Contraception Editorial May 2010

Reframing Unintended Pregnancy Prevention: A Public Health Model

By: Diana Taylor, Amy Levi, Katherine Simmonds

The goal of reducing unintended pregnancy was identified in Healthy People 2000,¹ but the measures and objectives created to reach this goal have often focused solely on increasing access to contraception. While increasing access to contraception is a vitally important tool, it does not sufficiently address the problem of unintended pregnancy. Clarifying the roles and responsibilities of primary care clinicians and providing them with state-of-the-art tools and training in this aspect of reproductive health care is equally important for solving this public health challenge. In order to achieve this goal, we need to establish culturally appropriate evidence- and competency-based clinical guidelines for the prevention and management of unintended pregnancy that can be integrated into primary care and the broader health system and that are built on a comprehensive public health framework for pregnancy prevention that specifies the essential competencies required of all members of the health care team.

There are several reasons for health professionals to make unintended pregnancy a high priority. First, unintended pregnancy is an extremely common occurrence in women’s lives — half of all pregnancies in the United States are unintended.² Furthermore, higher rates of unintended pregnancy among African-American and Hispanic women indicate a major health disparity in this aspect of reproductive health.³ Second, unintended pregnancy has negative consequences for the health of women and their children,⁴ and is associatedwith significant costs to the health care system.⁵ In spite of its frequency and significant costs, unintended pregnancy has received less attention in both research and the developmentofclinicalandpreventivecare strategies thanother similarly important health threats. This oversight can be attributed to the general fragmentation of health care services coupled with the politicization of reproductive health, and abortion in particular. These trends have contributed to the persistence of high rates of unintended pregnancy in the United States. Primary care providers have both an opportunity and a responsibility to their patients and society at large to help reduce the number of pregnancies that are not intended.

Role of unintended pregnancy prevention in primary care

In addition to a fragmented system for preventing and managing unintended pregnancies, there is also a severe lack of comprehensive sexuality education in the United States. As a result, many women do not fully understand how the reproductive system works, causing an underestimation of their actual risk of pregnancy, whether planned or unplanned. This lack of knowledge combines with a cultural unease among health professionals about discussing sexual topics, limited time for health care appointments and the lack of a coordinated system of prevention-focused clinical guidelines and evidence-based strategies for unintended pregnancy prevention that results in a system-wide failure to successfully provide prevention services to women at risk of unintended pregnancy.

Prioritizing unintended pregnancy prevention and management in the public health sector

Preventive services have been found to be effective methods to meet national health goals. The US Preventive Services Task Force (USPSTF), first convened by the Public Health Service in 1985, rigorously evaluates clinical research in order to assess the merits of preventive measures, including screening tests, counseling, immunizations and preventive medications .⁶ These primary and secondary preventive service recommendations, originally intended to inform primary care clinicians, now provide definitive standards for preventive services as well as for health care quality measures that address national health objectives.

The second edition of the USPSTF’s Guide to Clinical Preventive Services, published in 1996, included a section on unintended pregnancy and found periodic counseling on effective contraceptive methods for all women and men at risk for unintended pregnancy to be an effective preventative measure garnering a “B” rating, reflecting the highest magnitude of net benefit as well as the highest level of evidence supporting the provision of specific preventive service.⁷ Specific clinical guidelines for all sexually active adults and adolescents were included and recommended. However, in spite of the continuing high rate of unintended pregnancy, especially among minority and low-income women, subsequent guides have not included recommendations for preventing unintended pregnancy. In contrast, most preventive services guidelines in other clinical areas receiving A or B recommendations that are linked to national health goals have been regularly updated.⁶

Furthermore, recent advances in prevention and technology for early detection and management of unintended pregnancies which have demonstrated improved safety and efficacy are not reflected in existing USPSTF prevention guidelines and other evidence-based clinical practice guidelines for the prevention and management of unintended pregnancy are virtually nonexistent. A review of the Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse identifies existing clinical practice guidelines that are narrowly focused on only a few components of unintended pregnancy prevention and management. In Preventive Services for Adults, one of the only guides that mention unintended pregnancy, preconception and pregnancy prevention counseling are classified as “Preventive Services for Which the Evidence is Currently Incomplete and/or High Burden and Low Cost, Therefore Left to the Judgment of Individual Medical Groups, Clinicians and Their Patients (Level III)”.⁸

Although little high-quality research has demonstrated that counseling improves contraceptive use,^9,10 the USPSTF provides guidelines for clinicians regarding effective counseling interventions, and currently recommends that health care providers use every patient interaction as an opportunity to provide prevention-related and health counseling and education.⁶ A number of factors account for the lack of development of unintended pregnancy prevention guidelines. Most important have been severe budget cuts to the federal agencies that have historically provided leadership for sexual and reproductive health care service standards combined with the pervasive politicization of reproductive health, especially contraceptive and abortion care. Furthermore, the agencies such as AHRQ and USPSTF have prioritized development of prevention guidelines for major chronic diseases which have higher quality evidence for meeting national health goals. Finally, development of evidence-based pregnancy prevention guidelines by professional organizations have either not been posted to the AHRQ National Guideline Clearinghouse or have been limited to narrow elements of unintended pregnancy management (e.g., National Abortion Federation’s Abortion Clinical Policies).

Reducing unintended pregnancy by establishing a comprehensive prevention framework

Normalizing contraceptive and abortion services within a prevention framework that is integrated into the broader health system is one way that health professionals can be mobilized to contribute to established national goals for reducing unintended pregnancy. Clinical practice guidelines, when developed by professional consensus and based on systematically reviewed and developed evidence, provides a model for quality care and a strategy map for busy clinicians. However, as discussed, no such comprehensive evidence-based clinical practice guidelines currently exist for the prevention and management of unintended pregnancy. Ideally, such guidelines would address screening and management of early unintended pregnancy using organized, systematic primary, secondary and tertiary prevention strategies.

Primary prevention consists of health care services, medical tests, counseling, health education and other actions designed to prevent the onset of a targeted condition. Routine immunization is one well-known example of primary prevention.¹¹ Primary prevention for unintended pregnancy should focus on activities prior to conception that increase the chance that a pregnancy is desired and planned and minimizes health risks for mother and fetus. Such strategies include preconception care, contraception counseling, culturally appropriate sexual and reproductive health education and dispensing and prescribing contraceptives including emergency contraception. To achieve the Healthy People 2010 objectives for reducing unintended pregnancy,³ a focus on preconceptual as well as perinatal health promotion has been recognized as an appropriate part of women’s health care by the American Academy of Pediatrics;¹² the American College of Obstetricians and Gynecologists;¹³ the Association of Women’s Health, Obstetric and Neonatal Nurses;¹⁴ the March of Dimes⁴ and others. Preconception care overlaps with other Healthy People 2010 objectives that focus on positive health behaviors such as quitting smoking, taking prenatal vitamins, eating well and exercising.

Counseling approaches that mobilize a patient’s own decision and implement her intentions have been associated with successful contraceptive adherence.⁴ Primary care providers can also use their interactions with patients to address other cultural or gender-based influences on unintended pregnancy, including empowering women to negotiate contraceptive use with their partner and helping women identify and internalize their role in planning pregnancies. Health professionals who provide care to women and men of reproductive age in other clinical settings can also incorporate preconception health screening and health promotion strategies into their practice. Both unintended pregnancy prevention and preconception health promotion should be addressed when providing care to patients with chronic diseases. Male partners’ risk factors and the opportunity for pregnancy and infection prevention with male patients should not be overlooked.

Secondary prevention strategies are health care services designed to identify or treat individuals who have a disease or risk factors for a disease but who are not yet experiencing symptoms of the disease. Pap tests and high blood pressure screening are general examples of secondary prevention. Secondary prevention strategies for unintended pregnancy prevention are implemented once a pregnancy is detected. Essential prevention activities at this level include the following: pregnancy diagnostics, including screening for ectopic and early pregnancy loss; counseling and education about pregnancy options, including information about the choices of continuing versus terminating, and when indicated, specific information about adoption, or medication and aspiration abortion; referral and support for any decision reached; and post-abortion care and follow-up that includes psychosocial support and/or counseling, and contraception counseling and provision. Depending on state regulations and professional practice guidelines, prevention activities may include the actual provision of medication or aspiration abortion for some primary care clinicians. Regardless of their scope of practice, all health professionals should be able to appropriately assess individuals who present requesting pregnancy testing or who are at risk of unintended pregnancy and be competent to provide patient-centered counseling and coordinate interventions relevant to the results of that assessment.¹⁵

Tertiary prevention strategies are represented by preventive health care measures or services that are part of the treatment and management of persons with clinical illnesses. One example of tertiary prevention includes insulin therapy to prevent complications of diabetes. Tertiary prevention in women with unintended pregnancy includes identifying and evaluating late unintended pregnancies requiring advanced psychosocial care and support related to continuing the pregnancy, placing the infant for adoption or choosing termination.

Mobilizing primary care clinicians to help solve the unintended pregnancy problem

All health professionals, and particularly primary care providers, have enormous potential to contribute to the realization of national health goals related to unintended pregnancy and reproductive health. Primary care clinicians, such as nurse practitioners, physicians and physician assistants,¹⁶ are uniquely trained in coordinated, family-centered patient care as well as the provision of culturally appropriate patient education that is grounded in the primary care setting. Primary prevention strategies in the form of preconception care should be integrated into all clinical settings in which primary care clinicians provide services. This care would include other Healthy People 2020 objectives, which improve pregnancy outcomes (such as quitting smoking, taking prenatal vitamins, eating well and exercising). Primary care clinicians can also use their interactions with patients to address other aspects of behavior related to unintended pregnancy including empowering women to negotiate contraceptive use with their partner and to identify and internalize their role in planning pregnancies. Finally, to have a greater impact, public health and primary care services must empower women in other aspects of their lives, including increased access to educational and employment opportunities providing safe housing, and reducing influences that engender powerlessness. Developing a national consensus about core prevention competencies for all primary care clinicians that are evidence based and culturally appropriate is an important next step and provides direction for unintended pregnancy prevention clinical guideline development. Education about the prevention of unintended pregnancy at all three levels of preventive care should be a standard component of all professional primary care clinician training programs. Aligning efforts to reduce unintended pregnancies with other public health approaches is the best way to advance this goal.

Acknowledgement: Manuscript review and preparation by Dr. Tracy Weitz and Rebecca Anderson at UCSF/ANSIRH.

Diana Taylor
Advancing New Standards in Reproductive Health (ANSIRH)
Bixby Center for Global Reproductive Health (Bixby Center)
University of California, San Francisco (UCSF)
Association of Reproductive Health Professionals (ARHP)
Oakland, CA

Amy Levi
School of Medicine
UCSF San Francisco, CA

Katherine Simmonds
School of Nursing MGH Institute of Health Professions
Charlestown, MA

References

1. National Center for Health Statistics. Healthy People 2000: Final Review. Hyattsville, MD: Public Health Service; 2001.
2. Jones RK, et al. Repeat abortion in the United States. Occasional Report. New York: Guttmacher Institute; 2006. No. 29.
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13. American College of Obstetricians and Gynecologists. Preconception care (ACOG Technical Bulletin No. 205). Washington, DC; 1995.
14. Hobbins D. Full circle: The evolution of preconception health promotion in America. J Obstet Gynecol Neonatal Nurs 2003;32 (4):516–22.
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16. Donaldson M, et al, editor. Primary Care America’s Health in a New Era. Washington, DC: Institute of Medicine, National Academy Press; 1996. p. 36, 44–5.

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Used with permission from Elsevier, Inc.