Last week, ACOG, the most important professional organization representing over 60,000 American gynecologists, issued new guidelines about “patient-centered” contraceptive counseling. Coincidentally or not, the ESCRH (European Society for Contraception and Reproductive Health), held a webinar on the same subject.
It is refreshing to see a shift in language and attitude among gynecologists who understand the importance of focusing on the patient. Contraceptive services are more necessary today than ever before, because fewer couples are marrying, those that do are marrying at later ages, and more people are postponing or declining “parenthood”.
Implementing a patient-centered care model will go far in achieving the goal of true informed consent, shared decision-making and patient satisfaction. It might also lead to higher rates of method continuation and lower rates of unplanned pregnancies. Yet while these new ideas are welcome and praise-worthy on paper, we need to face reality and recognize the many obstacles that will make these guidelines difficult if not impossible to implement.
The statement begins with a claim that “counseling is an opportunity (for gynecologists) to solicit an individual’s values, preferences, and insight into what matters most to them as it relates to contraception.”
While counseling is an opportunity to clarify a person’s needs and preferences, it assumes that physicians have the time, training, skills and openness to engage in the “counseling” process. How realistic is this when a typical clinic appointment is under 15 minutes and physicians have little if any training in counseling. When it comes to communicating accurate information about statistical efficacy, providers tend to overemphasize efficacy for perfect use while under-emphasizing efficacy for typical use. This kind of bias seriously distorts the picture and misleads patients.
Furthermore, most providers are far from being well-informed about all methods of contraception. Without unbiased information, in the context of the specific patient and their individual needs, there can be no true “informed consent.” And finally, if we recognize that counselling about contraception is directly related to sexual issues and sexual relationships, then how do we make sense of the fact that most providers report being uncomfortable discussing sexual issues with their patients?
The American document was jointly produced by ACOG’s Committee on Health Care for Underserved Women. It asserts that providers “acknowledge the historical and ongoing reproductive mistreatment of people of color and other marginalized individuals.”
How might this goal actually be achieved? Does the ACOG committee plan to lobby medical schools to add a course about the (dark) history of modern gynecology? Will a history book on the subject (and there are many) become required reading for gynecology residents?
When the overwhelming majority of gynecologists believe that they know best, and when the number one influence on what physicians actually recommend and prescribe to their patients is information ingested from pharmaceutical companies, then we might need to view all women as underserved.
Furthermore, when nine out of ten British female doctors report sexism in the workplace, what might this say about the behavior and attitudes expressed towards those who identify as LGBTQ? A growing body of literature is addressing these issues. When we acknowledge the deep racial and gender bias and stereotyping in a profession largely characterized by white, male dominance, the default superiority of the male body vs the subordination and inferiority of females and the research deficits in women’s health, it is difficult to imagine a dignified encounter based on true equality.
The document states that physicians should adhere to an “ethical code of shared-decision making which means each patient’s expertise in their own lives and bodies is on equal footing with the clinician’s expertise.”
While virtuous, we cannot ignore the studies that show huge gaps between user desires, satisfaction and expectations regarding contraceptive information received from gynecologists, and their ability to provide such information.
Most physicians are still stuck in the “one-size-fits-all” approach, in large part because they are only familiar with and confident about hormonal and IUD methods. We can only reach “equal footing” and shared-decision making when providers know how to ask relevant questions, listen to what patients are saying, and are fully informed and open to discussing all available options- without bias.
Likewise, female patients need to firmly voice their preferences, concerns and priorities, while adjusting their expectations that the gynecologist can or should “know everything,” is impartial and will always act in an unbiased and ethical fashion. Providers need to understand that their patients are more educated and literate than ever before and are capable of collecting reliable information, weighing the pluses and minuses and reaching their own decisions.
A systematic review confirms that increasing numbers of contraceptive users in western countries do not want to repress their natural hormones nor do they want to suffer the common side effects of hormonal and IUD methods. Look no further than to the millions of people who are ditching hormonal methods for apps and device-based methods.
Are gynecologists listening? While the ESCRH gives lip service to the “shared decision” model, European gynecologists still sound intent about promoting “invasive” methods as the default options. When reading their published articles, one cannot help but get the message that if only providers took a more direct interest in the patient and spent more time “explaining” how methods work, then patients will go along with their advice. This kind of paternalism is disrespectful and outright unacceptable.
Additionally, providers need to be aware that for many, achieving the highest, theoretical efficacy is not the only priority. More and more contraceptive users are prioritizing health, safety, pleasure and quality of life over the convenience, spontaneity and freedom which comes from the suppression of natural cycles with synthetic hormones and the subsequent side effects this causes.
If physicians are expected to be informed by the values of equality and inclusiveness- then it is also time for them to acknowledge the responsibility of male partners and the pressing need for developing effective and reversible male methods. Male partners need to be included in this conversation. Lest we forget that it is men who are fertile 24/7 and not women who are only fertile for less than a week per cycle.
Overall, the shift in perspective by both the American and European professional groups is certainly welcome, but it needs to be followed up by actions and a radical overhaul of the provider-patient relationship as we know it in the context of managed health care.
But let’s end on a positive note: The vacuum for providing counselling around contraceptive issues is being filled by numerous NGO’s like Planned Parenthood in the U.S. and by reproductive and sexual health educators who have been operating outside the formal health system for decades in many countries.
These groups are the front-line, para-health care workers who have studied education, counseling, social work, public health, nursing, psychology and sexuality. They have been trained with the skills to counsel clients and they have the hands-on experience, motivation and time to address the reproductive needs of adolescents and adults in a holistic framework.
The educational models developed by these groups need to be acknowledged. Government recognition, support and expansion of these services is vital, and can reduce the already-burdened pressures on physicians who face serious constraints in providing these services in a clinical setting.
The question that begs to be asked: Should contraceptive counseling even be the responsibility of gynecologists, considering they are not trained as counselors or educators? Perhaps the formal medical system is not the best framework for addressing these needs. Most countries lack a formal infrastructure to provide comprehensive sexual health education and contraceptive clinics that include counselling. The British model stands out as an exception.
In England, contraceptive counseling and clinic services are viewed as an inseparable pillar of the public health system. They are not only supported by the government and government trusts- they are accessible and free of charge! In the rest of the (western) world, perhaps health consumers will be better served by independent, community-based organizations that provide such services, which already exist in many places.
Contraceptive counseling is only one piece on the reproductive health continuum of basic needs. To meet the diverse needs of diverse communities, the current model of “women’s health” care is flawed and inadequate, in part because patients are not part of the conversation which determines policy and because women’s health complaints are still dismissed and trivialized.
Much like Maslow’s hierarchy of needs, we need a comprehensive, integrated and holistic system of health care which expands beyond the narrow confines of accessing birth control when we want to prevent or delay pregnancy, or medical care when we are pregnant or giving birth. We need a comprehensive and holistic system which includes non-physicians too, for providing, healthy sexuality education and communication in addition to mental health professionals who can address sexual abuse and trauma, screening for sexual pain and other sexual problems, sexually-transmitted infections, unplanned pregnancy and abortion and gynecological cancers.
Medical care must include services for marginalized groups, such as the disabled, non-binary people, and others with special needs. The clinic visit with a gynecologist will always be primary, but cannot be viewed as a “one-stop” and “stand-alone” solution for meeting people’s complex sexual and reproductive health needs. If this vision cannot be actualized within the health system then smarter innovators will develop alternatives outside…
It is one thing to issue progressive-sounding guidelines, but words are insufficient if they do not lead to actual change. Implementing a true, patient-centered care model will require tremendous investments and efforts- by medical providers, HMO’s and the gynecological associations. So while we wait for the health system to adapt, it is up to us – health consumers, para-health professionals, community leaders and activists- to envision a more equitable, diverse and inclusive paradigm shift and what the next era of comprehensive reproductive health care might look like. And let us be mindful of the invaluable role of grass-roots, community-based and NGO organizations who are doing this job and meeting the needs of so many. They deserve our unending support and praise.
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