Engaging women in discussions about reproductive goals in health care settings is increasingly recognized as an important public health strategy to reduce unintended pregnancy and improve pregnancy outcomes. “Reproductive life planning” has gained visibility as a framework for these discussions, endorsed by public health and professional organizations and integrated into practice guidelines. However, women’s health advocates and researchers have voiced the concern that aspects of the reproductive life planning framework may have the unintended consequence of alienating rather than empowering some women. This concern is based on evidence indicating that women may not hold clear intentions regarding pregnancy timing and may have complex feelings about achieving or avoiding pregnancy, which in turn may make defining a reproductive life plan challenging or less meaningful. We examine potential pitfalls of reproductive life planning counseling and, based on available evidence, offer suggestions for a patient-centered approach to counseling, including building open and trusting relationships with patients, asking open-ended questions, and prioritizing information delivery based on patient preferences. Research is needed to ensure that efforts to engage women in conversations about their reproductive goals are effective in both achieving public health objectives and empowering individual women to achieve the reproductive lives they desire.
In a recently released opinion, the American Congress of Obstetricians and Gynecologists (ACOG) joined a growing number of health care organizations in advocating for “reproductive life planning” in health care settings. Reproductive life planning is a counseling strategy in which women are encouraged to proactively identify their reproductive goals and make a reproductive life plan. Introduced in 2006 by the US Centers for Disease Control and Prevention (CDC) as part of a broader public health effort to improve preconception health, reproductive life planning has since been integrated into practice guidelines for Title X reproductive health clinics and included as a component of the Quality Family Planning Guidelines jointly published by CDC and the Office of Population Affairs.
The public health rationale for reproductive life planning is derived from national health statistics indicating poorer outcomes for women and infants in the US compared to other industrialized nations, including declining but persistently high rates of unintended pregnancy as well as high rates of maternal and perinatal morbidity and mortality. Although data on the effect of reproductive life planning on health outcomes are sparse, the hope is that these conversations will reduce unintended pregnancy by improving contraceptive use and reduce adverse maternal and perinatal outcomes by helping women to address health concerns before conception.
Women’s health advocates and researchers, however, have voiced concerns about the potential for reproductive life planning counseling to have the unintended effect of alienating rather than empowering some women. These concerns are based on research suggesting that planning pregnancy may not be a meaningful or attainable goal for some women and that pregnancy intentions exist on a spectrum, with many women holding complex and conflicting feelings about pregnancy that could make the process of defining a reproductive life plan challenging. Indeed, preliminary qualitative data on the acceptability of reproductive life planning suggest that, while women value conversations about their reproductive goals, their preferences for information vary based on their intentions and feelings about future pregnancy. For example, women without clear desires for future pregnancy may not be open to receiving information about preconception health or to defining a plan for their reproductive futures.
The evolving national discussion about reproductive life planning acknowledges the potential limitations of a narrowly interpreted reproductive life planning framework, as evidenced by online resources recognizing that women may be ambivalent or unsure of their pregnancy intentions and that longer term or “life” planning may not always be a realistic or meaningful goal. Building on this discussion, we explore the evidence underlying concerns about limitations of the framework and propose an expanded approach to accommodate the range of women’s diverse goals and needs using principles of patient-centered care.
Potential Pitfalls of Reproductive Life Planning
In published guidance regarding reproductive life planning, providers encourage women to actively consider whether and when they intend to pursue pregnancy, and then promote effective contraceptive methods among women who do not desire pregnancy and offer preconception counseling to women who desire pregnancy. While it is emphasized that women will move between categories over time and more recent materials acknowledge that women may be unsure about their intentions, the assumption is generally that women with unclear or ambivalent feelings about pregnancy should be encouraged to form a clear intention to either pursue or avoid pregnancy.
Researchers in social science and medicine have long challenged the assumption that pregnancy intention is dichotomous and have suggested that, instead, it is a continuum shaped by a complex set of personal, social, and cultural factors. While many women may have clear intentions to pursue or prevent pregnancy at a given time, studies indicate that as many as 30% of women express pregnancy intentions in the middle of the spectrum, often termed “ambivalence.” Many women perceive both negative and positive consequences of pregnancy and childbearing, which can result in complex or mixed feelings toward a potential pregnancy that cannot necessarily be resolved with counseling.
This potential mismatch between a focus on dichotomous intention and a woman’s own perspectives regarding future pregnancy could negatively impact the provider-patient relationship and interfere with her ability to get the care she needs. For example, a woman who is not actively seeking pregnancy but is open to an unplanned pregnancy might welcome counseling about how to prepare for a healthy pregnancy. If counseling does not elicit the complexity of her feelings about pregnancy, an opportunity to offer preconception counseling might be missed. Furthermore, counseling that does not elicit a woman’s positive orientation toward a potential unplanned pregnancy might result in lack of understanding or judgment by providers of her decision to choose a less effective contraceptive method.
Another potential challenge arises from evidence that “pregnancy planning” may not be a meaningful concept to all women. This may derive from a woman’s general orientation toward planning behaviors or from specific attitudes toward pregnancy and childbearing influenced by cultural, economic, religious, or relationship factors. For example, qualitative studies have shown that some women hold beliefs about religion or fate that lead them to prefer a more passive or less constrained approach to pregnancy, while others perceive drawbacks of active planning such as the disappointment or stress involved with delayed conception.
Studies have also demonstrated that some low-income women do not view pregnancy planning as an achievable goal in the context of their lives. This stems from the fact that the socially acceptable conditions for planning a pregnancy, such as relationship and financial security, may be unattainable for them. Allowing a pregnancy to “just happen” may therefore be perceived by women as more socially acceptable than planning a pregnancy in nonideal circumstances. Although the reproductive life planning framework does not prescribe normative social or economic requirements for planning, providers may incorporate these factors into counseling in a “parental style of authority.” An unintended consequence of this may be that women may experience shame for reproductive choices that lie outside of social norms or feel that judgment on the part of the provider undermines their reproductive autonomy.
Finally, a key objective of reproductive life planning is to facilitate counseling about modifiable preconception health risks at every visit, with the goal of promoting behaviors that lead to healthier pregnancies. Preconception health counseling has the potential to empower women with information, skills, and resources to improve their health in anticipation of a pregnancy. However, evidence suggests that preconception counseling may feel less relevant to women who have no short-term desires for childbearing or are uncertain about their long-term pregnancy goals. Preconception counseling in situations where a woman is not seeking or considering pregnancy could thus be perceived as prioritizing her health as a potential mother or the health of a theoretical fetus over her health as an individual.
A Patient-centered Approach
Discussing pregnancy desires, feelings, and goals in health care settings has the potential to empower women to make informed decisions about their reproductive lives. However, as discussed, the reproductive life planning framework as narrowly applied carries inherent risks, including the risk that providers will overlook critical dimensions of women’s thoughts and feeling about pregnancy and alienate women who do not conform to normative expectations about when and under what circumstances pregnancy should occur.
A first step toward addressing these potential pitfalls is to focus on patient-centered communication ( Table 1 ). Patient-centered care has been increasingly recognized as a critical component of quality health care. Patient-centered counseling aims to provide education to patients that integrates evidence-based recommendations with patient preferences, recognizing that patients’ individual values and preferences should be an integral factor in decisions made about their health care. Achieving this goal requires building partnerships with patients, where patients function as experts on their preferences and needs and providers function as experts on the medical evidence.
| Potential pitfalls | Patient-centered alternatives |
|---|---|
| Assuming all women will have a binary intention to either pursue or avoid pregnancy. | Asking open-ended questions that allow women to express ambivalent or mixed feelings about pregnancy. |
| Assuming that all ambivalence can and should be resolved. | Working collaboratively with women to identify strategies that meet their needs in the setting of ambivalence (ie, preparation for possibility of pregnancy). |
| Assuming that women will perceive unintended pregnancy as a universally “bad” outcome. | Recognizing that some women who do not have an active intention to pursue pregnancy may welcome unintended pregnancy. |
| Assuming that “pregnancy planning” is a concept that all women find meaningful and relevant. | Recognizing that some women may not value planning, or may feel that planning is not attainable due to their life circumstances (ie, lack of financial or relationship stability). |
| Allowing personal judgment of women’s reproductive desires or goals to influence counseling. | Providing nonjudgmental counseling and support, which respects women’s reproductive autonomy. |
| Assuming all women who could potentially become pregnant will be receptive to preconception counseling. | Tailoring information delivery to women’s preferences and needs, based on open conversations about reproductive goals. |
With its prioritization of patient preferences and inherent respect for the diversity of patients’ goals and experiences, the patient-centered care framework provides insight for how to expand the reproductive life planning framework to accommodate the full range of attitudes toward pregnancy. Underscoring the importance of patient-centered care in counseling about reproductive goals, ACOG’s recent committee opinion on reproductive life planning included a recommendation for respectful counseling that elicits patients’ values and preferences.
Several small qualitative studies have examined women’s preferences for counseling related to reproductive desires and goals, and can provide preliminary insights for provider-patient communication in this area. First, studies highlight that women value a comfortable, trusting relationship with providers when discussing pregnancy intentions or goals and prefer counseling that is nonjudgmental. Second, women appreciate when providers initiate discussions about pregnancy goals in clinic visits, as they may be reluctant to raise the issue themselves. Third, women express a desire for providers to elicit their individual values and preferences and deliver information and counseling in a manner that addresses issues that are relevant to them.
Investigation into women’s preferences related to preconception health counseling specifically indicates that women generally prefer an approach that emphasizes promoting healthy pregnancies rather than one that provokes fear of adverse pregnancy outcomes. Several studies found that women with chronic conditions, such as diabetes, may experience stress and fear about their ability to adhere to prepregnancy recommendations and thus prevent pregnancy complications, suggesting a need for supportive counseling that builds self-efficacy.
A Patient-centered Approach
Discussing pregnancy desires, feelings, and goals in health care settings has the potential to empower women to make informed decisions about their reproductive lives. However, as discussed, the reproductive life planning framework as narrowly applied carries inherent risks, including the risk that providers will overlook critical dimensions of women’s thoughts and feeling about pregnancy and alienate women who do not conform to normative expectations about when and under what circumstances pregnancy should occur.
A first step toward addressing these potential pitfalls is to focus on patient-centered communication ( Table 1 ). Patient-centered care has been increasingly recognized as a critical component of quality health care. Patient-centered counseling aims to provide education to patients that integrates evidence-based recommendations with patient preferences, recognizing that patients’ individual values and preferences should be an integral factor in decisions made about their health care. Achieving this goal requires building partnerships with patients, where patients function as experts on their preferences and needs and providers function as experts on the medical evidence.
| Potential pitfalls | Patient-centered alternatives |
|---|---|
| Assuming all women will have a binary intention to either pursue or avoid pregnancy. | Asking open-ended questions that allow women to express ambivalent or mixed feelings about pregnancy. |
| Assuming that all ambivalence can and should be resolved. | Working collaboratively with women to identify strategies that meet their needs in the setting of ambivalence (ie, preparation for possibility of pregnancy). |
| Assuming that women will perceive unintended pregnancy as a universally “bad” outcome. | Recognizing that some women who do not have an active intention to pursue pregnancy may welcome unintended pregnancy. |
| Assuming that “pregnancy planning” is a concept that all women find meaningful and relevant. | Recognizing that some women may not value planning, or may feel that planning is not attainable due to their life circumstances (ie, lack of financial or relationship stability). |
| Allowing personal judgment of women’s reproductive desires or goals to influence counseling. | Providing nonjudgmental counseling and support, which respects women’s reproductive autonomy. |
| Assuming all women who could potentially become pregnant will be receptive to preconception counseling. | Tailoring information delivery to women’s preferences and needs, based on open conversations about reproductive goals. |
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