Reproductive Life Plan

Talking with your patients of reproductive age about their interest in becoming pregnant in the future is one way to focus a primary care visit. This conversation should be approached respectfully and with the intention to support the person in achieving their goals and patience in knowing that many people may find it difficult to answer this question.

The One Key Question® initiative, developed by the Oregon Foundation for Reproductive Health,  is a simple algorithm designed to identify your patient’s preventive reproductive health needs by asking “Would you like to become pregnant in the next year?” and providing the follow up care based on her/their response (yes, no, unsure, ok either way). This question can be treated as one of your practices “vital signs”. Her response will allow you to determine the likelihood of conception and target care appropriately.

Desires pregnancy in the next year and thus needs:

• extra emphasis on preconception content

Is at risk for an unintended or unplanned pregnancy in the next year and thus needs:

• some preconception content because nearly 50% of pregnancies each year are “unintended”
• extra emphasis on family planning and encouragement to deliberately consider her short and long term pregnancy desires

Does not desire pregnancy in the next year and thus needs:

• routine preventive care
• encouragement to seek additional care if her plans about becoming pregnant change
• if sexually active, appropriate contraceptive counseling

Assessing the Reproductive Life Plan

Women who do not desire pregnancy in the next year or are unsure of their desires may become clearer about if and when they want to become pregnant through use of a reproductive life plan.

The Every Woman Southeast Coalition discusses in their webinar, “Who’s Making the Decision?”: Strategies for a Client-Centered Reproductive Life Plan, ways to identify reproductive life plan questions that clarify pregnancy intention, strategies for shared decision making, as well as ethical challenges and potential bias that could influence consumer-provider communication.

Another approach for helping people frame their reproductive life plan, based on previous CDC guidance is available here. The link provides a PDF document that is appropriate for staff education and can be posted as a reminder of the questions and the directions to take based on patient responses. In summary, the CDC approach recommends this series of queries:

Do you plan to have any (more) children at any time in your future? (open-ended and allows branching to yes, no and “not sure”)

• If yes, I do plan to have any or more children at some time in the future

How many children would you like to have? (encourages the person to consider that there is a choice about the number of children one has).

How long would you like to wait until you [or your partner] becomes pregnant? (encourages the woman to vision her own future and allows clinician to determine if the current encounter needs a preconception health orientation, specific information regarding interpregnancy interval, age-related fertility issues, etc.)

What family planning method do you plan to use until you [or your partner] are ready to become pregnant (gives the person an opportunity to formulate and communicate a personal strategy thereby encouraging patient centered counseling).

How sure are you that you will be able to use this method without any problems? (encourages the patient to recognize that methods can have problems and provides clinician opportunity to match counseling and method recommendation to patient’s personal challenges).

• If no, I do not plan to become pregnant ever, or again

What family planning method will you use to avoid pregnancy? (gives an opportunity to formulated and communicate a personal strategy to achieve plan)

How sure are you that you will be able to use this method without any problems? (encourages the patient to recognize that methods can have problems and to consider matching method choice to personal circumstances)

People’s plans change. Is it possible you or your partner could ever decide to become pregnant? (relays the message that plans can change and that is okay, but deliberate decisions about becoming pregnant are possible and desirable).

Ideally, reproductive life plans will have been considered prior to a clinical visit.

RLP assessments can be accomplished many ways:

• Clinical interview
• Including key questions in previsit paperwork
• Completed with other paperwork in the waiting room

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 this 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.

Additional considerations when assessing reproductive life plans:

• 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.
• Formulating a reproductive plan for the short or long term is a process.
• A number of research studies are underway to assess the impact of RLPs
• It is anticipated that routine and consistent reinforcement of the importance of reproductive planning will impact the nation’s unintended pregnancy rate.
• Unintended/unplanned pregnancies are associated with poorer pregnancy outcomes so reducing the rate is likely to impact pregnancy outcomes.

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