Birth spacing and family planning remain a major public health issue, considered one of the ten greatest public health accomplishments of the 20th century (22,23) and providing women the option to choose whether and when to be pregnant enhances maternal and child health (24-26). Focusing on increasing utilization of highly effective reversible contraception (the term, LARC, was not typically used), the findings from this study revealed issues and concerns of a sample population served by the safety-net hospital in a major southeastern city, including: the role of patients’ goals in their decision making, the importance of women’s support systems, trust and respect for clinicians providing obstetric care, inaccurate and misleading information these women are exposed to, and the absence of religious concerns about contraceptive choices.
Although a number of published studies have examined barriers to adolescent use of contraception including LARC, we identified a notable void for studies that addressed issues and concerns of adult urban women, particularly African American women (14,15,27). While institutional barriers impede use of LARC, other studies have concluded that addressing misconceptions can reduce disparities in utilization of LARC (28-30). For some populations, immediate postpartum LARC placement also appears to have advantages over other strategies to access LARC (31). This study focused on adult women and identified factors, specific to urban adult women, that can influence decisions to utilize LARC. Although findings about contraceptive use and concerns were similar to other studies, immediate postpartum use of LARC did not emerge as an issue. Our results complement those of other studies with other populations such as adolescents (32). Other studies have also documented high interest in LARC by women who have had recent unintended pregnancies and women who do not want to become pregnant within the next two years (33). In particular, the findings from this study are uniquely positioned to inform implementation strategies designed to overcome impediments to optimal patient decision-making concerning use of contraception.
Implications for Policy and Practice:
In addition to the potential role of increased LARC utilization to reduce unintended pregnancies and induced abortions (1,2), shorter periods of birth spacing have increasingly been linked to infant (34,35,36) and maternal (37,38) morbidity and mortality. We conducted this study in the county that has the highest <18 month interpregnancy interval rate of Florida’s 20 largest counties in population size in 2017. The <18 month interpregnancy interval rate for this county, with the largest proportionate African American population of Florida’s larger counties, was also 19.5% higher than the state <18 month interpregnancy interval rate. Public policies that increase access to LARC by decreasing non evidence-based concerns of women as well as reducing the financial barriers are in the public interest as well as the interest of the women who may receive these services.
While family planning including contraception may primarily reside within the purview of public health, primary care and community-based organizations, healthcare institutions play a key role in facilitating the use of LARC immediately following childbirth. At this critical opportunity for providing LARC, these institutions face challenges not only related to increasing access to LARC, but also to effectively communicate with patients to enable informed patient decision making. Concerns about coercive use of LARC (39,40), appear far less relevant where access to LARC by urban minority women in Florida is so limited.
Although organizational issues tend to be the focus of implementation research, the individual patient issues and concerns regarding contraception in general, and effective reversible contraception, in particular, that were identified through this research can pose a substantial barrier to a patient’s decision to utilize LARC during immediately following childbirth. Greater understanding of the issues and concerns of the patient population can enhance provider-patient health communication at this critical juncture. Dehlendorf and colleagues (41-43) have extensively documented the need for improvements in patient counseling and education by providers. The results of this study may be especially useful for two major tools for provider-patient communication, Tailoring and Motivational Interviewing, both which
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We believe these focus group conclusions provide important information which reinforce the basic principles of patient centered implementation strategies such as tailoring and MI based approaches for optimal provider-patient communication related to using LARC. In addition, they can provide clinicians, including those in training, with insights regarding issues important to their patients and facilitate their engaging in effective, empathetic interactions with them.
We found that issues of reproductive coercion associated with contraception did not emerge during these focus group discussions, although these issues have been raised by others in the community. The context that LARC is readily accessible by more economically privileged women and that economically disadvantaged women may have only very limited access to LARC, resulting in denial of effective contraception and greater risk for unintended pregnancy may represent the most relevant social equity issue related to LARC in this population.
The institutional adaptation process represents another key domain of the Consolidated Framework for Implementation Research. Although the provider-patient interaction is only one component of institutional QI, it can be critical to achieving optimal evidence-based outcomes, in this case initiating LARC postpartum, prior to hospital discharge. Key performance metrics for education/counseling can be built into an Electronic Health Record (EHR)-based, simple check list with key points during service delivery (pre- and post-partum). In addition to measurement, data collection and monitoring of key elements of communication, the EHR-based check list can serve as decision support for providers. Key elements such as: a) discussion of patient goals and their relation to having children, b) eliciting and acknowledging support mechanisms, and c) addressing common issues and concerns, could be programmed into the EHR, thereby institutionalizing effective LARC communication as well as providing a mechanism to monitor and track progress related to the primary outcome of patient utilization of LARC.
We suggest that Motivational Interviewing has the potential to counteract inaccuracies and myths in a non-judgmental and respectful manner, particularly since our results indicate the clinicians are relied on to provide accurate information. Consequently, it may be important for providers to be prepared to address some of the common myths such as:
- Contraception is NOT effective. This common assumption can be addressed by explaining the tiered approach to contraceptive efficacy, detailing how some methods are highly effective (implants, IUDs), while others are moderately effective (pills, patch, ring, injections) and still others are less effective (condom, spermicide, withdrawal).
- Contraception causes intolerable side effects that women fear. This concern is best addressed by candidly detailing side effects associated with different contraceptives and addressing fears. In particular, the bleeding changes associated with hormonal contraceptives and IUDs should be candidly reviewed with women considering initiation of this methods. Proactive counselling regarding bleeding changes associated with progestin-only contraceptives has been found to increase user continuation (49).
- Regular ‘cleansing’ provided by menstruation is perceived by some women to be vital to women’s health. In many cases, explicit discussions with women regarding why regular bleeding is not necessary in women using hormonal contraception can address this myth. In some circumstances, pointing out that breastfeeding and pregnant women do not bleed regularly can be helpful. It may also be helpful to point out that changes in bleeding do not mean the contraceptive’s efficacy is diminished. If women concerned about possible negative health effects of not bleeding regularly have access to other women who can describe in a reassuring fashion their own experiences with menstrual changes associated with use of hormonal contraception, this can be helpful. Some women believe that if they do not have regular menstrual cycles, old and unhealthy blood accumulates in their uterus. Acknowledging this concern and pointing out that the lining of the womb becomes thin during use of hormonal contraception or lactation can be helpful.
Our findings from this research have important implications for educational and counseling interventions that have been successfully used to enhance other healthcare services. However, research and evaluation studies will be required to confirm if these approaches are effective in increasing utilization of LARC by urban adult population, particularly immediately following childbirth. This study also has important implications for Implementation Science which tends to focus on organizational factors influencing adoption, while ignoring the need to adapt to concerns of patients. A more patient-centered approach that focuses on patient factors may be critical for more effective adoption of evidenced based interventions, a primary purpose of implementation research.