Da-ta-and-Reports.aspx. Insurance Division webpage on the law: www.patientprivacy.oregon.gov
- Providing Quality Family Planning Services (QFP), Recommendations of CDC and U.S. Office of Population A airs, 2014, page 13: http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
- CDC: A Teen Friendly Reproductive Health Visit: http://www.cdc.gov/teenpregnancy/pdf/teenfriendlyclinic_8.5×11.pdf
- Advocates for Youth Parents Sex Ed Center: http://www.advocatesforyouth.org/parents-sex-ed-center-home
Services for Postpartum and/or Breastfeeding Women
- Ensure the clinic is breastfeeding-friendly for patients and staff. Breastfeeding and postpartum women will feel more comfortable seeking services in an environment that is receptive to their needs.1
- Encourage and support access to contraception services prior to resuming sexual activity, which often may occur before the routine six-week postpartum visit. Encourage contraceptive use prior to resuming sexual activity.2,3
- Offer a broad range of methods and ensure staff can counsel and support the use of each available contraceptive method, including Lactational Amenorrhea Method (LAM).2,3
- Discuss the spacing of pregnancies and the patient’s reproductive life plan during pregnancy and in the postpartum period. Offer contraception that supports patient’s plan.2,3
- Obstetric providers should counsel pregnant women about all forms of postpartum contraception in a context that allows informed decision-making. Immediate postpartum LARC should be offered as an effective option for postpartum contraception.4,5
- Breastfeeding-friendly physician’s office: optimizing care for infants and children, 2013: http://www.guideline.gov/content.aspx?id=46908
- Association of Reproductive Health Professionals 2013, https://www.arhp.org/publications-and-resources/quick-refer-ence-guide-for-clinicians/postpartum-counseling/contraception
- US MEC revisions for postpartum contraception, 2011: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6026a3.htm
- The American College of Obstetricians and Gynecologists. Committee Opinion on Immediate Postpartum Long-Acting Reversible Contraception, 2016: https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co670.pdf?dmc=1&ts=20160826T1311208590
- Health Evidence Review Commission (HERC) Coverage Guidance: Timing of Long-Acting Reversible Contraceptive (LARC) Placement, 2016: http://www.oregon.gov/oha/herc/Coverage- Guidances/LARC-CG.pdf
Broad range of FDA approved methods:
includes a choice of combination oral contraceptives (phasic and monophasic), at least one non-oral combination contraceptive (ring or patch), a progestin-only pill and injectable, IUD and IUS, sub-dermal implant, latex and non-latex male condoms, female condoms, two types of spermicide, diaphragm or cervical cap, Fertility Awareness Method (FAM), emergency contraception pills (ECP) for immediate use, information about abstinence and withdrawal, and information and referral for sterilization.
on the premises, such as in the clinic, in the building or on the campus, so that a patient does not have to travel to another location such as a separate retail pharmacy.
Contraceptive choice is an important aspect of quality care as patients may be more likely to select a method that fits her/his unique circumstances.
- Provide a broad range of FDA-approved methods available on- site or by referral.2
- Administer EC for immediate use on-site according to proven efficacy guidelines for appropriate weight and body mass index (BMI).3,4
- Dispense up to a one-year supply of FDA-approved methods on-site. Dispensing a one-year supply of pills is associated with a 30% reduction in the odds of conceiving an unplanned pregnancy, compared with dispensing just one or three packs.5
- Providing Quality Family Planning Services (QFP), Recommendations of CDC and U.S. Office of Population A airs, 2014, page 13: http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
- Broad range of FDA approved contraceptive methods as de ned in the Oregon Health Authority Reproductive Health Program Manual, Section A.6: http://public.health.oregon.gov/HealthyPeo- pleFamilies/ReproductiveSexualHealth/Resources/Documents/ FP_Program_Manual/sectiona.pdf
- Association of Reproductive Health Professionals. 2011. Update on Emergency Contraception: http://www.arhp.org/Publica-tions-and-Resources/Clinical-Proceedings/EC/Methods
- EC: Challenges and Choices. Algorithm for Dispensing Emergency Contraceptives Rapkin, R.B., Creinin, M. OBG Management 2011; 23(8): slides 16-24: http://www.ctcfp.org/wp- content/uploads/EC-Challenges-Choices1.pdf
- Number of Oral Contraceptive Pill Packages Dispensed and Subsequent Unintended Pregnancies Foster, Diana Greene PhD; Hulett, Denis; Bradsberry, Mary; Darney, Philip MD, MSc; Policar, Michael MD, MPH Obstetrics & Gynecology: http://journals. lww.com/greenjournal/Fulltext/2011/03000/Number_of_Oral_ Contraceptive_Pill_Packages.8.aspx#
Contraceptive Procedures: LARC Insertion/Removal and Diaphragm Fitting
- Remove barriers/delays to receiving LARCs. For example, do not require Pap test or negative STI results for asymptomatic patients prior to inserting LARCs.1
- Train staff on insertion/removal procedures for all LARCs (including assistive staff). Offer annual LARC update training.1
- Arrange mentorship programs for clinic staff and provide mentoring for outside clinicians.1
- Encourage single-day insertion appointments.1,2
- Maintain an adequate supply of LARCs to ensure same-day availability and use of Paragard® as EC.1,2
- Train staff on diaphragm fitting. Offer Caya® as an alternative diaphragm that doesn’t require fitting.
- Stock and dispense spermicidal formulation appropriate for use with a diaphragm.
Patient Support for Contraception Management
Many of the strategies and resources recommended in Component 2.2: Counseling and Education are relevant to this Component. The strategies below are also recommended to support patients and their use of contraception.
- Provide education for contraceptive methods that are based on the patient’s stated needs and priorities.
- Include medical contraindications as appropriate, prior to initiation and throughout reproductive health care, as patient lifestyle, reproductive goals, medications/ contraindications and side effects will change.1,2,3,6
- Use decision aids and a tiered counseling approach for nonjudgmental, accessible patient problem-solving. This will increase effective adoption, change, and maintenance of contraception of choice.1,2,3,4,6
- Co-create a patient-centered plan for contraceptive choice using the highest degree of consistent correct use of method.1,2,3
- Confirm the patient’s understanding of their method of choice.
- Address safety concerns and how to contact the clinic when they have questions or concerns.
- Ensure that all clinics have a 24-hour call-back policy for patient telephone calls about contraceptive concerns. Communicate this to the patient.1,2,3,5
- Create a follow-up plan to sustain the method (follow-up visit in three months, IUD check appointment in six weeks, etc.).
- Encourage immediate contact with the clinic about concerns, uncertainty about maintaining methods as planned, adjustments, and emergency contraception as needed.1,2,3,4,7
- Use effective reminders such as text messages or reminder cards for Depo shots or refills.1,7
- Train staff as to how they will route triage calls from patients with contraceptive questions, or who need emergent care or to make a follow-up appointment.1,6
- For example, will staff send calls to one person or is everyone trained?
- Maintain staff supports for providing quality contraceptive care: updated evidence-based training on methods, standing orders for RNs to dispense methods, updated clinic reference resources (e.g. QFP, Contraceptive Technology, etc.).1,2,3,6
- Providing Quality Family Planning Services (QFP), Recommendations of CDC and U.S. Office of Population A airs, 2014, pages 7-13: http://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
- Association of Reproductive Health Professionals – contraceptive decision-making tool: http://www.arhp.org/methodmatch
- World Health Organization – evidence-based contraceptive decision-making tool: http://www.who.int/reproductivehealth/pub- lications/family_planning/9241593229index/en
- National Campaign to Prevent Teen Pregnancy – clinician tool with tips to improve contraceptive use: http://thenationalcam- paign.org/resource/careful-current-and-consistent
- Center for Evidence Based Practice-Case Western Reserve University – introduction to motivational interviewing: https://www.centerforebp.case.edu/practices/mi
- References for understanding and problem-solving issues (e.g. irregular bleeding) related to specific methods:
- U.S. Selected Practice Recommendations for Contraceptive Use, 2013: adapted from the World Health Organization selected practice recommendations for contraceptive
use, 2nd edition. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion. MMWR Recomm Rep 2013;62:1–60. [PubMed] [Full Text]
- Hatcher, R.A., et al., (20th ed.) (2011). Contraceptive Technology. Ardent Media, Inc.
- Dickey, Richard, P., (15th ed.) 2014. Managing Contraceptive Pill Patients. Fort Collins, CO: Emis Medical Publishers
- U S. Medical Eligibility Criteria for Contraceptive Use, 2010. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep 2010;59(RR-4):1–86. [PubMed] [Full Text]
- Understanding and using the U.S. Medical Eligibility Criteria For Contraceptive Use, 2010. Committee Opinion No. 505. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:754–60. [PubMed] [Obstetrics & Gynecology]
- Bedsider – method finder tool and appointment reminder services: www.bedsider.org