The world health community has affirmed the “basic right of individuals to decide freely and responsibly the number, spacing and timing of their children” (UN 1994). The gap between need for and access to contraception varies, but exists in all countries (Guttmacher 2016).
Reproductive Justice (RJ) includes the human right to maintain personal bodily autonomy, have children, not have children, and parent children in safe and sustainable communities; RJ principles recognize the limited choices marginalized communities face in reproductive health services, as intersecting systems of oppression impact access to care (SisterSong).
Contraception is primary health care. All patients with reproductive potential should be counseled regarding their reproductive preferences and offered contraception if desired as a part of routine primary and abortion care (CDC QFP 2017). Optimal contraceptive counseling supports patients to make fully-informed decisions by providing unbiased information about the full range of options (Senderowicz 2020). Given the social and historical context in which some communities’ reproduction has been devalued, counseling should be responsive to each patient’s priorities and concerns rather than direct patients towards using contraception, or towards the selection of any specific method or method type (Dehlendorf 2014) and include information on the risks, benefits, and side effects of methods that meet their preferences. Quality and effectiveness of counseling has been validated by a person-centered contraceptive counseling measure (Dehlendorf 2018). Patients are more likely to be satisfied with their counseling, continue use, and like a selected method 6 months later if they responded that they felt as if their provider:
- Respected them as a person
- Listened to their values about their method
- Centered their values and preferences
- Gave them enough information to make a decision
Core principles / steps in quality contraceptive counseling include:
- Establishing and maintaining rapport with the patient
- Assessing the patient’s needs and personalizing discussions accordingly
- If the patient has a strong interest in one method, asking permission before providing information on others.
- Considering methods that align with patient priorities, such as:
- Changes to menstrual bleeding
- Route, ease of use, or remembering, and cost
- Privacy from a partner or parents
- Hormonal or non-hormonal
- Impact on sex and / or pleasure
- Working with the patient interactively to establish a plan
- Anticipate & address barriers to accurate/consistent use for chosen method
- Simplifying the decision process (i.e. appropriate language and visual aids)
- Confirming patient understanding
- Using active learning strategies such as teach back (CDC QFP 2017)
Addressing bias and reproductive coercion in family planning
Many marginalized communities including people of color, low-income or uninsured people, indigenous people, immigrants, and people with disabilities have been aggressively targeted by providers for long acting reversible contraception (LARC) as an effort to limit family size, and have also been subjugated to a long history of sterilization abuse (NWHN/SisterSong 2021). This history demands that providers recognize their own implicit biases and ensure people are provided information about a full range of contraceptive options.
Understanding and addressing one’s own biases is a life-long process and requires that providers acknowledge and challenge their assumptions about certain individuals and / or communities. Providers should invest in the patient’s experience and preferences, rather than in a particular method or outcome. (See related content in Chapter 2)
Addressing contraception as a part of abortion care services is an important part of ensuring people’s long-term reproductive health needs are met. However, people may not want to talk about contraception on the day of their abortion consultation or in the setting of abortion (Brandi 2018). Patients may feel they are not ready to decide, or they may be overwhelmed by the information they are receiving. It is also common for people undergoing abortions to criticize themselves for their use or non-use of contraception, and to blame themselves when their method fails. Because of abortion stigma and self-blame, patients may feel pressured to choose and start a contraceptive method that day, even though they may not want to.
During abortion care, the provider should help to diminish any self-blame and shame by normalizing abortion services and encouraging the patient to set their own contraceptive priorities. Setting their own contraceptive priorities in an abortion consultation may mean that they are open to hearing about options, or that they don’t want to talk about or consider contraception at that time, and that is okay, too.
- To avoid delays, send scripts to the pharmacy, mail, or pre-pack for pick up.
- Provide virtual or telehealth visits for counseling and initiation for some methods.
- Initiate bridging method as needed, pending a follow-up visit for IUD, implant, sterilization, or DMPA (consider SQ self-administration):
- Use evidence-based extended use (Ti 2020, Ali 2017), if patient desires.
- Provide both contraceptive initiation & LARC removal as essential services.
- In the absence of medical issues, contraception may often be refilled without a visit.
- Dispensing 12 months is safe, effective, and improves continuation (Foster 2006).
|Evidence-Based Extended Use|
|Method||FDA-approved duration||Evidence-based duration|
|CuT IUD (Paragard®)||10 years||12 years|
|LNG 52 mg IUD (Liletta®)||8 years||8 years
|LNG 52 mg IUD (Mirena®)||8 years||8 years|
|LNG 19.5 mg IUD (Kyleena®)||5 years|
|LNG 13.5 mg IUD (Skyla®)||3 years|
|Implant (Nexplanon®)||3 years||5 years|
Counseling for side effects and common concerns
Many patients have used various contraceptive methods and may have strong opinions about a method based on their personal/peer experience. Investing in a patient’s experience requires authentically listening to, and identifying, a patient’s preferences.
- Empathize with the patient: “That sounds really difficult.”
- Normalize their experience: “I hear that from a lot of patients”.
- Reassure the patient: “I can remove your IUD for you today”.
- Offer options that honor the patient’s preferences: “We can remove your IUD today. Would you be interested in hearing about potential options to help manage the bleeding?”