Contraception Counseling & ComplianceWHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational Grants provided by Women's Health and Education Center (WHEC)
Contraception is a women's health issue. It is about choices and human rights, not fear, guilt and shame. The negative images and concepts perceived regarding family planning and contraception in some religious and social arenas are the major factors for non-compliance and meager usage of birth control methods in many areas of the world. Unintended pregnancy is a major health problem in the United States. In the 2002 National Survey of Family Growth assessment, 1.22 million, or 31% were reported as unintended. When abortions were included, the total number of unintended pregnancies increased to 2.65 million, or 49% of all pregnancies. Contraception is not the end of life ... it is a beginning to quality of life. "Responsible" sexual behavior and family planning should be part of men's health checks as well. This will increase the compliance of various birth control methods. It takes two people to conceive. The total fertility rate analyzed according to the economic status and standard of living (set by individual countries) will be useful in determining the true successes and failures of family planning programs for each country. In reality, most successes in reducing the fertility rate are achieved in upper and middle socio-economic classes rather than in low socio-economic segments of population. It is the uninvolved that hinder the breaking of the cycle of poverty and retards overall economic growth in that country.
The purpose of this document is to help healthcare providers and women to identify their individual health care needs, and to make choices that will meet those needs. It also means that the patient has satisfied her personal preferences and arrived at the choice that best fits her life. A fundamental tenet in ethical, female-centered care is that women have a right to participate in their choice of contraceptive method. A woman who has actively chosen a method is more likely to use it consistently and correctly. Health benefits of hormonal contraception are also discussed. All contraception-methods offer health benefits in terms of reduced risk of unintended pregnancy, abortion, ectopic pregnancy, pregnancy complications, and pregnancy-related death. The help comes in focusing attention on the section of society with the most desperate needs.
Recent estimates indicate that at current fertility rates, the world population could increase to 25 billion by the end of the century. Even with an anticipated global reduction in fertility due to the increased availability of family-planning services, the world population can be expected to grow from the current 6.4 billion to almost 10 billion by 2100. According to the 2002 National Survey of Family Growth (NSFG), 62% of reproductive-aged women use contraception. The majority of these women chose traditional methods, such as oral contraceptives (OCs) or sterilization. This survey reflected an encouraging trend from the 1982 and 1995 NSFG surveys, showing an increased use of the most effective contraceptive methods. By 2002, approximately 65% of users were choosing methods with the lowest failure rates, compared with about 58% in both the 1982 and 1995 surveys. However, there was also an increase in the number of contraceptive nonusers from 35.8% to 38.1% between 1995 and 2002. In the 2002 survey, 7.4% of women who reported that they were sexually active and did not intend pregnancy used no contraception -- an increase from 5.2% in 1995. This indicates that although users of contraception are choosing more effective methods, more women are also contraceptive nonusers, and are therefore at risk for unintended pregnancy.
In addition, imperfect or inconsistent user of contraception accounts for many unintended pregnancies. Failure rates are highest among women who use methods that require an act of compliance at the time of intercourse. Decisions regarding contraception for women with coexisting medical problems may be complicated. In some cases, medications taken for certain chronic conditions may alter the effectiveness of hormonal contraception, and pregnancy in these cases may pose substantial risks to the mother as well as her fetus. The rate of permanent, irreversible sterilization in the United States has increased, especially among women in their later reproductive years. On a statistical basis, the efficacy of sterilization and long-acting intrauterine contraception appear to be comparable. Moreover, there can be an element of regret associated with an irreversible method, so it is important to ensure that patients understand all options for preventing pregnancy before proceeding with surgery. Ultimately providers must find the optimal contraceptive "fit" for each patient. This requires considering not only safety and efficacy, but also the patient's preferences. Relentless increases in the population of low socio-economic segments of the society is not unique to developing countries, it is a major problem in the United States as well.
The ever-expanding size of families on the welfare system and the non-compliance of birth control methods is a significant strain on the national resources resulting in slower growth. An organized program of contraceptive counseling provides adequate information for patients to be comfortable with their decision about their contraceptive methods. Patients are most satisfied with physician counseling. Patients rely heavily on previous experience with the contraception and are less likely to rely on the media or their own perceived effectiveness of the contraceptive method, possibly relying more heavily on the information given by the physician. Patients who receive face-to-face physician counseling rely on the physician's opinion and less on external sources of information when choosing a contraceptive method.
Individual Patients, Individual Choices:
With such a wide range of contraceptive options now available, healthcare providers face the challenge of matching each patient with the method that is best for her. Proper evaluation of the woman's individual reproductive desires, medical complications, and other health concerns is a necessary first step. Consideration should also be given to lifestyle issues and patient preferences regarding form and route of administration. Ultimately, education is the key to compliance, long-term use and success. Women's contraceptive needs change throughout the reproductive life cycle, and must be reevaluated over time. It is important to address specific concerns of young women to promote compliance. Counseling is essential to provide accurate information about the mechanisms, efficacy, and safety of available options. In addition, non-hormonal options include periodic abstinence, natural family planning with cycle maintenance, withdrawal, spermicide, sponge, male or female condom, diaphragm, cervical cap, copper-bearing IUD, and male or female sterilization. Understanding the needs and characteristics of the individual patient can help the provider to direct her toward the method that will best suit her needs in terms of efficacy, safety, and ease of use. Healthcare providers must also consider comorbidities (e.g., obesity, medical contraindications to hormonal contraception) that may influence contraceptive choice.
A number of factors influence quality of care, including amount / quality of information given, the physician's technical competence, patient-physician relationship, mechanisms used to promote continuity of care, and constellation of service available. Women generally want information about efficacy and safety, but the delivery of this information should be tailored to her level of understanding, age, and current knowledge. The provider-patient relationship is a powerful element, as the patient must reveal private information about herself. Continuity of care allows the provider to assess and promote consistency of contraceptive use. Regularly scheduled follow-up is beneficial as a woman moves through mid-life, as providers can identify and address other medical and health issues as they arise. Offering these additional medical and gynecologic services in the family-planning setting can encourage patients to stay with the provider or group, comply, and maintain a healthy, active lifestyle into menopause and beyond.
In many countries, reproductive health services do not actively include post-abortion family planning services for women who are treated for complications of unsafe abortion. This greatly increases the risk of further unintended pregnancies and unsafe abortions. Women who have had an abortion are perhaps the most at risk for future unwanted pregnancies, but their needs are usually neglected by family planning programs. A range of contraceptive methods, accurate information, sensitive counseling, and referral for ongoing care should be available to all women who have had an abortion. Acceptance of contraception or a particular contraceptive method should never be a prerequisite for obtaining abortion. It is the responsibility of policy-makers and healthcare providers to ensure that women have access to such services. Even where the laws are highly restrictive much can be done, and in some cases changes in practice are the first step towards change in policy. A woman's psychological and social needs, as well as the capabilities of the family planning service, should be taken into account in determining post-abortion contraceptive protocols. Long-term provider-dependent methods may not be appropriate if a woman is anxious, in pain or under emotional or physical duress. In addition, programs on family planning and abortion care should take into account the needs of special groups, such as adolescents and HIV-positive women seeking abortion.
Changing Needs Over The Life Cycle:
Women's contraceptive needs change throughout the reproductive life cycle, and must be reevaluated over time. The contraceptive goals of most young women are to postpone childbearing and preserve fertility, such that the mean age at first birth rose from 24.6 years in 1970 to 27.2 years in 2000 in the US. In addition, because most of the common sexually transmitted diseases (STDs) such as gonorrhea and chlamydia occur in women aged <25 years, prevention of STDs is also an important consideration for young women. Condoms provide the best protection against STDs, but are less effective in preventing pregnancy than hormonal methods. Therefore, double protection with a barrier method and a hormonal method should be recommended to most young women. However, the rising incidence of divorce leads to many older women who resume dating and who may also be appropriate candidates for STDs prevention with barrier contraception. For women who have begun childbearing, the goal may be to find contraception that preserves fertility while allowing for spacing pregnancies without complete avoidance. Most women at this stage are in monogamous, long-term relationships, so STDs are less of a concern. Choice of contraception may be determined by medical conditions and experience / degree of satisfaction with contraception in the past, as well as the number of children desired and the amount of time desired between pregnancies.
It is important to address specific concerns of young women to promote compliance. This population tolerates side effects poorly, and is susceptible to misinformation from many types of media sources. Counseling is essential to provide accurate information about the mechanisms, efficacy, and safety of available options. Oral contraceptives are the most popular choice for this group, but other options with greater ease of use, as well as different side-effect and benefit profiles, should be reviewed with each patient. Additional issues common among young women include concerns about undergoing and paying for gynecology examination, and the need to keep office visits and contraceptive methods confidential from parents or partners. A potential avenue for increasing compliance among young is to emphasize possible non-contraceptive benefits, including decreased menstrual bleeding / cramping or even amenorrhea for the duration of use. Patients should also be advised of the schedule for follow-up visits, which are required for assessing satisfaction and compliance.
Prenatal care represents a unique opportunity to target interventions to prevent unintended pregnancy. The postpartum period offers not only a captive population for contraceptive education but also a highly motivated population. During the postpartum period, many women select a new form of contraception. Their contraceptive education and subsequent selection of a contraceptive method represent an important opportunity to prevent future unintended pregnancies. Currently, women have a wide variety of contraceptive methods from which to choose. Contraceptive education should be a standard component of postpartum care. There are many factors that play a role in the contraceptive decision-making process, including: ease and convenience of the method, fear of pregnancy, previous experience with other methods of contraception, cost of the method and side effect profile of the particular method. Currently, several types of contraceptives are available; they include barrier, hormonal and intrauterine methods. Within each contraceptive category, manufacturers have developed new delivery methods and dosing schedules in an effort to improve patient compliance and to provide more contraceptive options to the patient.
In the perimenopausal years, the emphasis moves away from family planning and maintaining fertility. Effectiveness in preventing conception again becomes a priority. Half of pregnancies in this age group are unintended, and of those 65% are terminated, giving this age group the highest abortion rate. Male and female sterilization may be a viable option for this age group. In addition, the non-contraceptive health benefits of hormonal methods may become important. It is critical to evaluate the health status of perimenopausal women before and during hormonal contraception, as they are more likely than younger women to have conditions that are contraindications or relative contraindications to hormone use. The use of hormonal contraception to regulate the menstrual cycle and control vasomotor symptoms may make it difficult to know when menopause has been reached and contraception is no longer necessary. The optimal end-point has not been identified, but strategies may include continuing use to age 55 years, by which time most women have reached menopause, or discontinuing hormonal contraception at age 51 years (the median age of menopause) and employing barrier contraception until the patient is amenorrheic for at least 6 consecutive months.
Health Across The Life Span:
The total fertility rate (TFR) -- the number of births per woman of childbearing age; has been declining from 5 in 1985 and to 2.9 in 2000. It is expected to reach 2.3 by 2025. The world average, however, conceals large differences among countries and regions. Contraceptive prevalence is strongly related to the level of fertility, explaining about 90% of variance in TFR; it is estimated that current contraceptive use -- the percentage currently using contraception among couples with the woman of reproductive age, is now approaching 60% globally, compared with about 57% in 1990. In the developing countries prevalence reached 53% in 1990 and 56% in 1995. In the developed world it averaged 72% in 1990 and 73% in 1995. Recent estimates show that in the countries that have reported, at least 50% of the population has access to temporary methods of contraception. For the world as a whole, the number of women of reproductive age in 2025 is expected to be 1.6 times higher than in 1990, and the number of married women to grow slightly less (to 1.5 times the number in 1990). It is also expected that contraceptive prevalence among them will increase globally to 70% by 2025.
Adolescent fertility -- babies born to young women aged 15-19, is an emerging concern throughout the developing and the developed world. These are high-risk births from the perspective of the health of both mother and child, and also high-cost births when associated negative effects on the quality of life and role of women in society are considered. Adolescents account for 18% of all women of reproductive age in most of the developing regions of the world and their numbers are expected to grow worldwide by at least 60 million between 1995 and 2025. Adolescent fertility is estimated at 66 births per 1000 women aged 15-19 years in 1995 worldwide (it is falling compared with overall fertility rates). It is expected to reach 52 births per 1000 adolescent women by 2025, with projected births declining by 6% of the number occurring in 1995 over the course of the next 30 years, mainly due to rising age at marriage, increasing educational and economic opportunities for young women and increased use of contraception. Unfortunately, non-compliance and discontinuation remain common in adolescents.
As women live longer than men, the quality of their longer life becomes of central importance. Women have different circumstances, challenges and health concerns from men as they age. For women in developing countries who survive the early life span stages to reach middle age, life expectancy approaches that of women in developed countries. Enhancing health potential in the future depends on preventing and reducing premature mortality, morbidity and disabilities.
Counseling consists of exchange of information, facts, and views; subsequent discussion; and deliberation leading to a decision. The provider's communication skills have a major impact on the patient. Contraceptive use improves when the provider listens and responds specifically to the patient's expressed concerns. Office staff should be non-judgmental, and provide a supportive, confidential environment for all women who seek reproductive counseling. Ideally, counseling involves two-way communication. The healthcare provider's role is not merely to disseminate information, but to elicit information and gauge the patient's needs and concerns. It is essential to ensure confidentiality, and reassure patients that privacy is paramount. Choice of language can also be relevant. Patient education should be reinforced with take-home aids such as brochures, appropriate web-sites, information from the product manufacturer, and/or follow-up telephone calls from the office staff.
There is no magic pill or a quick-fix solution to the population explosion. Governments, health care providers and religious leaders working together, can make a substantial difference in brightening a healthful future for families around the world. Not all forms of contraception are appropriate for all women. In helping each patient find the right contraceptive choice, providers must match the patient's individual goals, lifestyle, health status, and personal preferences with the efficacy, safety, and route of administration of various contraceptive methods. As women's contraceptive priorities change throughout the reproductive life cycle, their needs should be reevaluated over time. In addition, the impact of lifestyle issues on consistency of contraceptive use and compliance should be assessed and monitored. Finally, patient education regarding proper use and side effects is crucial, as misunderstanding may impede contraceptive success. The desire for a healthier and better world in which to live our lives and raise our children is common to all people and all generations. We are slowly learning one of life's most important lessons: not just how to live longer; but also how to stay longer in good health with less dependence on others.
Public health is the art of applying science in the context of politics so as to reduce inequalities in health while ensuring the best health for the greatest number. Due to political nature of women's healthcare, implementation of a healthy public policy have been the most difficult achievements. Appropriate preventive, curative and community care has a central role in the pursuit of the health-for-all targets.
- World Health Organization (WHO)
- United Nations Population Division
World Population Prospects (requires Adobe Reader)
- Family Health International
Women's voices, women's lives: the impact of family planning. Crosscutting themes and their implications.
- US Centers for Disease Control and Prevention.
Female Sterilization: Summary of Surgical Sterilization in the United States: Prevalence and Characteristics
- US Agency for International Development, Management Sciences for Health
The Provider's Guide to Quality & Culture
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