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Shared Decision-Making in Contraceptive Care

Shared decision-making (SDM) is a broader framework within which contraceptive counseling may be conducted. 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 women 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. Additionally, clients who felt the provider had a method preference were less likely to be satisfied with their method.

Interested in learning more about incorporating shared decision-making into sexual and reproductive health care? Watch Dr. Dehlendorf’s discussion on SDM here.

For most contraceptive counseling interactions, Every Body Texas recommends taking a shared decision-making approach. Using this approach means providers no longer use the tiered-effectiveness of methods as a default to counsel clients (a previously recommended practice that is mostly directive in its approach). Instead, practicing SDM centers the client when reproductive life goals are explored and ensures that reproductive health decisions are made based on both the providers expertise and the client’s preferences.

Shared decision-making consists of five components:

1. Build rapport and establish trust with the patient.

    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
    • Ask open-ended questions (see Toolkit section on Other Counseling Tools)
    • 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 this exercise from the Providing Quality Contraceptive Counseling & Education: A Toolkit for Training Staff.

    2. 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?"

    • 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
    • Return to fertility
    • (Specific) side effects

    Ask 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.

    3. 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?

    4. Facilitate the selection of a contraceptive method that fits with the patient’s preferences (see Pregnancy Prevention section of the Toolkit).

    “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.”

    5. Ensure the patient understands that if they are dissatisfied with their choice their decision can be revisited and make appropriate plans for follow-up.

    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.

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