What does “success” look like in a person-centered contraceptive access project?

We recognize the long history of reproductive oppression of Black, Indigenous, and People of Color. It is this history of injustice that requires us to be vigilant against any current efforts that mirror the past. While encouraging that contraceptive access projects are using more inclusive language and increasingly define their work as person-centered, it’s not enough to simply use these terms. Action must be behind the language.

We collectively defined person-centered contraceptive access projects as having the following characteristics:

1. Although clinical quality is incredibly important, we believe that health care providers practicing evidence-based medicine is a minimum expectation. It’s possible for a person to have an interaction with their health care provider that is high quality from a clinical perspective but low quality from a person-centered perspective.
2. Include patients in the design and delivery of any project. Actively receive and act on feedback from patients. The Contraceptive Justice framework (defined below) provides a useful assessment of quality from the patient’s perspective.
3. Routinely ask patients for their feedback on their experience receiving family planning care. The Person-Centered Contraceptive Counseling Measure (PCCC) is an excellent example of a validated performance measure related to the person-centeredness of contraceptive counseling provided. It’s important to use validated measures and surveys because simply asking a patient if they were coerced will not provide reliable data on whether the patient was coerced; coercion is a complex experience that cannot be illuminated with one yes/no question. Furthermore, contraceptive access projects must commit and have processes in place to act on data collected from patient experience and satisfaction surveys.
4. Because uptake is not the same as access, proxy measures related to contraceptive provision do not offer a complete snapshot of physical and financial access. Further, these proxy measures can create significant harm because they can urge providers to promote one method or class of contraceptive methods over patients’ individual choices. Increasing access to contraception does not and should never mean increasing the use of or uptake of contraception. All people should have access to the full range of contraceptive methods and there should never be a target or benchmark for the percentage of people using any particular method or class of methods.
5. Satisfaction with the health care provider is different from satisfaction with a method. Both should be measured from the patient perspective. Method switching and discontinuation do not automatically mean lower satisfaction but instead could indicate the opposite--the patient may feel more comfortable contacting their provider with side effects they do not like and ask for alternative methods.
6. While unintended pregnancy prevention may be a desired outcome for some, current measures of unplanned and unintended pregnancy do not accurately or reliably reflect the complexity of people’s decision around if and when to become pregnant. Asking if a pregnancy was intended or unintended is a convenient way for researchers to assess pregnancy intentions at one point in time but does not always reflect the experience of each patient.  Furthermore, erroneously using unintended pregnancy prevention as a key outcome for all patients of reproductive age leads to the use of directive counseling towards LARC methods as they are highly effective at preventing pregnancy regardless of a patient’s variation in need and preference.
7. Patients should receive contraceptive counseling that is patient-centered and informed by shared decision-making. One of the most common types of patient education tools is the tiered effectiveness chart. Relying on tiered effectiveness as the primary way of discussing birth control options has many limitations and challenges because contraceptive choice is preference-sensitive and personal. Patients may not prefer effectiveness at preventing pregnancy as their primary reason for selecting a method. Other types of more patient-centered tools include information about physical and emotional side effects, cost, ease of use, menstrual impact, treatment of health conditions, STI prevention, etc.
8. Contraceptive access projects that have a particular focus on people with low incomes and/or people without insurance should examine the underlying motivations for only focusing on these populations through a historical and intersectional lens. Efforts to decrease the fertility of certain populations in hopes of “saving money” or “reducing government spending” are grounded in reproductive oppression and eugenics and should be strongly condemned.

Although separate from the characteristics above, it’s important to recognize that a person’s experience with receiving care is influenced by that person’s access to health insurance, confidential services, and a wide range of providers. An uninsured or under-insured person will have far fewer options for accessing care than a person with insurance that they feel safe using.

Next Steps

Developing validated performance measures takes a lot of time and money. While we are supportive of this process, we also recognize many domains of quality will not likely achieve recognition by accrediting bodies. Our vision of every person receiving quality, person-centered care is only radical because quality is rarely defined as responsive to the needs and preferences of individuals.

We propose the development of a patient-developed assessment that clinics could use to determine if they are providing high quality, person-centered care. This would include a community informed process to define reproductive well-being using the Contraceptive Justice framework, which identifies thirteen domains of high quality health care, see below.

Contraceptive Justice is all people having the social, political, and economic power, rights, access, and resources to receive contraceptive care that is:

• Person-Centered: respectful of and responsive to each person’s values, preferences, and needs and ensures that the person’s values guide all health care decisions (i.e., honors your values, preferences, and needs)
• Confidential: practices ensure privacy regarding personal, identifiable medical information  and recognize the right of all people, including young people under 18 years of age, to provide informed consent in order to disclose such information.
• Comprehensive – providing complete information and the full range of services and methods
• Medically Accurate – providing information that is supported by objective scientific research
• Developmentally Appropriate – providing information that is responsive to a person’s age and/or stage of social, emotional, physical, and cognitive development (i.e., respectful of both the patient’s stage in life and individual needs)
• LGBTQQIA+ Affirming – affirming of and providing information and services relevant to Lesbian, Gay, Bisexual, Transgender, Queer, Questioning, Intersex, and Asexual identities and communities (i.e., affirming of all sexual orientations and gender identities)
• Accessible – easily approached or obtained financially and physically
• Trauma-Responsive – acknowledging the reality and impact of trauma and responding with appropriate care
• Culturally and Linguistically Affirming – providing effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred language, health literacy, and other communication needs (i.e., affirming of all cultures and in the patient’s preferred  language)
• Harm Reduction Grounded – reducing the harm or risk associated with environments and experiences through practical policies, programs, and practices that meet people where they are at
• Pro-Choice – affirming of the basic human right to self-determination, including to the right to use or not use contraception, choose a preferred method of contraception, or a pregnancy option such as abortion (i.e., recognizing that while the Pro-Choice movement has focused on abortion, the right to maintain bodily autonomy extends beyond one health care service)
• Sex- and Body-Positive – affirming and supporting that any sexual activity that is safe and consensual and that all bodies are good bodies (i.e., not tolerant of slut-shaming and fatphobia)
• Challenging of Explicit and Implicit Bias, Shame, and Stigma – recognizing that good intentions are not enough and actively working to reflect on and interrupt bias, shame, and stigma and the systems of oppression that create them (i.e., anti-racist, intersectional, moving from ally to accomplice)

One way to operationalize these concepts is through a patient-driven quality assessment process, described below. This assessment process is in the concept development phase currently; we welcome feedback on this idea.

Patient-Driven Quality Assessment Process

Phase 1

We propose the development of a clinic quality self-assessment tool that is driven by the lived experience of patients. This publicly available clinic self-assessment tool would provide clinics with a starting point for action. Patient Advisory Councils in three distinct geographic areas would co-develop the clinic self-assessment tool based on the Contraceptive Justice framework defined above and a set of domains of quality that contraceptive care should meet.  These Councils would develop and test a prototype clinic self-assessment tool in three locations with a set of pilot clinics. We recognize that clinics and providers will need additional support, time, and resources to meet the definition of person-centered.  A process evaluation throughout Phase 1 would reveal the actual time and money it takes to implement quality improvement efforts based on this clinic assessment tool.

In addition to clinics completing the self-assessment tool, patients would complete an online assessment of their experience receiving care. Patient assessments would be combined with clinic self-assessments to provide an overall picture of quality from multiple perspectives. The most important starting point for all of this work is a patient-driven, community-informed assessment tool.

Phase 2

At the end of Phase 1 we would make the clinic assessment tool available to the public and offer resources to clinics who wish to improve their quality, based on lessons learned from Phase 1. To encourage implementation of this new tool, we would begin with outreach to current contraceptive access projects and Title X grantees.

We expect this process to require time, money, and collaboration. However, we are at a crossroads as a movement. We can continue focusing on specific methods for specific people in specific places or we can move to a vision of quality care that is truly reflective and affirming of people’s lived experiences.

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