From the Editor

Can we solve the problem of inadequate contraception for women at high risk for adverse pregnancy outcomes?

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In a study of 488,175 women aged 15 to 44 years receiving care from clinicians at Kaiser Permanente Northern California, contraceptive counseling documentation was compared among women prescribed US Food and Drug Administration (FDA) category A or B medications (nonteratogenic) versus FDA category D or X medications (teratogenic).14 The rate at which women had no contraceptive counseling recorded was similar whether a teratogenic (47.6%) or nonteratogenic (46%) medication was prescribed. Clearly, there is a gap between current and optimal practice when teratogens are prescribed to women of reproductive age.

What could improve contraceptive services for women with serious medical problems?One promising approach is to include contraception status as a vital sign for all women and men of reproductive age. Most electronic medical records prioritize assessment of such health vital signs as allergies, smoking status, depression screening, falls prevention, blood pressure, temperature, heart rate, weight, and height. Contraception status is of equal importance to these vital signs in women and men of reproductive age and should be routinely documented.

Another intervention is to create a standard of care in which reproductive-age women with major medical problems are routinely referred to a clinician who has the time and skill to provide a comprehensive contraception visit. Health systems could take greater responsibility for managing the contraception practices of their members. For example, within a given accountable care organization the electronic health record could be used to identify adult women of reproductive age with diabetes and an HbA1c level greater than 7%. These women could be contacted to ascertain their contraception status and their need for a contraception health visit. Electronic health records could be utilized to identify all reproductive-age women taking a teratogenic medication. A computer-generated alert could be sent to the responsible clinician recommending referral to an obstetrician-gynecologist for a contraceptive services visit.15

Pharmacists could be more proactive in highlighting the importance of contraception for women prescribed teratogens and in recommending a contraceptive visit. In some states pharmacists can offer an oral hormonal contraceptive to women who are prescribed a teratogen and at risk for becoming pregnant.

How do you propose to address lack of counseling?As an experienced clinician, you likely have ideas about how to improve contraceptive counseling for women with significant medical problems. Please let me know what interventions you think would best improve the use of contraception in this group of high-risk women by emailing me at OBG Management:

Tell us…What are your ideas to improve contraception counseling for women with significant medical problems that put them at high risk for adverse pregnancy outcomes?

Send your letter to the editor to Please include the city and state in which you practice

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