Contraceptive counseling in managed care: preventing unintended pregnancyin adults

Abstract

This study examines contraceptive counseling received by adult women in their managed care plans and the relationship between counseling and women’s contraceptive attitudes and practices. Telephone interviews were conducted with a random sample of 898 women ages 18 to 44 enrolled in a commercial health maintenance organization (HMO) or point-of-service (POS) health plan. Counseling received in the past 2 years was measured on three dimensions: exposure through any communication channel; content of information; and personalization of discussion. Multiple logistic regression analysis was used to examine the determinants of counseling and the relationship between counseling and four outcomes: satisfaction with counseling received, self-efficacy for preventing unintended pregnancy, current use of contraception (if at risk of unintended pregnancy), and intent to contracept in the next year (if at risk). Overall, 60.5% of women were at risk of unintended pregnancy; among those at risk, 69% received any counseling in the past 2 years, compared with 38% among those not at risk. Receiving personalized counseling (as opposed to no counseling or only informational counseling) significantly increases the odds of satisfaction with counseling, current contraceptive use, and intent to contracept. Informational counseling alone (without personalization) significantly increases the odds of contraceptive use. Women ages 40–44 were less likely than younger women to receive counseling and to use contraception if at risk of unintended pregnancy. We conclude that receiving contraceptive counseling in managed care is associated with contraceptive attitudes and practices among adults and that there is substantial room for quality improvement in the provision of contraceptive counseling.

Introduction

Unintended pregnancy—that is, pregnancies that are mistimed or unwanted at the time of conception—is an important public health problem in the United States. According to the 1995 National Survey of Family Growth, 49% of pregnancies and 31% of births were unintended, and 54% of unintended pregnancies ended in abortion. The problem is not limited to adolescents, as is commonly thought. While the percentage of pregnancies that are unintended is highest among women under age 18 (about 83%), relatively high proportions are apparent in adult women at the early and later stages of the reproductive age span: 59% of pregnancies among women ages 20 to 24 are unintended, and 51% of pregnancies in women ages 40 and over are unintended. Over their lifetimes, about 48% of U.S. women have an unintended pregnancy, and 28% have an unplanned birth.1 The social, economic, and health consequences (to women, children, and families) of unintended pregnancy have been documented by a committee of the Institute of Medicine.2

A Healthy People 2010 objective is to increase the rate of intended pregnancy to at least 70% of all pregnancies.3 One approach to reducing rates of unintended pregnancy is providing contraceptive counseling during primary care visits. Numerous professional associations (including the American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and American Academy of Pediatrics) recommend counseling patients about preventing unintended pregnancy. The U.S. Preventive Services Task Force recommends “periodic counseling about effective contraceptive methods … for all women and men at risk for unintended pregnancy.”4 Yet there is a lack of research on the relationship between patient counseling in the primary care setting and adult women’s contraceptive use,5 and this information gap hampers efforts to improve pregnancy prevention services.

This study tests the hypothesis that adult women who receive contraceptive counseling in their managed care plans, compared with women who do not receive counseling, have more positive contraceptive attitudes and are more likely to use contraception if at risk of unintended pregnancy.

Enrollment in managed care plans has been growing rapidly, and the majority of insured persons are now in some type of managed care arrangement. In 1998, 54% of all insured women in the United States and nearly two-thirds of privately insured women reported that they were enrolled in health maintenance organizations (HMOs) or preferred provider organizations (PPOs).6 Yet little is known about how health plans assist women to prevent unintended pregnancies. Current quality of care measures used in managed care plans do not address pregnancy prevention, so data are not available on health plan performance. Policy initiatives to date have focused on two issues relevant to pregnancy prevention in managed care: benefits coverage of prescription contraceptives in employer-based health insurance and mandated direct access to obstetrician/gynecologists (ob/gyns).

Lack of insurance coverage of prescription contraceptives is an important barrier to use of the most effective contraceptive methods.7, 8 While Medicaid covers family planning services, many privately insured women do not have access to a contraceptive benefit.9 Research on private insurers finds that managed care plans of all types generally provide better coverage of contraception than traditional indemnity insurance, but coverage varies by type of managed care plan; PPOs and point-of-service (POS) networks are less likely to cover contraceptives than HMOs.10 Furthermore, information about coverage is not readily available to consumers. In a five-state study of managed care plans, researchers found that only half of commercial health plans and one-third of Medicaid managed care plans provided enrollees with a list of covered contraceptive methods.11

State and national efforts to increase contraceptive coverage in employer-sponsored health plans have escalated. As of October, 2000, 13 states had enacted legislation mandating insurance coverage of contraceptives under the same terms and conditions as for other prescription drugs, and another nine states had more limited provisions for contraceptive coverage.9 The Equity in Prescription Insurance and Contraceptive Coverage Act, which would cover all employers, was introduced in Congress in 1997, but has yet to be acted on. Recent rulings by the Equal Employment Opportunity Commission and a federal court in a case brought against Bartell Pharmacy have provided a precedent for defining exclusion of contraceptive coverage from employee health coverage as sex discrimination. These rulings may set a precedent for other cases and may also encourage voluntary expansion of contraceptive benefits by other employers.

Lack of direct access to ob/gyns in health plans is also a potential barrier to contraceptive use. Managed care plans require enrollees to have designated primary care providers (PCPs) who provide referrals to specialists. Most PCPs are family practitioners or internists, rather than reproductive health specialists; nationally, only 7% of women enrolled in managed care plans report that on ob/gyn is their regular physician and 49% see an ob/gyn in addition to their regular physician.6 Generalist physicians may not feel comfortable screening women for exposure to unintended pregnancy or providing contraceptive counseling. Conversely, some women may not be comfortable talking to a generalist physician about their contraceptive needs. Policy initiatives to ensure women’s access to ob/gyns in their health plans have occurred in some states: in 2000, 38 states and the District of Columbia had policies requiring health plans to provide direct access to ob/gyns without a PCP referral, and 16 states and the District of Columbia required plans to permit women to designate ob/gyns as their PCPs.9 Direct access to ob/gyns is a provision of the patients’ bill of rights currently before Congress.

Neither insurance coverage of contraceptives nor direct access to ob/gyns is likely to be a panacea. Improving the delivery of contraceptive counseling and services also will be necessary to reduce unintended pregnancies. Each primary care visit is an opportunity to screen for exposure to unintended pregnancy and to provide information about contraceptive options, but research finds that family planning counseling is not widely provided in primary care settings. In surveys of providers involved in women’s primary care, 26% of internists, 36% of family practitioners, 53% of nurse practitioners, and 65% of ob/gyns reported that they provide routine family planning counseling.12 In the 1995 National Survey of Family Growth, 14.5% of all women ages 15 to 44 reported receiving birth control counseling in the past 12 months; the largest percentage of women receiving birth control counseling (26%) were ages 20 to 24.13 A 1999 national survey of women ages 18 to 64 found that only 35% of women of reproductive age who had visited an ob/gyn in the past 2 years had received counseling on birth control.14 Thus there is much room for improvement in contraceptive counseling.

The availability and quality of counseling are believed to influence individuals’ decisions to use contraception and the effectiveness with which contraceptives are used,15, 16 yet there is no standard definition of contraceptive counseling. The National Survey of Family Growth defines birth control counseling as “counseling about whether to use birth control methods, how to get them, information about different methods, and how they are used.”13 The U.S. Preventive Services Task Force defines counseling interventions generally as “those in which the patient receives information and advice regarding personal behaviors (e.g., diet) that could reduce the risk of subsequent illness or injury.”4 According to the Task Force, the objectives of patient education and counseling are to change health behaviors and improve health status by increasing patients’ knowledge levels and confidence in their ability to affect their health (i.e., perceived self-efficacy). As this implies, counseling is more than imparting information. Bruce distinguishes information-giving, which she does not regard as counseling, from interpersonal relations, or the affective content of the client-provider transaction; the latter is concerned with influencing clients’ confidence, satisfaction with services, and probability of continuity of care.15

Little research on U.S. populations has addressed the relationship between counseling and contraceptive adoption or continued use, particularly among adults.17 Evidence of the effectiveness of counseling comes primarily from evaluations of specific pregnancy prevention programs or from studies of high-risk adolescent populations.2 For example, Nathanson and Becker found that nurse-client interactions in family planning clinics predicted female adolescents’ use of contraceptives over a 12-month follow-up period.18 However, results from family planning clinics, where many clients have formulated an intent to contracept, may not be generalizable to primary care settings.

The plausibility of the hypothesis that counseling is associated with contraceptive use is supported by evidence that provider counseling influences women’s use of other preventive tests and interventions. Studies of mammography screening find that one of the most common reasons reported by older women for not obtaining mammograms is that their physicians did not recommend it.19, 20, 21 In addition, experimental studies have found that education and counseling interventions improve mammography screening rates.22, 23, 24, 25 Studies of hormone replacement therapy (HRT) also confirm the importance of counseling. Newton and colleagues found that physicians were the most important source of information about HRT reported by women in one managed care plan and a strong influence on their HRT use; this occurred despite the fact that substantial proportions of women reported using other sources of information about HRT as well (e.g., print media).26 In the 1998 Commonwealth Fund Survey of Women’s health, the two primary reasons given for initiating use of HRT were a doctor’s recommendation and seeking relief of menopausal symptoms.27 Schauberger and colleagues report that an educational program directed at both physicians and patients increased the rate of HRT use among postmenopausal women over a 3-year period.28

Theories of health behavior attempt to explain how individuals adopt or fail to adopt health-promoting behaviors (e.g., exercise, smoking cessation, use of screening mammography) or maintain those behaviors over time. Theories such as the health belief model, the theory of planned behavior, and the transtheoretical model provide a basis for examining the relationship between contraceptive counseling in the health care setting and contraceptive behavior. These theories recognize that knowledge alone is not sufficient to motivate individuals to adopt health-promoting behaviors and that factors such as values, expectations, and social influences also are important determinants of health behaviors.29 In addition, these theories draw attention to intervening steps between the acquisition of information and health-promoting behavior, such as building self-efficacy and forming behavioral intent.

The function of counseling in the health care setting could be to further the adoption of health behaviors through several pathways. Counseling can provide information and help clarify the options available to the individual, thus empowering individuals to make informed decisions with respect to their health. Counseling can help alleviate fears about specific options or reduce anxiety about social consequences of options, thus addressing some of the nonrational components of health decision making. Providing information and enabling individuals to cope with their concerns help build self-efficacy for behavior change. Counseling also can help individuals move from one stage of behavior change to another—for example, from the precontemplation stage, in which there is no intent to take action, to the contemplation stage, when an intent is formed to change behavior in the near future—or to maintain a health behavior once adopted.

In addition, because women are known to value the quality of communication in choosing a physician or health plan,30 receiving counseling is likely to be associated with higher satisfaction with health care. In the 1998 Commonwealth Fund Survey of Women’s Health, the number of counseling services received in the past 12 months, out of a total of seven counseling topics measured, was the strongest predictor of women’s ratings of their physician’s performance and of the quality of communication with their physicians.6 Satisfaction, in turn, is likely to be associated with return visits to the provider and with adherence to medical recommendations.31

Contraceptive counseling is defined here as a form of interpersonal (as opposed to public) communication. It includes information-giving as well as opportunities for clients to express their concerns, values, and preferences and to ask questions. Information may be provided through multiple communication channels, and using multiple channels may have a synergistic impact, with written or video material reinforcing oral communication.16 In health care settings, counseling may include face-to-face discussions between the patient and her provider; group discussions; peer counseling; telephone hot lines or information resource lines; print or video materials made available in information kiosks or resource centers; and telephone or mail follow-ups or reminders. In the case of contraceptive counseling, the goal is to empower women to prevent unintended pregnancy.

Counseling is conceived as having three dimensions: 1) exposure refers to whether or not any counseling occurs through any communication channels; 2) content refers to the information imparted during counseling; and 3) personalization refers to the degree to which women’s needs and preferences are addressed. The key hypothesis is that receiving any counseling in the past 2 years will be associated with higher satisfaction with counseling received, greater self-efficacy for preventing unintended pregnancy, and, if at risk of unintended pregnancy, intentions to contracept and current use of contraception. A further hypothesis is that counseling that is personalized to the individual’s circumstances will be more strongly associated with contraceptive attitudes and use than counseling that is informational but not personalized. Finally, the associations between counseling and these dependent variables will hold when controlling for provider and respondent characteristics that might be expected to modify the relationship between counseling and attitudes or behavior.