Advanced Client Centered Contraception Counseling Skills

Workshop

Patty Cason MS, FNP-BCUCLA School of Nursing

Planned Parenthood Los Angeles

Disclosures

• Advisory Board/ConsultantTeva, Actavis, Merck, Bayer, ContraMed

• Trainer/speakerMerck, Actavis

Objectives

• Identify reproductive life plan questions that efficiently clarify reproductive intention.

• Demonstrate use of rephrasing• Display familiarity with a tiered effectiveness

approach to counseling• Identify and support patient's positive health

related behaviors in order to maximize rapport and promote healthy contraceptive behaviors.

Pregnancies in the USA 2008

Unintended pregnanciesIntended pregnancies

49%

Finer LB, Zolna MR. Am J Public Health. 2014

51%

% of pregnancies that are unintended by income

<100% of poverty

100-199% of poverty

≥200% of poverty

0

10

20

30

40

50

60

70

Income as a % of federal limit

Finer LB, Zolna MR. Am J Public Health. 2014

What is the goal?

1. To decrease rates of unintended pregnancy?2. To help patients prevent unintended

pregnancy?3. To increase LARC use?4. To increase inter-pregnancy intervals?

To help clients clarify what they want and help them get it?

Shared Decision Making

“A collaborative process that allows patients and their providers to make health care decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.”

–Informed Medical Decisions Foundation

http://www.informedmedicaldecisions.org/

Shared Decision Making in Family Planning

• Consistent with client’s desires for family planning counseling– Focus on client’s preferences–Provision of decision support, without

pressure• Associated with improved satisfaction with

counseling and with choice of method

Dehlendorf C, Contraception, 2013

REPRODUCTIVE LIFE PLAN PREGNANCY INTENTION

• A self-assessment of life goals

• Focus on broad categories– Education– Work/Career – Family Planning

• Assist or guide as needed

Purpose

• Reveal client’s genuine reproductive intentions.• So he or she clarifies what is most important to

them. So he or she can:

• Obtain necessary information.

• Make choices.

• Fulfill their own goals.• Ambivalence is expected

Three Questions

1. Do you think you would like to have (more) children some day?

2. When do you think that might be?3. How important is it to you to prevent

pregnancy (until then)?

How does it help?

Clarifies how motivated he

or she is to become

pregnant or prevent

pregnancy

…so we discuss

appropriate interventions

+/-Contraception

+/-Preconception

CareOr Basic Infertility Services

For Contraception

Appropriate contraception

Highly effective?

“Non contraceptive” benefits?

Need Concealed contraception?

Bleeding patterns?

Alternate questions:

• How would it be if you were to become pregnant over the next few months?

• What are your pre-pregnancy goals?• How would you feel if you became

pregnant now?

Patient Education Resource• “User friendly”, accurate information on all

contraceptive methods• Will set up reminders for contraception

adherence• Many fun and helpful toolsHttp://bedsider.org/

Next questions

• What are you looking for in a contraceptive method?

• What are you considering that might help you ________(whatever her goal is)?

Language for LARC

“This method is good for up to 10, 5, 3 years but if you want to get pregnant before then or you would like it removed for any reason, come in, we will remove it and your ability to get pregnant will return to whatever is normal for you immediately.”

Language for LARCRather than using the words “long acting”, use• Top tier• The most effective methods• The best we’ve got• Cadillac, Mercedes, BMW…• The methods “we all” use• Highly effective methods

Re-phrasing

• “So I hear you saying …(your boyfriend wants

you to have a baby right now but you’re not so

sure) do I have that right?”

• “It sounds like….(it’s super important to you to

wait until you are out of school before you

become a parent) is that what you mean?”

Alternates

• “Many of my patients say that they…is that

what you mean?”

• “So you feel pretty strong about… Is that

accurate?”

ROLE PLAY

Role Play PreparationFor when you play the client:

Think of someone you know well. • Pick someone who doesn’t want to be

pregnant any time soon• Yourself, a friend, relative, acquaintance, or a

child of one of your friends.

Know

• What they do for work or school• Their approximate age • Have they ever been pregnant, have kids, had

abortion(s) or miscarriages• What is important to them in their life• Basic knowledge of their values

• Break into pairs

• One person role plays being the clinician/counselor– be yourself.

• Ask the pregnancy/reproduction intention questions and REPHRASE what the client says after each reply

• Then switch roles

Three Questions

1. Do you think you would like to have (more) children some day?

2. When do you think that might be?

3. How important is it to you to prevent pregnancy (until then)?

• “So I hear you saying …………………do I have that right?”

• “It sounds like………………… is that what you mean?”

Re-phrasing

Ambivalence

Rewards

ObstaclesOn the other are obstacles

On one hand we want to accomplish our goals

Obstacles

Ambivalence in many forms• Wants to please or hold onto a mate • Attention from parents or community• Reassurance that she is fertile

Obstacles

• All contraceptive methods have potential side effects

• Fear of negative health effects • Risk for unplanned pregnancy is theoretical• Perception of risk is not fully rational and is

based on past life experience---ask

Obstacles

• Contraceptive sabotage by a partner• Drugs, alcohol• Religious reasons

Reproductive Coercion

Behavior intended to maintain power and control in a relationship related to reproductive health by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent.

Reproductive Coercion

Explicit attempts to:• Impregnate a partner against her will• control outcomes of a pregnancy• coerce a partner to have unprotected sex• interfere with contraceptive methods.

Obstacles

• Logistical constraints–Cost–Wait times, work schedule, transportation,

childcare• Adherence to second and third tier methods– Forgets to adhere – Too busy to adhere

Obstacles

Intermittent/inconsistent sexual partnering• Believes she doesn’t need contraception (today)• Ask specific details of what she did and when• Ask if she intends or would like to be sexual with

someone in the next month, year… two years

Stratified Reproduction

The differential valuing of reproduction such that the procreation of some people and groups is valued by those with social and political power, and the fertility of other people and groups is not.

Reproductive Control

• Women who perceive that they have a lack of reproductive control do not necessarily formulate clear pregnancy intentions

• The benefits of a planned pregnancy may not be evident

Kennedy, S. et al (2014). J Health Care Poor UnderservedBorrero, S. (2015). Contraception

Intention ≠ Acceptability

• When preconception intention and planning do not occur, decisions about the acceptability of a pregnancy are made once the pregnancy occurs

• Many women expressed happiness with (the prospect of) a pregnancy, regardless of their intention

Kennedy, S. et al (2014). J Health Care Poor UnderservedBorrero, S. (2015). Contraception

Planning

Pregnancy planning, distinct from pregnancy intention, was described as a very deliberate act in which both partners discuss and reach consensus about the timing of pregnancy and then take steps to prepare for a potential pregnancy, including “getting your finances in order.”

Kennedy, S. et al (2014). J Health Care Poor UnderservedBorrero, S. (2015). Contraception

Planning“Because nearly all of the women in our study had strong feelings about the ideal circumstances (specifically, being in a committed relationship and financially stable) in which one should plan a pregnancy, yet few, if any, women actually achieved either relationship or financial stability, pregnancy planning seemed irrelevant and rarely occurred.”

Borrero, S. (2015). Contraception

“It just happens”• The current conceptual framework that

views pregnancy-related behaviors from a planned behavior perspective may be limited among low-income populations

• Perceptions of low reproductive control*• Perceptions of low fecundity* • Male partner reproductive coercion*

Borrero, S. (2015). Contraception

*potentially modifiable

Try NOT to Disagree

• Whenever possible, find something in what she or he is saying to agree with and then add your scientific or medical information.

• “Yes! …. and…” Instead of “No” or “But”

Accept Ambivalence• Expect• Look for• Find• Accept • And help resolve ambivalence

• We guide patients towards decision-making that is in line with their own goals by helping them explore and resolve their own ambivalence.

Accept Ambivalence

• Merely developing the discrepancy is a powerful way to help patients make better choices.

• Non judgmentally.

REALLY!

On the One Hand

• “So it sounds like on one hand you are saying that it’s very important to you to wait until you are ready, and yet on the other hand, a part of you would like to have a baby now? Do I have that right?”

• “On the one hand you would really like to finish school before you become a parent yet on the other hand it’s hard to be consistent with your (pill use, or depo use, or condom use)…”

pause for a reply

Neutral Words

• Avoid labeling negative feelings using words like:

– “You sound angry” (or anxious).

• Better to use neutral words:

– “It sounds like______is concerning to you”

– “I hear you saying ______was hard to deal with”

ROLE PLAY

Questions

• What are you thinking about that might help you get to ….(your goal)

• What are you looking for in a contraceptive method?

“On the one hand…on the other hand”

On the one hand

Point Out Health-Supporting Behaviors

• Condom use, adherence to a method, exercise, diet improvement.

• Important because:– You are both on the same side –He or she will trust you–He or she is coming from their “best self”

Positive Feedback

• “It’s great that you were so strong in standing up for yourself (in another situation…)”

• “You are obviously smart…. (give a concrete example)”

• “You’ve clearly thought about this a lot…so what do you make of this situation?”

Positive Feedback• “Wow, that is a great question (concrete

example)…”• “Not many people (your age) act so responsibly

about using a condom every time.” • “You are clearly interested in protecting

yourself.”

Information Sandwich

Sandwich the information you want to give between questions:

Question: “How would it be for you if you didn’t get your period while you are using the implant?”“My mom said it’s important to get my period every month”

Information Sandwich

Information: “Your mother is completely right, when you are not on contraceptive hormones it is important to get you period every month, it’s great that you know that... Interestingly, if a woman is using contraceptive hormones it keeps her uterus very healthy and thin. It actually prevents cancer of the uterus”Question: “Knowing that, how would it be for you not getting periods?”

ROLE PLAY

Maria: Confidence Ruler

Counseling: Case 1, Cont.

Intention Ruler

“How do you feel about getting pregnant right now? On a scale of 1-10. 1 being the worst feeling you

can imagine, and 10 being the happiest you could possibly feel.”

1 2 3 4 5 6 7 8 9 10

Unhappy Most happy

Melanie Gold DO

Small Talk

• Ask about school, family or what kind of work he or she does (this can be before starting the content of the visit or during the exam)

Focus on:• Re-phrasing• Pointing out positives

Small Talk

• “It sounds like you are incredibly busy with all that you have on your plate with work and school.”

• “Working and taking care of a little one must make it challenging to schedule a visit for your depo shot.”

References• ACOG Committee Opinion: Motivational Interviewing: A Tool for behavior Change;

423; Jan 2009.• Barnes AJ, Gold MA.Promoting healthy behaviors in pediatrics: motivational

interviewing. Pediatr Rev. 2012 Sep;33(9):e57-68• Barnet B et al. Cost-effectiveness of a Motivational Intervention to Reduce Rapid

Repeated Childbearing in High-Risk Adolescent Mothers Arch Pediatric Adolescent Med. 2010;164(4):370-6

• Barnet B et al. Motivational Intervention to Reduce Rapid Subsequent Births to Adolescent Mothers: A Community-Based Randomized Trial Ann Fam Med 2009;7:436-45.

• Biermann J, Dunlop AL, Brady C, et al. Promising practices in preconception care for women at risk for poor health and pregnancy outcomes. Matern Child Health J. 2006;10:S21–S28

• Burke BL, Arkowitz H, Menchola M. The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. J Consult Clin Psychol 2003;71(5):843–61.

References• Dehlendorf C et al. Preferences for decision-making about contraception and

general health care among reproductive age women at an abortion clinic. Patient Educ Couns. 2010;81:343–348

• Dehlendorf C et al. Women's preferences for contraceptive counseling and decision making. Contraception. 2013 Aug;88(2):250-6

• Emmons KM, Rollnick S. Motivational interviewing in health care settings. Opportunities and limitations. Am J Prev Med. 2001;20:68–74

• Gold Melanie et al. Motivational Interviewing Strategies to facilitate Adolescent Behavior Change. Adoles Health Update. 2007;20(1):1-7.

• Hecht J et al. Motivational Interviewing in Community-Based Research: Experiences From the Field. Annu Behav Med. 2005;(29)Suppl:29-34.

• Floyd RL, et al. Preventing alcohol-exposed pregnancies:a randomized controlled trial. Project CHOICES Efficacy Study Group. Am J Prev Med 2007;32:1–10.

References

• Hettema J, Steele J, Miller WR. Motivational Interviewing. Annu Rev. Clin Pychol. 2005.(1):91-111.

• Kols AJ, Sherman JE, Piotrow PT. Ethical foundations of client-centered care in family planning. J Womens Health. 1999 Apr;8(3):303-12.

• Langston AM, Rosario L, Westhoff CL. Structured contraceptive counseling — a randomized controlled trial. Patient Educ Couns. 2010;81:362–367.

• Lopez LM et al. Theory-based interventions for contraception. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007249.

• Madden T, et al. Structured contraceptive counseling provided by the Contraceptive CHOICE Project. Contraception. 2013 August; 88(2);243-249.

• Petersen R, et al. Applying motivational interviewing to contraceptive counseling: ESP for clinicians. Contraception; 69(3):213-7.

References

• Rinehart W, Rudy S, Drennan M. GATHER guide to counseling. Popul Rep J. 1998;48:1–32.

• Rollnick S, et al. Motivational Interviewing in Health Care. New York: Guilford Press; 2008

• Rubak S, Sandbaek A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and metaanalysis. Br J Gen Pract 2005;55(513):305–12.

• Secura GM, Allsworth JE, Madden T, Mullersman JL, Peipert JF. The Contraceptive CHOICE Project: reducing barriers to long-acting reversible contraception. Am J Obstet Gynecol. 2010;203(115):e111–e117.

• Schillinger D, Closing the Loop: Physician Communication With Diabetic Patients Who Have Low Health Literacy . Arch Intern Med. 2003; 163(1):83-90.