We explored the perspectives of providers working in four multidisciplinary primary care clinics at a single health system regarding challenges to contraceptive counseling in primary care. This study was conducted as part of a larger effort to develop system-based strategies to improve contraceptive counseling within our health system. Providers cited multiple challenges to the provision of contraceptive counseling services in their practices. Similar to studies on barriers to the provision of general preventive services17
and STD screening18
in primary care, providers reported challenges at the provider, perceived patient, and health system levels. Our results suggest that no single approach to improving provision of contraceptive counseling services will likely suffice. Rather, a variety of strategies is needed to effectively improve the provision of these services.
Many reasons have been suggested to explain why primary care providers do not offer recommended prevention services to patients, including lack of reimbursement, patient refusal, and lack of time. Studies demonstrate that the large number of screening and counseling recommendations make provision of prevention services, including contraceptive services, challenging.12,19–21
Hence, providers often feel forced to decide whom to provide services to on a case-by-case basis. Our finding that providers' use of a variety of techniques to identify women to whom they will provide contraceptive counseling reflects this. Although we acknowledge the existence of financial, time, and system-based challenges that can be cited to explain the low rates of delivery of contraceptive counseling services in primary care, the reality is that existing practices that restrict a woman's access to complete information or referral services have been construed by some as unethical. The provision of basic contraceptive counseling is part of the scope of basic practice for PCPs,7
and many providers are not meeting this requirement. Certainly, referring patients with complicated medical histories for contraceptive counseling with a contraceptive specialist makes sense; however, the vast majority of reproductive-age women do not fall into this category and would benefit from brief, targeted contraceptive counseling delivered in the primary care setting. Providers need to strike a careful balance between addressing patients' acute care and prevention needs, maximizing reimbursement and adhering to time constraints. Given the low reimbursement rates for contraceptive and family planning services, cost-effective solutions are needed to help providers appropriately identify patients in need of contraceptive services.22
In the meantime, policy advocates should continue to lobby to obtain adequate reimbursement for contraceptive and other family planning services.
Providers overwhelmingly thought that they lacked the knowledge and skills to provide contraceptive counseling. Over the last three decades, studies have consistently reported that contraceptive training for PCPs is insufficient.23–32
Opportunities for practicing providers to obtain continuing medical education (CME) regarding advances in contraceptive methods also are limited.24,33
Thus, our finding that providers' report an overwhelming lack of knowledge, comfort, and self-efficacy for providing contraceptive counseling services comes as no surprise; however, it is disconcerting that this problem persists. Developing standardized curricula in contraception counseling, adding contraceptive questions to provider certification examinations, offering CME opportunities, and increasing the availability of electronic counseling resources represent just a few tools that have been proposed to address the problem.33
Success depends on training programs and health systems assuming responsibility for making these things happen.
Providers described a number of barriers they believe patients bring to contraceptive counseling encounters that limit effective counseling interactions. These include preexisting patient preferences for particular methods, patient desire for pregnancy or pregnancy ambivalence despite medical contraindications to pregnancy, and religious prohibitions, to name a few. Providers' perspectives of patient-level barriers are surprisingly similar to women's own reports of what limits their use of effective contraceptive options.34
These challenges represent areas of conflict during patient-provider communication about contraception that may cause reduced contraceptive counseling because of patient refusal to engage in counseling discussions (or lack of follow-through with contraceptive recommendations), as opposed to provider noncompliance with counseling guidelines. To develop effective approaches for increasing the provision of contraceptive counseling, it is critically important that we understand the barriers that patients and providers bring to the counseling process. Few studies have assessed optimal strategies for counseling women about unintended pregnancy and contraceptive use.34
Client-centered counseling techniques, such as motivational interviewing approaches, have been proposed.35,36
However, more rigorous randomized controlled trials of such interventions are needed to test the efficacy of these approaches for assessment of women's contraceptive needs.37
The major barrier to contraceptive counseling will always vary between individual providers. Thus, an effective strategy for increasing contraceptive counseling may be to make screening for pregnancy intentions and assessing a woman's contraceptive need routine for all reproductive-age women. As with pain assessments, all reproductive-age women could be asked about their pregnancy intentions and current contraceptive use at every visit, not just at annual examinations or when patients have specific reproductive complaints. This brief screening would remind providers to address both contraception and preconception counseling. Although one may think contraception might not come up during an acute care visit for an infection, it often should. If, for example, during an acute care visit, an antibiotic or other medication is prescribed whose metabolic pathways interfere with contraceptive effectiveness, the provider must be attuned to the potential medication interaction and recommend that the woman use a backup contraceptive method temporarily. Similarly, if during any visit, a new medical diagnosis is made for which pregnancy is contraindicated or increases a women's risk of complications for herself or her fetus, the provider should recognize this, address it, and offer contraception, if appropriate. Integrating routine screening into clinic routines would also help patients and providers to view this topic as a normal, expected part of primary care. As found with pain screening, however, mandatory screening will not ensure that providers respond appropriately to women's need for information, especially if providers lack confidence about their contraceptive knowledge.38
This study was motivated by our interest in identifying system-based strategies to improve contraceptive counseling within our health system. Although no single intervention is likely to address all barriers to contraceptive counseling in primary care, EMR systems have been proposed as an important systems-based tool for identifying patients in need of contraceptive counseling.39
Based on our results, two functionalities of EMRs were suggested: routine prompts for providers to provide contraceptive screening and counseling and links to up-to-date information about contraceptive methods and medical eligibility criteria, especially for medically complicated patients.40
For example, if a patient has a medical condition and her provider is unsure if a particular method is appropriate to use, hyperlinks within the EMR could rapidly give the provider access to online resources, such as Micromedex or the World Health Organization's Medical Eligibility Criteria. EMR systems have not yet been universally implemented in the United States and will not address all barriers, such as patient-level barriers, time constraints, or the need for skilled personnel to initiate the most effective and least user-dependent contraceptive methods (e.g., IUDs, Implanon). Developing creative ways to provide contraceptive services outside of the traditional physician-patient face-to-face encounter is warranted. Contraceptive counseling offered via group visits with physicians, physician extenders, or health educators has been proposed. Social marketing campaigns using print or electronic media to educate women about their contraceptive choices represent another option.21,33
Given the complexity of factors limiting the provision of contraceptive counseling in the primary care setting, practices that employ several strategies will likely be most effective.
There are several important limitations to mention. First, we examined a heterogeneous group of provider types. Different provider types (pharmacist, nurse practitioner, physician) may have differing levels of knowledge, training, or comfort regarding contraceptive counseling. Similarly, they are subject to different professional norms that influence their counseling practices.22
This study was unable to tease out these differences. Second, our sample lacked gender and racial/ethnic diversity. Although findings were consistent between focus groups, suggesting their validity, we cannot exclude the possibility that a different sampling framework that stratified by gender or race/ethnicity might have identified different or additional themes. Third, the qualitative nature of this study allowed us to identify the range of barriers consistently cited by providers within our system; however, our approach did not allow us to rank these items or determine which are the primary barriers operating at each level.41
Fourth, this set of barriers is not exhaustive. We identified barriers that pertain to the provider community; additional challenges to the promotion of contraceptive counseling certainly exist. Finally, we present only provider perspectives. Patients may perceive a different or additional set of barriers. To effectively improve contraceptive counseling services, the challenges of both must be understood and addressed.