Engage patients early and often
Experts say that early intervention starting in adolescence and continuing through adulthood can be key to establishing more favorable outcomes, particularly when physicians find ways to check in with patients frequently. "These conversations take less time than we think because our patients know a lot already," says Glenna Martin, MD, a board-certified family medicine physician in Seattle, Wash., and fellow with Physicians for Reproductive Health (PRH). "Primary care providers are creative problem-solvers, so whether [it's] adding a question on the intake form, putting more posters in your office to remind you and patients to talk about reproductive health or a flag in the EHR, everyone can find the solution that works best for them."
Starting this dialogue early with adolescents and young adults can drastically decrease unintended pregnancy rates, as demonstrated by the success of the Colorado Planning Initiative. The initiative, launched in 2009, made low- and no-cost long-acting reversible contraceptives (LARCs) along with additional educational and health services available to low-income women throughout the state via Title X family planning clinics. By 2014, both birth and abortion rates declined by nearly 50 percent for participants aged 15-19 and 20 percent among those aged 20-24.
While such a program may be difficult to mimic in day-to-day primary care practice, annual well child visits offer built-in face-to-face encounters ideal for the provision of sexual health and contraceptive education. The American Academy of Pediatrics (AAP) suggests using motivational interviewing to help young patients talk through their feelings on sexuality, brainstorm solutions that suit their lifestyle and deepen engagement and trust along the way. For those patients who do not wish to practice abstinence, the AAP recommends using LARCS as the first-line contraceptive choice.
The level of parental involvement during these encounters varies. "It's very, very individual [and] goes both ways," Caudle says. "Often, I'll ask the parents to step out, so I can have a private conversation with the child." Other times, parents are the ones inquiring about contraceptives on the child's behalf.
Since birth control does not provide adequate protection against sexually transmitted infections, reiterating condom usage and benefits as part of any contraceptive conversations is warranted as well. Regardless, physicians must carefully navigate these situations and follow their state's confidentiality laws to ensure the preservation of minor patients' privacy.
Beyond the female framework
|Did you know? The CDC offers a preconception checklist for patients called Steps to a Healthier Me and Baby-to-Be. Consider using it as a patient handout to keep the conversation going.|
By and large, females of reproductive age have typically been the core focus of pregnancy risk screenings and reproductive health initiatives. "Primary care physicians have been encouraged to ask any reproductive aged woman they see: Do you plan to get pregnant in the coming year?" says Ingrid Skop, MD, an OB/GYN in San Antonio and chairman-elect of the American Association of Pro-Life Obstetricians & Gynecologists (AAPLOG). While these efforts shouldn't be abandoned, this type of narrow approach may only address one subset of patients, leaving others without access to critical services and counseling.
One often underserved demographic is male patients. "I think it would be useful for PCPs to ask a variation of the pregnancy question to men: Are you in a relationship? Do you and your partner desire pregnancy this year? Are you using effective contraception? Are you having sexual intercourse outside of a relationship?" Skop says. Discussing the risks associated with sexual activity such as unintended partner pregnancy and STIs can be empowering. "As a society, we need to help men feel included and engaged, [especially] in the event a woman becomes pregnant."