The Fine Line Between Informing and Coercing: Community Health Center Clinicians’ Approaches to Counseling Young People About IUDs

Abstract

CONTEXT While community health centers (CHCs) are meeting increased demand for contraceptives, little is known about contraceptive counseling in these settings. Understanding how clinicians counsel about IUDs in CHCs, including whether they address or disregard young people's preferences and concerns during counseling, could improve contraceptive care. METHODS As part of a training program, 20 clinicians from 11 San Francisco Bay Area CHC sites who counsel young people about contraception were interviewed by telephone in 2015 regarding their IUD counseling approaches. An iterative grounded theory approach was used to analyze interview transcripts and identify salient themes related to clinicians’ contraceptive counseling, IUD removal practices and efforts to address patient concerns regarding side effects. RESULTS Most clinicians offered comprehensive contraceptive counseling and method choice. While several clinicians viewed counseling as an opportunity to empower their patients to make contraceptive decisions without pressure, they also described a tension between guiding young people toward higher‐efficacy methods and respecting patients’ choices. Many clinicians engaged in what could be considered coercive practices by trying to dissuade patients from removals within a year of placement and offering to treat or downplay side effects. CONCLUSIONS Providers try to promote their young patients’ autonomous decision making, but their support for high‐efficacy methods can result in coercive practices. More training is needed to ensure that providers employ patient‐centered counseling approaches, including honoring patient requests for removals.

Acceptability of immediate postpartum and post‐abortion long‐acting reversible contraception provision to adolescents: A systematic review

“…After LARC-focused education, many adolescent mothers will indicate a preference for LARC, 61 yet data from a recent study demonstrated that in a sample of mostly African-American adolescents, those with higher autonomy decision-making subscale scores were less likely to prefer LARC. 80 The promotion of LARC as a universally acceptable antidote to high adolescent pregnancy rates has received criticism due to inequitably high promotion of these devices to marginalized or priority communities, including teenagers 49 and women in developing countries, 81 and the user's reliance on providers for LARC insertion and removal. 82,83 While a lack of access to LARC amplifies unrealized sexual and reproductive health goals and limits individual autonomy and choice, so, too, can discriminatory promotion and inaccessible LARC removal, potentially leading to negative experiences of care and disengagement from the health system.…”

“…[46][47][48] However, researchers are concurrently attempting to understand adolescent decision-making and document the practices of healthcare professionals in the context of LARC provision, particularly to "high-risk" groups such as adolescents. 49 In a preliminary search of the literature we identified a relative lack of research on acceptability and personcentered outcomes despite increasing emphasis on IPP/IPA LARC. An autonomous contraception decisions.…”

“…Poor accessibility disproportionally impacts adolescents and, in support of this concern, researchers have found that the uptake of LARC methods (including post‐abortion) increases when financial barriers are removed 46‐48 . However, researchers are concurrently attempting to understand adolescent decision‐making and document the practices of healthcare professionals in the context of LARC provision, particularly to “high‐risk” groups such as adolescents 49 . In a preliminary search of the literature we identified a relative lack of research on acceptability and person‐centered outcomes despite increasing emphasis on IPP/IPA LARC.…”

A comparison of contraceptive services for adolescents at school‐based versus community health centers in Oregon

“… 28 , 29 , 30 Furthermore, adolescents who report receipt of contraceptive counseling are more likely to use a moderately or most effective method. 31 Counseling must always respect adolescent autonomy, 32 and counseling for adolescents must be tailored for developmental stage, information needs, and need for confidentiality. 8 , 11 …”

Agency in Contraceptive Decision-Making in Patient Care: a Psychometric Measure

“…1 Several qualitative studies from the patient perspective have explored how provider bias can show up in contraceptive care, limiting the patient's ability to make fully voluntary choices. [2][3][4][5] In this study, we define contraceptive agency as the ability and capacity to decide about contraception, without undue influence, judgment, or coercion from healthcare providers. Contraceptive agency is especially important among patients in communities that have experienced reproductive harms, including from racism or contraceptive coercion in the healthcare system.…”