Shared Decision-Making in Contraceptive Care
Shared decision-making (SDM) is a broader framework for contraceptive counseling. SDM asserts that the provider-client interaction should be neither wholly directive nor consumer driven, but instead, shared. The provider brings to the visit their skills and expertise and the client brings their lived experience, needs, and preferences.
Research shows that clients counseled using an SDM approach were more likely to be satisfied with their counseling experience and had significantly higher satisfaction with their method than those who made a choice independently. Importantly, clients who felt the provider had a method preference were less likely to be satisfied with their method.
Dr. Dehlendorf discusses SDM in the video below.
For most contraceptive counseling interactions, Every Body Texas recommends taking a shared decision-making approach. Using this approach means no longer using the tiered-effectiveness of methods as a default to counsel clients. This approach is highly directive to clients and prioritizes effectiveness over all other attributes. Instead, practicing SDM centers the client’s needs and priorities when reproductive life goals are explored. It ensures that reproductive health decisions are made based on both the provider's expertise and the client’s preferences.
Shared decision-making consists of five components:
Click the + to expand the sections below to read more.
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Build rapport and establish trust with the client.
The Family Planning National Training Center’s Contraceptive Counseling Process Guide lists the following activities as ways to establish and maintain rapport:
Warmly greet the client by name and introduce yourself
Be genuine, showing respect and empathy
Ask about the client’s reason(s) for today’s visit, plan and prioritize visit
Explain private and confidential services. If your client is a minor explain they may not be able to get contraception without parental consent.
Ask open-ended questions
Respectfully affirm what you see and hear by showing interest, support, and cultural awareness
Show that you care by listening (verbally and non-verbally)
Reflect on what you observe and hear to gain a deeper understanding (see Toolkit section on OARS)
Summarize key points throughout with a focus on the client’s goals
If using EMR, position the monitor to keep eye contact
Practice with your team on how to establish rapport with the exercise on page 2.1-1 from the Providing Quality Contraceptive Counseling & Education: A Toolkit for Training Staff.
The OARS Model is a great tool for engaging clients and building trust.
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Elicit and inquire about the client’s contraceptive preferences, without assuming that efficacy is of primary importance.
"What is important to you about your method?"
Depending on the client’s response, you may want to have some follow-up strategies.
Effectiveness: Use natural frequencies, for example: “Less than 1 in 100 women get pregnant on IUD” or “9 in 100 women get pregnant on pill/patch/ring”
Frequency of using method: “There are methods you take once a day, once a week, once a month, or even less frequently. Is that something that makes a big difference to you?”
Different ways of taking methods: “How do you feel about the way you use the method? Like a pill vs. a shot?”
Return to fertility: “Is having flexibility with your fertility important to you? How quickly would you want to return to being able to get pregnant?”
(Specific) side effects: Ask the client about previous experiences and/or what they may have heard from their friend’s experiences, for example: “Have you experienced any side effects from birth control?” Be sure to respond to concerns in a respectful manner.“That’s too bad your friend had that experience. I haven’t heard of that before, and I can tell you it definitely doesn’t happen frequently.”
Don’t forget to discuss the benefits of methods as well.
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Provide additional information based on the client’s expressed interests.
Provide scaffolding for decision-making by providing evidence-based information including risks, benefits, and side-effects for contraceptive methods that best align with clients’ stated preferences. This is an Iterative process focusing on information most relevant to the individual and helping them to map preferences on to methods.
Ask yourself: “Given their preferences, what information do they need?”
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Facilitate the selection of a contraceptive method that fits with the client’s preferences.
Based on the information the client provides, help the client select a method that works best for them. The Preventing Pregnancy section of this toolkit can give you more resources.
“I am hearing you say that avoiding pregnancy is the most important thing to you right now. In that case, you may want to consider either an IUD or implant. Can I tell you more about those methods?”
“I’ve heard from you that the absolute most important thing is not getting pregnant, and that you also want something that makes your period lighter but keeps it regular. Let’s look at this chart to explore your options.”
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Make appropriate plans for follow-up and ensure the client understands that if they are dissatisfied with their choice, they can revisit their decision.
Clinic schedules may allow little time for thorough discussions on contraceptive options which means the client may receive a large amount of information quickly. Research suggests that the greater the amount of information presented, the less a client remembers correctly and that 40–80% of medical information provided is forgotten immediately. Therefore, ensuring client understanding is important to ensure successful contraceptive use.
To ensure client understanding, take a moment to:
Invite the client to ask questions
Try asking:
“What questions do you have?”
rather than
“Do you have any questions?”
Invite the client to share back their understanding
Try the teach-back method. For example, you may start by asking:
"We covered a lot today and I want to make sure that I explained things clearly. So let's review what we discussed. Can you please describe how you will use your Nuva Ring and what to do if you have questions?"
Use easy to understand educational tools and handouts to ensure all clients, regardless of their literacy level, can understand
The Reproductive Health National Training Center offers the following educational resources:
- Explaining Contraception: Job Aids for Healthcare Providers - uses plain language to explain how each method functions as well as risks, advantages and potential side effects.
- Birth Control Method Options chart
Other educational resources:
More Tools and Resources
Review Incorporating Shared Decision-Making in the Family Planning Setting and the Improving Contraceptive Counseling through Shared Decision-Making Curriculum for more information on the above components and examples provided.
Every Body Texas recommends providing access to contraceptive decision aids at all phases of the client’s appointment, including availability in the clinic waiting area. Use of a decision aid may help clients determine the contraceptive method most in line with their goals.
The Person-Centered Reproductive Health Program at UCSF developed My Birth Control, a decision support tool to assist people in their selection of a contraceptive method and assist in a shared decision-making approach to contraceptive counseling. The tool was piloted and evaluated and proved successful at helping clients feel more confident about their method choice in addition to other benefits.
Decide + Be Ready is an app-based contraception decision aid originally designed for individuals in the armed forces but can be used by anyone. While not as sophisticated as My Birth Control, it is easily accessible and provides basic information about methods, use, side effects, and return to fertility.
The content on this page was last reviewed and updated in October 2023.
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