While the unintended pregnancy rate for women ages 15 to 44 years decreased by 18% between 2008 and 2011, almost half of pregnancies in the United States remain unintended.1 On a more positive note, however, women who use birth control consistently and correctly account for only 5% of unintended pregnancies.2 As family physicians (FPs), we can support and facilitate our female patients’ efforts to consistently use highly effective forms of contraception. The 5 initiatives detailed here can help toward that end.
1. Routinely screen patients for their reproductive intentions
All women of reproductive age should be screened routinely for their pregnancy intentions. The American College of Obstetricians and Gynecologists (ACOG) encourages clinicians to ask women about pregnancy intendedness and encourages patients to develop a reproductive life plan, or a set of personal goals about whether or when to have children.3 The Centers for Disease Control and Prevention (CDC) has also developed a reproductive life plan tool for health professionals to encourage women and men to reflect upon their plans.4 So just as we regularly screen and document cigarette use and blood pressure (BP), so too, should we routinely screen women for their reproductive goals.
Ask women this one question. The Oregon Foundation for Reproductive Health launched the One Key Question Initiative, which proposes that the care team ask women ages 18 to 50: “Would you like to become pregnant in the next year?”5 A common workflow includes the medical assistant asking women about pregnancy intentions and providing a preconception and/or contraceptive handout, if appropriate. The physician provides additional counseling as needed. Pilot studies of One Key Question indicate that 30% to 40% of women screened needed follow-up counseling, suggesting the need for clinicians to be proactive in asking about reproductive plans. (Additional information on the Initiative is available on the Foundation’s Web site at http://www.orfrh.org/.)
This approach assumes women feel in control of their reproduction; however, this may not be the reality for many, especially low-income women.6 Additionally, women commonly cite planning a pregnancy as appropriate only when they are in an ideal relationship and when they are living in a financially stable environment—conditions that some women may never achieve.
Another caveat is that women may not have explicit pregnancy intentions, in which case, this particular approach may not be effective. A study of low-income women found only 60% intended to use the method prescribed after contraception counseling, with 37% of those stopping because of adverse effects, 23% saying they wanted another method, and 17% citing method complexity.7
Reproductive coercion from male partners, ranging from pressure to become pregnant to method sabotage, is also common in low-income women.8 Regular conversations that prioritize a woman’s values and experience are needed to promote reproductive autonomy.
2. Decouple provision of contraception from unnecessary exams
Pelvic exams and pap smears should not be required prior to offering patients hormonal contraception, according to the Choosing Wisely campaign of the American Board of Internal Medicine and ACOG.9,10 Hormonal contraception may instead be provided safely based on a medical history and BP assessment. Adolescents, minority groups, obese women, and victims of sexual trauma, in particular may avoid asking about birth control because of anxiety and fear of pain from these exams.11 The American College of Physicians recommends against speculum and bimanual exams in asymptomatic, non-pregnant, adult women.12 Pap smears and sexually transmitted infection (STI) testing should be performed at their normally scheduled intervals as recommended by the US Preventive Services Task Force (USPSTF) and not be tied to contraceptive provision.13
Assess pregnancy status using criteria,rather than a pregnancy text
Use the CDC’s criteria to assess pregnancy status rather than relying on a urine pregnancy test prior to providing contraception. Once you are reasonably sure that a woman is not pregnant (TABLE 114), contraception may be started. Some physicians have traditionally requested that a woman delay starting contraception until the next menses to ensure that she is not already pregnant. However, given the evidence that hormonal contraception does not cause birth defects, such a delay is not warranted and puts the woman at risk of an unintended pregnancy during the gap.15
Furthermore, there is an approximate 2-week window in which a woman could have a negative urine pregnancy test despite being pregnant, so the test alone is not completely reliable. In addition, obese women may experience irregular cycles, further complicating the traditional approach.16
Another largely unnecessary step … The US Selected Practice Recommendations (US SPR) from the CDC notes that additional STI screening prior to an intrauterine device (IUD) insertion is unnecessary for most women if appropriate screening guidelines have been previously followed.14 For those who have not been screened according to guidelines, the CDC recommends same-day screening and IUD insertion. You can then treat an STI without removing the IUD. Women with purulent cervicitis or a current chlamydial or gonorrheal infection should delay IUD insertion until after treatment.