Evidence-based Contraceptive Counseling

1. Jacki Witt, MSN, WHNP-BC, SANE-A Evidence-based Contraceptive Counseling

2. Advisory Board Member: Agile Therapeutics, Watson Pharmaceuticals and Afaxys Pharmaceuticals Disclosures

3. Objectives • Discuss counseling vs education in a family planning context • Compare three methods/frameworks for effective contraceptive counseling (RLP, MI and Tiered Counseling) • Delineate at least three evidence-based principles for counseling in a family planning setting

4. Counseling • Guidance of the individual by use of standard psychological methods. • The counselor's goal is generally to orient the individual toward opportunities that can best guarantee fulfillment of his personal needs and aspirations. The counselor usually attempts to clarify the client's own thinking rather than to solve his problems. (Merriam-Webster)

5. Educating • To instruct or provide with information (Merriam-Webster)

6. Counseling in the family planning setting • Patient-centered, shared decision making and patient engagement in a nonjudgmental manner

7. Reproductive Life Plan (RLP)

8. RLP: What is it? • A self-assessment of life goals • Goals in several broad categories (based on the social determinants of health) • Education • Work/Career • Family Planning • We assist or guide as needed

9. RLP: Purpose • To reveal patient’s genuine intentions regarding reproduction • Individual absorbs what is most important to her/him • So that she/he can: • obtain necessary information • make choices • adhere to her plan • fulfill her own goals. • Ambivalence is expected

10. RLP: How does it help? • It shows how motivated someone is to become pregnant or prevent pregnancy • Once this is clarified we can begin the process of offering appropriate interventions • Contraception or not • Highly effective or not • Preconception Care • Life goals prior to planned pregnancy

11. Sample RLP questions: Do you want to have (more) children? (Someday?) If so: • When? (Or how old would you like to be?) • How many children would you like to have? • How long do you want to wait between pregnancies? • How would you feel if you were to become pregnant over the next few months? • What are you hoping to accomplish before then?

12. Discovering clients’ true motivations • The point of a RLP is to get substantive information from our clients about what is motivating them so we can help them make better choices • The client is the one who will make the choices

13. Motivational Interviewing(MI)

14. Motivational Interviewing with contraception counseling • Saves time • Effective • Client centered

15. When is MI not needed? A patient says: “Give me the most effective method you’ve got!”

16. MI has been used for • Addiction counseling and treatment • Contraception counseling • Behavior change • Diabetes self management • Weight loss • Medication adherence

17. MI: the approach • Start from a place of respect • Guiding not directing • Not “me vs. you” rather…“us together on the same side” • Help patients feel motivatedby having them verbalize their own reproductive and life goals • Identify what is personally meaningful or of value to the patient rather than those things that we think are most important

18. MI: the benefit • Reduces frustration with the patient and subsequently ourselves • Removes our ego… • “I need to make this patient do what’s good for her.” • “I want to protect her from an unnecessary unplanned pregnancy!” • “If I can’t get through to my patient, I fail.” • Our morale will be exhausted without success

19. Ineffective strategies Taking sides in the patients ambivalence • Threatening bad outcomes; • “You’ll get pregnant if you don’t ...” • This gets their attention but doesn’t work for behavior change • Giving advice assumes this person simply doesn’t know enough. • To offer one idea after another = exhaustion

20. Accept ambivalence • MI elicits behavior change by helping clients explore and resolve ambivalence. • Expect, find, accept and show ambivalence • Also called developing discrepancy • Just showing the discrepancy is a powerful way to help patients make better choices

21. Ambivalence We want to accomplish our goals OBSTACLES REWARDS There may be many obstacles

22. Motivation for contraceptive use • With PERFECT use of contraception • 1 year, • 3 years, • 5-10 years, • 20+ years…what will happen?? • The best case scenario... NOTHING!

23. 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

24. Obstacles • Contraceptive sabotage by a partner • Logistical constraints • Cost • Wait times • Work schedule • Transportation • Childcare

25. 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

26. Tiered effectiveness Counseling

28. Case Studies

29. Sandy 16 yr old G1 P0 TAB 1 RLP: • Wants to get pregnant now • Ask about her life goals • Find something about her behavior that is “mature” and refer to it • Review PCC (insert reality) • Demonstrate that you believe she is in charge of her own life

30. Rather than tell her she’s too young: • “You will be a wonderful mother some day…and to be an even better mother, what would you like to accomplish before you have a baby? (or in addition) ” • “Sounds like you’ve given this some thought (or “you are obviously smart”), what are some ways you see yourself handling this?”

31. Maria BMI 3122 year old G2 P0 TAB 2 student RLP: • Wants children one day. At least 3 years from now. Wants to be married, finish school. She’s clear that she is not willing to have another abortion • Prior DMPA (gained weight), very concerned that hormones cause weight gain. Mostly has used withdrawal and doesn’t believe she has ever gotten pregnant that way

32. Maria • “You said that you are using the pull out method now. And on the one hand you feel that if you get pregnant you would continue the pregnancy, yet you also are pretty sure you don’t want to have a baby right now. Do I have that right?” • “What would you like to accomplish before you have a baby? And what else?” (Refer to RLP life goals)

33. Maria • “If delaying pregnancy until you finish school is very important to you, would you be interested in using one of the top tier methods?” • “Since a lot of women who rely on their partner to “pull out” get pregnant, would you like to talk about pre-natal vitamins and other things that are important to do to prepare for pregnancy?”

34. Understanding objections • If we listen well enough to where the resistance has come from we can develop discrepancy (describe the ambivalence)

35. Confidence Ruler Melanie Gold DO QUANTITATIVE APPROACH: ‘the ruler’ 0 2 4 6 8 10 Least Most “Think of how you feel about getting pregnant right now and then see if you can tell me where you fall on a scale of 1-10. 1 being that it would be the worst thing you can imagine, and 10 being that it would make you the happiest you could possibly be.”

36. Demonstrate Ambivalence in Maria • “a 2” • “Why would you say you aren’t you a lower #?” • “I’m not ready for a baby but I know that I won’t have another abortion because I am an adult and having a baby wouldn’t be the absolute worst thing in the world” • “Why do you think the # might not be higher?” • “I really want to wait a few more years!”

37. Or qualitative questions: • “How would you feel if you got pregnant now?” • “How ready are you for pregnancy?” • “How important is it to you to avoid pregnancy?”

38. Repeat or rephrase examples • ….”Let me make sure I understand….” • “So on one hand you don’t want to get pregnant…do I have this right? Yet, you are not using birth control. How does this fit in with your not wanting to get pregnant?” Her reply uncovers the ambivalence

39. Make it real • “On one hand you really want to get pregnant in the future, but not right now, and on the other hand, it sounds like a part of you would like to have a baby now? Do I have that right?” • “Have you discussed this with your partner? Do you plan to tell him? How do you think he would react?”

40. What now? Open ended… • What do you think you will do? • What birth control are you thinking can help you... (fill in with her stated goal)? • What do you see as your options? • Where do we go from here? • What happens next? Rather than: • Do you have any questions? • Do you understand?

41. Final steps • Plan for obstacles; they have great intentions but they return to their lives once they leave the office (it’s a long way from the exam room to the bedroom) • Close the deal • Operationalize same day LARC placement • Ask “How do you feel about this” • Plan concrete next steps

42. Take home messages (Jaccard & Levitz, 2013) • Based on Jaccard and Levitz – Adolescent Counseling • Principle 1: Demonstrate the “key three” attributes of effective counselors -- expertise, trustworthiness, and accessibility • Principle 2: Address issues of confidentiality and the role of parents in contraceptive decision-making

43. Principle 3: Use skills-based strategies to actively engage the client in learning and remembering important points and provide them with easily accessible and reliable information sources • Principle 4: Address all four facets of contraception – method choice, correct use, consistent use, and method switching

44. Principle 5: Make choosing a method manageable and give priority to more effective methods • Principle 6: Consider how the method fits the lifestyle of the client by raising other key social-behavioral factors • Principle 7: If the client is at risk of contracting a STI, which is almost always the case for adolescents, recommend dual protection--condoms plus a more effective contraceptive method

45. Principle 8: Give the client practical strategies to ensure accurate and consistent use of the chosen method of contraception • Principle 9: Address the issue of side effects ahead of time • Principle 10: If a client decides to change her method of birth control, encourage her to switch to an equally or more effective method and try to ensure that there are no gaps in protection

46. Principle 11: Be sure a staff member follows up with the client to see how things are going • Principle 12: Use quick-start options for any method that has such an option unless it is medically inappropriate to do so

47. References • ACOG Committee Opinion: Motivational Interviewing: A Tool for behavior Change; 423; Jan 2009. • Barnet B et al. Cost-effectiveness of a Motivational Intervention to Reduce Rapid Repeated Childbearing in High-Risk Adolescent Mothers Arch PediatrAdolesc Med. 2010;164(4):370-376 • Barnet B et al. Motivational Intervention to Reduce Rapid Subsequent Births to Adolescent Mothers: A Community-Based Randomized Trial Ann Fam Med 2009;7:436-445. • Dehlendorf, C et al. Women’s preferences for contraceptive counseling and decision making Contraception 88 (2013) 250-256. • Egarter, C et al. Contraceptive counselling and factors affecting women’s contraceptive choices: results of the CHOICE study in Austria Repro Biomed Online (2012 (24): 692- 697

48. References • Gold Melanie et al. Motivational Interviewing Strategies to facilitate Adolescent Behavior Change. Adoles Health Update; 20(1):1-7, Oct 2007. • Hecht J et al. Motivational Interviewing in Community-Based Research: Experiences From the Field. AnnuBehav Med. 2005. • Hettema, Steele, Miller. Motivational Interviewing. Annu Rev. ClinPychol. 2005. 1:91-111. • Hodgson, EJ et al. Family planning and contraceptive decisiion-makinbg by economically disadvantaged, African-American women Contraception (2013) 88: 289-296 • Jaccard, J and Levitz, N. Counseling adolescents about contraception: towards the development of an evidenced-based protocol for contraceptive counselors Jour of Adol Health 52 (2013) S6- S13 • Julius et al. Medication adherence: a review of the literature and implications for clinical practice. J PsychiatrPract. 2009 Jan;15(1):34-44

49. References • Lopez et al. Theory-based interventions for contraception. 2009 Jan, Cochrane Database. • Merki-Feld, GS & Gruber, IML. Broad counseling for adolescents about combined hormonal contraceptive methods: the CHOICE study Jour of Adol Health (2013) 1 - 6 • Petersen et al. Applying motivational interviewing to contraceptive counseling: ESP for clinicians. Contraception; 69(3):213-17. Mar 2004. • Rollnick S, et al. Motivational Interviewing in Health Care. New York: Guilford Press; 2008 • Rubaket al. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005 Apr;55(513):305-12. • Schillinger, “Closing the Loop” Teach-back is supported by research. Arch Intern Med/Vol 163, Jan 13, 2003