Tier-Based Contraceptive Counseling

How I Practice Video Series 
Mark Hathaway, MD, MPH, FACOG
Washington, DC

So I talk to women a lot about contraceptive counseling and I try to develop a quite rapport with them off the bat but I also want to make sure that I explain all of the contraceptive methods, especially the most effective ones.  And lots and lots of women in our country have not heard about the most effective methods or they’ve heard some not so great things about the most effective methods.  So there’s many different approaches to talking about different family planning contraceptive methods, I tend to use something called a tier based effectiveness or tier based counseling. 

This is one from bedside. It points to the most effective methods at the top, middle effective, and the least effective. One could argue that you start here and go up or start at the top and go down.  But any way it’s a nice way to categorize the methods.  I rarely go through all the methods, but I want to make sure that I am emphasizing that this is “your choice”, this is the patient’s choice. This is what we call shared decision making or patient-centered counseling. So that she understands that in the end, whatever method she chooses, I am going to support her.

I use a lot of models. In every exam room that I work in I have little IUDs. I show patients exactly what they feel like and they look like. This is a copper IUD, I can let them touch it, feel it. I show them that it’s flexible and bendable. I use my fist and I say this about the size of a uterus, this is a cervix. It goes inside. It’s very, very small.  I have the implants also; I show them that they’re about the size of a match stick and that they’re very pliable and bendable. So I make sure that they have a chance to see them and touch them.  Sometimes I have pill packs in the room and I show them what a pill pack looks like, if they’ve never seen pill packs before.

Then once I’ve gotten through those things and let’s say let’s say I focused on a method that they were really interested in, let’s say an IUD. I’ll go through the effectiveness of it – all of them are 99% effective or more. I’ll talk a little bit about how they work - they probably stop the sperm from getting to the egg, I’ll tell them a little bit about that. I’ll tell them a little bit about the side effects, which is very few, they are very simple, safe, effective to use. And I will mention this particular method will have more bleeding and spotting, I want you to know about that – it’s not a terrible thing, but it is an inconvenience, and I want you to understand that it could happen, and maybe a couple little strategies to help you get through that. Once they choose a method, the decision is all theirs so we confirm with them repeating back the information so again it’s in their hands -- what we call a teach back.  How effective is it, how long is it going to last, what are some of the side effects, what are some of the warning signs that I want to get you back in here as quick as possible or you call us, and when’s the next time I’m going to see you for a follow up. 

And the last thing I like to emphasize is that this is truly all about your decision. You get to decide. But its my job to make sure that you understand that there are some great effective methods out there and there are some not so great effective methods out there. And I don’t explain all of them to you then I’m not doing my job. So contraceptive counselling is really about helping patients see all of the methods, understand them all, and then make a good choice, the choice that’s appropriate for them, and the one that they want. 

This is how I practice.

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