Contraceptive Counselling (NO BABY Tool)

How I Practice Video Series 
Katharine White, MD, MPH, FACOG
Boston, MA

I frequently see patients in my office who have come in for an annual exam or a problem visit who also want to talk about contraception – it’s the “oh by the way, can I get birth control while I’m here?” kind of conversation. And even though I feel like that conversation does require a visit unto itself, I don’t want to deny her access to contraception while she’s in the office with me. So if I only have one or two minutes, I’ll ask her two questions: when does she want to have another baby or a baby and secondly, how important is it to her to avoid pregnancy until then. Because this starts to get at her values about when pregnancy is desired for her and just how effective that birth control method has to be. Because women value a lot in their birth control method and providers often focus mostly on efficacy when things like side effects and how easy it is to stop and start may be just as important for her as how effective the method is. If I’m lucky enough to have more like minutes to have this conversation, I’ll use a tool that I developed called NO BABY.  These letters in “NO BABY” stand for different elements of contraceptive counseling that can elicit some values that might be very important to your patient about her birth control choice.

The first letter is N and it’s a little bit of a cheat because it stands for “inside”. How does she feel about a birth control method that stays inside her body? I can tell a patient that an implant and an IUD are incredibly safe but some women really aren’t comfortable with the idea of a device staying inside, in which case I want to move on to counseling about other birth control methods that she may find more tolerable

The O stands for “okay with hormones” or “OCPs”. How does she feel about a method that has hormones in it? Similarly, to counseling a woman about IUDs and implants, I can give a woman a lot of reassurance that hormones are safe and effective to use but some patients who really don’t want a hormonal method, in which case we should focus our conversation on the non-hormonal methods.

The first B stands for “bleeding” and this is twofold. One, does she have bad periods that she might like to improve, whether bleeding or cramping, with a birth control method? And the second has to do with irregular bleeding and how well she can tolerate that because as we know the LARC methods in particular are associated with irregular bleeding very commonly for the first three to six months of use.

The A stands for “another” as in when does she want to have another or a baby in the future.

The second B stands for “boyfriend or partner.” Does her boyfriend or partner know that she is going to be using contraception and are they supportive of that decision? Because reproductive coercion, where our patient’s partners actively sabotage her birth control choices and efforts is more common that we often realize and if our patients are in a situation where they need a method to be private from their partner, that’s really valuable information for us to know.

And the Y stands for “yearly”. Most of our patients are coming in for yearly exams which is all they would need if they are using an implant or an IUD but if someone wants to use the contraceptive injection they would have to come into the office multiple times a year so it’s important to know if the patient thinks that she can do that. Similarly, how does she feel about going to the pharmacy for monthly refills of something like the pills or the patch.

So these six questions, while not completely comprehensive, get at a broad range of issues that women should think about when they are choosing a contraceptive method 

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