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. A 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

  • Ask every potentially fertile person about their reproductive goals and wishes.
    • Screening for pregnancy intention gives you information that provides opportunities to support women in receiving the care they deserve, including  education, support and advice to help them make decisions about reproduction and health and access to resources to help them achieve their goals.
    • A standardized and systematic approach is recommended over ad hoc and provider-driven verbal questioning to reduce bias and inequity in screening and service provision.
  • There are  several different models for screening:
    • One Key Question – “Would you like to become pregnant in the next year?”
      • 4 possible answers – Yes, No, Unsure, Ok either way
      • Remember that there is no “right or wrong” answer to this question!
      • Simple and easy to incorporate into routine intake questions and EHR workflows
      • It is very important to also include conversations around “How important is preventing a pregnancy to you?”
    • PATH: Pregnancy Attitudes, Timing, How important is pregnancy prevention?
      • PATH is designed to efficiently reveal relevant information that leads to a patient-centered conversation about preconception care, contraception and fertility as appropriate.
    • Reproductive Life Plan (RLP)
      • Original structure of creating a life plan around childbearing and parenting
      • Some patients may feel challenged by the difficulty of “planning” when so many other life factors make it less relevant.
      • Asks broader questions about the desire to ever have children as well as to consider the timing in one’s life when the person would like to have a family. This can be challenging to do in a clinical encounter, but can be a good approach in the context of other conversations around larger life goals, employment, school and relationships.

 

Risk Reduction Strategies

  • After screening for the person’s desires regarding pregnancy within the next year, provide counseling and education based on her response.
  • The One Key Question and PATH models provide algorithms including follow up questions, and provision of essential education and care.
  • Address contraception if she does not want to become pregnant immediately:
    • Ask what family planning method she wants to use to avoid pregnancy.
      • Abstinence should be accepted as a choice for those who are not in a sexual relationship.
    • Ask how confident she is that she will be able to use the method without problems.
      • If she is unsure about ability to use the chosen method effectively, provide counseling about other methods of contraception.
    • The woman’s desired choice should be matched with its appropriateness given her medical profile.
    • Every clinician is encouraged to download the US Medical Eligibility Criteria for Contraceptive Use (USMEC), 2016 for posting in their offices.
      • A USMEC app is also available for Apple devices
    • If a woman indicates that she desires a short interpregnancy interval (IPI):
      • 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.
    • Encourage every woman to be proactive when their plans about pregnancy change
      • Acknowledge that plans can change
      • Encourage the patient to contact your practice if their pregnancy desires change, so that they can reduce their 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 and how to access them, including emergency contraceptive pills and the copper IUD.. 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

  • Discuss that deciding if and when to have a pregnancy or child is an important first step to help the patient achieve reproductive goals, whether that is avoiding pregnancy or having a healthy pregnancy outcome..
  • Explain that a reproductive life plan is a tool to help women (and their partners) consider what they want to achieve regarding reproduction in both the short- and long-term.
  • Help 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. This is likely to result in more patient centered counseling and better patient satisfaction with the contraceptive method.
  • Encourage the patient to contact your office if she is worried or dissatisfied with her contraception method..
  • Educate women who are choosing no method of contraception or user-dependent methods about emergency contraception (EC) options, including emergency use of the copper IUD and emergency contraceptive pills. Provide information on how to access and use EC.
  • Do not consider responses to the RLP assessment as “right” or “wrong”. View the patient’s responses as an opportunity to start where the patient is and provide relevant education and counseling on health promotion and disease prevention
  • Do not infer that a plan is “good” or “not good”, as this invites the woman to disregard relevant guidance.

Clinical Guidance

  • For women who desire to become pregnant in the next year:
    • The primary care visit 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 components of the toolkit in providing care.
    • Determine when the woman hopes to conceive (e.g. in next month; not for at least 9 months, etc.) and provide guidance and education on appropriate short acting contraception.
    • If appropriate, provide education for the woman about the advantages of interpregnancy intervals of 18-59 months. Remember that decisions about when to become pregnant are highly individualized and based upon multiple considerations. Women 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.
    • Identify preconception risk factors for a compromised pregnancy outcome (such as chronic disease, potentially or proven teratogenic drug exposures, previous poor pregnancy outcome, substance use, etc.) and encourage the patient to delay childbearing until appropriate consultations and alterations in baseline health can be achieved.

Clinical Tools

ACOG. (2015). Emergency Contraception: Practice Bulletin No. 152.. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2015/09/emergency-contraception

CDC (2016) U.S. Medical Eligibility Criteria for Contraceptive Use. Morbidity and Mortality Weekly Report, 65(RR03): 1-103. http://www.cdc.gov/reproductivehealth/UnintendedPregnancy/USMEC.htm

U.S. Medical Eligibility Criteria for Contraceptive Use – smartphone app (Last updated 09/2017) https://itunes.apple.com/WebObjects/MZStore.woa/wa/viewSoftware?id=595752188&mt=8

U.S. Medical Eligibility Criteria for Contraceptive Use Summary Chart https://www.cdc.gov/reproductivehealth/contraception/pdf/summary-chart-us-medical-eligibility-criteria_508tagged.pdf

CDC (2016) U.S. Selected Practice Recommendations for Contraceptive Use. Morbidity and Mortality Weekly Report, 65 (RR 4): 1-66. https://www.cdc.gov/mmwr/volumes/65/rr/rr6504a1.htm

Bedsider Birth Control Methods: https://www.bedsider.org/methods  (Includes information on how to appropriately use each birth control method)

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

Bedsider: Information on Birth Control Methods. https://www.bedsider.org/methods

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 (2016). U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. Morbidity and Mortality Weekly Report, 65(RR03): 1-108.

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.