Before, Between & Beyond Pregnancy

All women and men of reproductive age will achieve optimal health and wellness, fostering a healthy life course for them and any children they may have.

All women and men of reproductive age will achieve optimal health and wellness, fostering a healthy life course for them and any children they may have.
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Family Planning and Contraception Desires Pregnancy

Background

Scope of Problem

  • Unintended/unplanned pregnancies are associated with poorer pregnancy outcomes including:
    • increased likelihood of abortion
    • exposures to potentially harmful substances in pregnancy
    • poor pre-pregnancy disease control
    • late entry to prenatal care
    • increased likelihood of low birth weight in offspring
    • maternal depression
    • reduced school completion and lower income attainment (if woman not married)
  • The current rate of unintended pregnancy is 49%.
  • Approximately 50% of unintended pregnancies occur in a month in which the woman used some form of contraception. This can be explained by:
    • Inconsistent or improper use
    • Discontinuation because of side effects
    • Ambivalence about pregnancy desires
    • Method failure
    • Partner sabotage
  • Short and long interpregnancy intervals (IPIs) have also been associated with increased risks for poor pregnancy outcomes.
    • In 2006, a meta-analysis of 67 articles studying the impact of IPIs determined that intervals < 18 months and > 59 months are significantly associated with growth restriction, low birth weight and preterm birth (Conde-Agudelo et al., JAMA 2006).
    • The analysis also found some suggestion that IPIs < 6 months and >50 months increase the risk of fetal and early neonatal deaths.
    • A recent analysis of interpregnancy intervals found that 35% of the sample conceived pregnancies within 18 months of a previous birth (Gemmill and Lindberg, Obstet Gynecol, 2013).
    • Another analysis found that excess risk for preterm birth may be reduced by up to 8% among African Americans and up to 4% for Causcasians by increasing the interpregnancy intervals to 18-23 months (Hogue, Menon, Dunlop, Kramer. AOGS, 2011).

Preconception Significance

  • Helping a woman achieve the highest level of wellness prior to conception as an important strategy to promote a healthy pregnancy and healthy outcome is difficult if not impossible if women do not actively consider when they want to become pregnant.
  • Addressing interpregnancy intervals can only occur prior to conception.
  • For this reason, the National Preconception Clinical Toolkit is built around assessing and addressing a woman’s reproductive life plan to determine:
    • Who desires pregnancy
    • Who is ambivalent or at risk for an unintended pregnancy
    • Who does not desire pregnancy

Risk Identification Strategies

  • Assessing every potentially fertile woman’s (couple’s) reproductive life plan is an efficient way to focus the primary care visit. The reproductive life plan (“RLP”) allows clinicians to assess desires and risks for conceiving before the next primary care visit.
  • One strategy which is being widely used is available on the CDC website at http://www.cdc.gov/preconception/documents/rlphealthproviders.pdf. The link provides an attractive pdf file that is appropriate for staff education and to post as a reminder of specific guidance in assessing a woman’s (couple’s) reproductive life plan.
  • Initially, many women will indicate they haven’t considered a lifetime reproductive plan. In such cases the following steps are likely to be helpful:
    • Ask woman if she hopes to become pregnant in the next year and tailor care based on the response;
    • Explain that many women haven’t formally considered their short and long term reproductive goals but it is beneficial to think through choices to maximize likelihood of achieving desires with the healthiest outcomes possible;
    • Encourage woman to actively consider her reproductive goals and, when appropriate, to discuss them with her partner, prior to her next visit;
    • Explain that plans are likely to change over time and that is to be expected. What is important is to undertake pregnancy when she is in an optimal state of health;
    • Provide some background information in the form of a handout. A simple introduction to RLPs for women and their partners and a related worksheet can be downloaded as a handout from http://www.cdc.gov/preconception/reproductiveplan.html.
  • Review the information under the toolkit tab “RLPA” to learn more about reproductive life plan

Risk Reduction Strategies

  • It is recommended that after ascertaining the woman’s desires about conception in the next year, the woman be asked:
    • What family planning method she wants to use to avoid pregnancy.
      • Abstinence should be accepted as a choice for women who are not in a sexual relationship
    • How sure she is that she will be able to use the method without problems.
      • If she is unsure about ability to use effectively, counseling about other options is indicated
  • The woman’s desired choice should be matched with its appropriateness given her medical profile.
  • For a woman who indicates she desires a short interpregnancy interval:
    • Provide non-judgmental education about the benefits of longer intervals;
    • Balance the benefits of longer intervals with the woman’s medical history, prior reproductive history, age and other considerations.
  • Every woman should be encouraged to be proactive when their plans about pregnancy change
    • A good strategy is to specifically acknowledge that this happens and provide encouragement to contact your practice before putting themselves at risk for an unplanned (and potentially at-risk) pregnancy.
  • Every woman who does not desire to become pregnant in the next few weeks should be offered information about emergency contraception (EC) options, including emergency contraceptive pills and the copper IUD, as well as advance provision or information on how to access emergency contraception. For a nice resource guide on EC for health care providers and their patients go to http://ec.princeton.edu/emergency-contraception.html.

Important Talking Points

  • Choosing if and when to have a pregnancy or child is an important first decision that will help a woman achieve her goals of either avoiding a pregnancy or having a healthy pregnancy outcome.
  • A reproductive life plan is a tool to help women (and their partners) consider what they want to achieve relative to reproduction in both the short and long term.
  • Helping the woman match her contraceptive choice to her reproductive desires, her confidence about using the method effectively and her medical eligibility for using the method is likely to result in more patient centered counseling and better satisfaction.
  • Accept that all contraceptives have problems by specifically encouraging the woman to contact your office if she is worried or dissatisfied with her method.
  • Accept that users often make errors in using methods of contraception and be sure that women choosing no method and women choosing user-dependent methods are aware of emergency contraception information, including emergency use of the copper IUD and emergency contraceptive pills, and know how to access and use.
  • Responses to the reproductive life plan assessment should never be considered “right” or “wrong” but rather an opportunity to start where the patient is and to provide relevant health promotion and disease prevention education and counseling.
  • Inferring that a plan is “good” or “not good” invites the woman to disregard relevant guidance.

Clinical Guidance

  • The primary care visit for women planning to become pregnant in the next year offers special opportunities to help a woman minimize risks and maximize health status to achieve the healthiest pregnancy and outcome possible. Be sure to consider all of the components of the toolkit in providing care.
  • Based on when the woman hopes to conceive (e.g. in next month; not for at least 9 months, etc.) provide appropriate short acting contraceptive guidance and education.
  • If a woman has a medical condition, refer to the US Medical Eligibility Criteria (USMEC, 2012) to identify an appropriate contraceptive method;
  • If appropriate, education for the woman (couple) about the advantages of interpregnancy intervals of 18-59 months should be offered; keep in mind, however, that decisions about when to become pregnant are highly individual and based upon multiple considerations. Women (couples) who choose to become pregnant with shorter than ideal interpregnancy intervals should not feel judged or be discouraged from working to achieve the highest level of health possible.
  • If the woman’s health profile reveals preconception risk factors for a compromised pregnancy outcome (examples of risk factors include chronic disease, potentially or proven teratogenic drug exposures, previous poor pregnancy outcome, substance use, etc.) the woman should be encouraged to delay childbearing until appropriate consultations and alterations in baseline health can be achieved.

Clinical Tools

ACOG (District II). (2009). Latest Options in EC: A Resource Guide for Health Care Providers and their Patients on Emergency Contraception. http://mail.ny.acog.org/website/ECResourceGuide.pdf>

CDC Recommendations on Reproductive Life Planning (Last updated 2011) http://www.cdc.gov/preconception/documents/rlphealthproviders.pdf

Association of Reproductive Health Professionals (ARHP): CME/CE opportunities including topics on contraceptive counseling. (Last updated 2012) http://www.arhp.org/professional-education/medical-education-opportunities

CDC (2010) U.S. Medical Eligibility Criteria for Contraceptive Use (Adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition). Morbidity and Mortality Weekly Report, 59(RR04): 1-85. http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm

U.S. Medical Eligibility Criteria for Contraceptive Use – smartphone app (Last updated 04/2013)https://itunes.apple.com/WebObjects/MZStore.woa/wa/viewSoftware?id=595752188&mt=8

U.S. Medical Eligibility Criteria for Contraceptive Use Summary Chart http://www.cdc.gov/reproductivehealth/unintendedpregnancy/docs/usmec-color-62012.docx

CDC (2013) U.S. Selected Practice Recommendations for Contraceptive Use. Morbidity and Mortality Weekly Report, 62 (RR 5): 1-60. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6205a1.htm?s_cid=rr6205a1_w

U.S. Selected Practice Recommendations for Contraceptive Use E-book http://www.cdc.gov/reproductivehealth/unintendedpregnancy/ebook.html

National Campaign to Prevent Teen Pregnancy: Tips to Improve Contraceptive Use Booklet (Last updated 2013) http://www.thenationalcampaign.org/resources/pdf/pubs/carefulcurrentconsistent.pdf

Clinician Resources for Advancing Long Acting Reversible Contraception: http://www.larcfirst.com/

Reproductive Health Access Project: Multiple evidence based resources on contraception including the “Quick Start Algorithm,” clinical case presentations, handouts and fact sheets. http://www.reproductiveaccess.org/key-areas/contraception/

Patient Resources

CDC Worksheet on Reproductive Life Planning (Last updated 2011)http://www.cdc.gov/preconception/reproductiveplan.html

Association of Reproductive Health Professional (ARHP): Tool to help women match their characteristics and needs to appropriate methods of contraception. (Last updated 2012) http://www.arhp.org/Publications-and-Resources/Patient-Resources/Interactive-Tools/Choosing-a-Birth-Control-Method

Planned Parenthood Federation: Patient Education on Contraceptives (Last updated 2013)http://www.plannedparenthood.org/health-topics/birth-control-4211.htm

References

Centers for Disease Control and Prevention (2010). U.S. Medical Eligibility Criteria for Contraceptive Use, 2010 (Adapted from the World Health Organization Medical Eligibility Criteria for Contraceptive Use, 4th edition). Morbidity and Mortality Weekly Report, 59(RR04): 1-6.

Conde-Agudelo, A., Rosas-Bermundez, A., and Kafury-Goeta, A. (2006). Birth spacing and risk of adverse perinatal outcomes: A meta-analysis. Journal of the American Medical Association, 295 (15) 1809-1823.

Gemmill, A. and Lindber, L.D.(2013). Short interpregnancy intervals in the United States. Obstetrics and Gynecology. 122 (1) 64-71.

Hogue, C.J., Menon, R., Dunlop. A.L, and Kramer M.R. (2011). Racial disparities in preterm birth rates and short inter-pregnancy interval: an overview. Acta Obstetricia et Gynecologica Scandinavica 90, 1317-1324.

Moos, M.K., Dunlop, A.L., Jack, B.W. et.al. (2008). Healthier women, healthier reproductive outcomes: recommendations for the routine care of all women of reproductive age. American Journal of Obstetrics & Gynecology, 199 (6B) S280-289.