Picture a typical primary care visit with a patient who is of reproductive age and may become pregnant. Maybe they’re visiting for a routine physical or an ear infection. Either way, you haven’t seen them recently, so you wait until their primary concerns are answered and then ask a simple screening question: “Do you plan to become pregnant in the next year?” Based on the response and the patient’s unique contraceptive needs and desires, a contraceptive care plan is devised with the patient.
Now for the bigger question: Does this scenario make you nervous? Or maybe it doesn’t seem like your job.
All providers who treat people who can become pregnant should feel confident asking about pregnancy intentions, screening for reproductive health services, and providing patient-centered contraceptive counseling.
Contraceptive care is often siloed within dedicated family planning and women’s health clinics and within certain visit types. Fortunately, that is starting to change as the stakes are higher than ever: reproductive autonomy is being limited across the country, and maternal mortality has reached an all-time high in the U.S., with Black women and those with low incomes the most at risk. But the ability to access the full range of contraceptive services has long been out of reach for many, a problem that predates the dueling crises of abortion bans and increasing poor maternal health outcomes.
A consensus is growing that there should be no wrong door for contraception. The capacity to provide contraceptive care in primary care settings is endorsed as a best practice by both the CDC and the Coalition to Expand Contraceptive Access.
Last month, the Annals of Internal Medicine published a review of current guidance on the various contraceptive options. The reason: “Contraception counseling and provision are vital components of comprehensive healthcare…Internal medicine physicians are uniquely positioned to assess pregnancy readiness and provide contraception.” Earlier this year, JAMA Health Forum published a paper exploring contraceptive service provision by primary care physicians, the goal of which was to help explain (and eventually remove) barriers to contraceptive access for patients relying on Medicaid. HHS recently invested in a multi-year partnership to offer healthcare organizations free training and technical assistance that aligns with current medical guidelines and best practices so they can offer the full continuum of contraceptive care.
This movement toward a world where every provider cares for the whole patient is important. Ensuring every primary care provider can and does play a role in the provision of high-quality contraceptive care is highly compatible with the philosophy of primary care and anticipatory guidance. For some, it may be coupled with complexity — or even controversy. But it’s an approach with promise to improve access to contraceptive services. If done carefully and with an intentional focus on patient-centered counseling and shared-decision making, improving access to contraception will improve patients’ health and well-being.
Around 46% of pregnancies in the U.S. are unplanned. On an individual level, an unplanned pregnancy can be a happy surprise, but we know in the aggregate that unplanned pregnancies increase the risk for health complications for parent and baby. Unintended pregnancy is linked to significantly higher odds of prenatal and postpartum depression — a leading cause of maternal mortality — and a higher risk of interpersonal violence from a partner, preterm birth, and low infant birth weight.
More than 19 million women of reproductive age live in a contraceptive desert, meaning they live in a county where the number of providers offering the full range of methods is not adequate to meet the needs of women who qualify for publicly funded contraception. Other research suggests women may be more likely to see a primary care provider than an ob/gyn for their well woman exam/general check-up. According to a 2020 survey from KFF, 79% of women reported having a general checkup in the prior 2 years, and they were most commonly seen by a primary care provider (62%). In the same survey, only 42% of women overall reported having a gynecological exam within the past 12 months.
Primary care providers will never be able to replace ob/gyns or specialty family planning clinics (nor should they), but they can assist in closing the gaps. This is especially important since states with abortion restrictions are seeing an exodus of ob/gyns and a steep decline in applicants for obstetrics and gynecology residencies.
Many primary care providers already provide contraceptive services, demonstrating the capability. While only 16% of primary care providers offer intrauterine devices and 14% offer the implant, a full 50% of primary care providers offer the pill, patch, ring, or shot. Not only must we increase the number of providers offering the full range of methods, we must also increase the number of providers using patient-centered principles and shared decision-making best practices.
Integrating contraceptive care into primary care services may not seem feasible to some providers. However, it’s possible to break down barriers like poor reimbursement, high inventory costs, and compressed clinic schedules that can make it seem overwhelming to consider screening for and provision of reproductive health services. In the end, equipping primary care providers with the skills and resources to provide the full range of contraceptive services isn’t a question of “can it be done?” It’s something that must be done.
Healthcare providers have a duty to help patients manage and maintain their health. For those patients who can become pregnant, realizing their pregnancy goals (whether that’s avoiding or becoming pregnant) is a key aspect of their health and well-being. Thus, all clinicians who care for patients who can become pregnant should become comfortable discussing pregnancy intent and contraceptive options, and should identify ways that they can embed high quality, patient-centered contraceptive care in their own unique healthcare settings.
Mark Edwards is CEO and co-founder of Upstream USA, a nonprofit working to expand opportunity and reduce unplanned pregnancy. Jennifer Childs-Roshak, MD, is a family physician, former CEO and president of Planned Parenthood League of Massachusetts, and a former member of Upstream’s Massachusetts’ advisory council.