A recent publication by Susan Wysocki, “The state of hormonal contraception today: enhancing clinician/patient communications” in the American Journal of Obstetrics & Gynecology addressed this issue quite well. She begins by addressing the effectiveness of current methods. Surveys of contraceptive methods show that less effective methods (to prevent pregnancy) are more frequently used than those methods with more inherent effectiveness. Methods that do not require daily intervention, such as implants, female sterilization, and intrauterine devices, are associated with higher effectiveness but are less often used due to a variety of factors. The less effective methods require multiple interventions by the user and are, not surprisingly, associated with more inconsistent use and thus, decreased effectiveness in preventing pregnancy.
The major issues as educators and clinicians in improving acceptance of and adherence to effective contraceptive methods are to allay fears, myths, and misperceptions while providing the best education and counseling possible. There is a lack of knowledge by many women not only with regard to correct information about the range of birth control options available to them, but also, about basic issues such as what makes a woman fertile. As a result, women may be incorrectly estimating their risks for pregnancy.
Once a woman focuses on the need for birth control and on the risks of unintended pregnancy, her perceptions about birth control methods become evident. Her considerations may include:
● Hormonal or non-hormonal.
● Daily or non-daily.
● Side effects and safety.
● Perceptions about particular methods, both true and false.
● Efficacy and return of fertility after use.
● Childbearing plans.
● Non-contraceptive benefits (i.e. acne, premenstrual dysphoric disorder, menstrual cycle disorder).
● Bleeding profile of method–every month, every couple of months, not at all, unscheduled bleeding issues.
● Her partner(s) responsibility in helping her to achieve her goal for not be coming pregnant (including the option of using condoms or vasectomy).
● Confidentiality of the visit.
Providing a woman with information about the health benefits of hormonal contraception, as well as the importance of correct and consistent use are essential. A number of factors can be identified as those that influence adherence: patient age (what is a good contraceptive choice at age 20 years may not be the best birth control method for a woman of 30 years of age), socioeconomic status, level of education concerning birth control, side effects of the method, therapy dispensing form and mode, prescribing information, and the health care delivery system. It is also important to understand that these factors are not universal to women because of their age, socioeconomic status, etc.
The clinician-patient interaction should serve three functions: gathering of information, educating the patient, and developing a therapeutic relationship. Setting the stage for contraceptive discussion includes obtaining information on the woman’s plans regarding childbearing (or not) and understanding what her goals are for preventing pregnancy. Preferences and priorities change over time. It is acceptable for a woman to change methods as her priorities change. Clinicians need to determine what influences a woman to choose a particular method to adequately discuss the advantages and perceived risks of that method. Clinicians can help women overcome barriers to accessing contraception. If methods are not affordable, clinicians should be able to refer patients to assistance programs and family-planning programs and offer generic versions of their chosen methods that may reduce costs. It is worthwhile to ask a woman to repeat her understanding of how to use a contraceptive and to reinforce that understanding at each visit. Supplying handouts and referring to website information provide another layer to patient knowledge and may lead to better acceptance and method use. Although each clinician needs to formulate his or her own techniques into practice, incorporating any of these strategies into counseling efforts will improve clinician patient relationships and, potentially, improve method use.