Most women spend the better part of 35 years trying to avoid pregnancy. Knowing how to choose the right contraceptive method at different life stages can be a challenging process. There is no silver bullet, no perfect method, no 100% efficacy or a “one size fits all” approach. The research continues to show wide gaps between perfect and imperfect use (method vs user failure). We know that nearly 50% of users stop or switch methods within one year of starting; discontinuation rates and side effects are estimated to explain 20-30% of unplanned pregnancies.
For physicians, prescribing birth control is fairly straightforward. Hormonal birth control and IUDs are usually the methods of choice. But for patients, choosing a method is more of a trade-off because hormonal methods and IUDs often cause side effects that impact health and quality of life. Choosing the right method requires a mindful examination of many factors: age, reproductive goals, past experiences, number of partners, current needs and preferences, attitudes and expectations, knowledge and education, cultural and religious beliefs, physical and mental health, lifestyle, relationship factors, and personal values. Clearly, there are numerous factors to consider.
For patients, their decision often comes down to settling for the lesser of “all evils,” rather than choosing the best method for their body and health. Finding the best fit means having to juggle the benefits of high efficacy with the drawbacks of unpleasant side effects. Since there is no win-win situation for all, the downsides often outweigh the upsides.
Here are 12 steps that Doctors can take
1. Have a more nuanced conversation with patients about the overall differences between contraceptive methods.
After all, each type of method requires a different mindset, priority, value, and skillset: Here’s a way to break them down into four groups.
Methods that require:
- No behavioral effort on the part of the user (IUDs and implants).
- Low levels of behavioral effort (remembering to take a pill every day or replacing a vaginal ring every month).
- Higher levels of effort (diaphragms, spermicides, condoms)
- User-controlled and 100% responsibility (such as the Fertility Awareness Method (FAM) or other Sympto-Thermal Methods (STM), fertility apps and devices).
2. Accept the fact that for many users, statistical efficacy is not the only important factor
When it comes to prioritizing birth control methods, most physicians view statistical efficacy as the over-riding consideration. They naturally want their patients to enjoy the “easiest to use” methods (like HBC and IUDs) as these methods confer high efficacy and are relatively “hassle-free.“ Yet all methods come with a non-monetary “price tag,” and only over time will a patient/couple learn whether their choice was good enough or whether the price they paid was “too high.”
3. Improve communication by asking relevant and personalized opening questions:
- “May I ask you some personal questions that will help decide which method might be the “best fit” for you?”
- “What methods have you used in the past and why did you stop using them?”
- “Since every method has its advantages and disadvantages, what is important to you in a birth control method? Then we can narrow down the options that will best meet your needs and expectations”
- “Are there methods you are thinking about or would like more information about?”
- “Have you made a decision about which method you prefer?”
4. Focus on the client rather than the method
- Listen and conduct a dialogue; try putting yourself in their shoes
- Try to gauge the patient’s needs, priorities, and preferences
- Present the diversity of methods without bias; take cues from patient.
- Personalize the context
- Acknowledge the patient’s right to autonomy, dignity, respect and her right to informed consent. She wants to share and weigh her options; she wants more control, and to be a proactive partner.
- Encourage discussion – at eye level
- “One size doesn’t fit all”
- Remember that a ’safe method’ must coincide with ”safe sex”
- Think “outside the (pill) box”
5. Stay informed
The world and technology are constantly changing. There are increasing numbers of trends and developments to follow (e.g. more patients are abandoning hormones for apps with lower efficacy).
6. Be honest
Be honest with your patients about what you know and don’t know. Before computers, physicians were the primary source of medical information and advice about contraception. Today it is the internet and social media.
7. Accept your time constraints
Physicians have limited time to adequately educate their patients. As such, they cannot be expected to engage in a thorough counseling process. So why not refer your patients to professional and educational resources and websites?
8. Recognize your biases
The goal is to focus on understanding the needs and preferences of the patient. Better to educate and inform rather than use your authority and expertise to convince her to use something that may not be appropriate for her particular needs.
9. Encourage patients to take responsibility
Let them do their homework by reading and collecting information. Women need accurate information about their cycles, their fertility, and all contraceptive method options in order to make informed decisions about their sexual health.
10. Reframe the way you think about efficacy statistics and the way you explain them
Remember to mention the difference between method failure and user failure and that all methods have their advantages and disadvantages. Emphasize that the best method for someone is the method they will use correctly and consistently.
11. Your patients want a partnership and shared decision-making.
Be willing to meet them half-way.
12. Screen your clients
If you are a mental health therapist, be sure to screen your clients by asking if they are taking hormonal methods (associated with anxiety, mood swings, and depression).
It’s a long way from the clinic to the bedroom. You can shorten the travel time by being open-minded and encouraging your patients to be active partners in the decision-making process. Your attitude, support and encouragement will go a long way in helping patients find solutions that will work for them and empower them to take responsibility for their sexual health and wellbeing.
- Contraceptive counseling and selection for women, C. Dehlendorf. UpToDate, 2019.
- Contraceptive Methods Women Have Ever Used: U.S. 1982-2010. K. Daniels, et al. National Health Statistics Report, CDC. Feb. 2013
- Women’s preferences for contraceptive counseling and decision-making. C. Dehlendorf et al, Contraception 88, pp. 250–256. 2013
- Personalized contraceptive counseling: helping women make the right choice. Rodriguez, J. et al. J of Contraception. 2016
- What matters most? The content and concordance of patients’ and providers’ information priorities for contraceptive decision-making. K.Z. Donnelly et al, Contraception 90, 2014
- Contraceptive Counselling: Best Practices to ensure quality communication and enable effective contraceptive use. C. Dehlendorf et al. Clinical Obstetrics & Gynecology, Vol. 57 (4) 12. 2014
- Sexual Acceptance of Contraception: Reviewing the literature and building a new concept. Annual Review Sex Research. J. Higgins and N. Smith, 2016