What I talk about when I talk about family planning

Author

Dr. Michelle C. Chan (biography and disclosures)

Disclosures: Received funding from the Society of Family Planning, Fellowship Research Grant, current research: Dispensing and Practice Patterns of Ulipristal Acetate 30 mg (Ella) as Emergency Contraception in British Columbia, Canada. Mitigating potential bias: Recommendations are consistent with current practice patterns, SOGC Contraceptive.

What I did before

In British Columbia, 2024 brings an opportunity to reflect on our family planning practice within medicine. BC started free universal contraception coverage for all residents under the BC Pharmacare program on April 1, 2023, and expanded prescribing to include pharmacists on June 1, 2023.¹ There is evidence that universal, standardized screening for pregnancy intent supports preventing pregnancy and optimizing preconception care for best outcomes.² In my practice I ask:

“Would you like to be pregnant in the next year?”²

Previously, for people at risk of becoming pregnant and who did not want to be, I reviewed contraception options with the patient including natural family planning (rhythm, calendar, withdraw), barrier, combined hormonal options (pill/patch/ring), progesterone-only options (depo/implant/pill), intrauterine devices (hormonal/non-hormonal), permanent irreversible fertility control (vasectomy/tubal). This is in addition to assessing whether there is contraceptive use (consistency and accuracy) and satisfaction with method choice.²

However, I did not use to include options for emergency contraception or abortion during counselling.

What changed my practice

Recent studies on emergency contraception and abortion as options in family planning have changed my practice:

1. A recent provincial study found that there is low awareness of the more effective emergency contraceptive pill, ulipristal acetate.³ Ulipristal acetate is superior to levonorgestrel emergency contraception in preventing pregnancy.⁴ It is more effective up to 120 hours from intercourse, compared to 72 hours for levonorgestrel, and it is more effective for those who are overweight.^5,6
2. A primary care study reviewing patients’ attitudes toward discussing abortion during contraceptive counseling found that normalizing abortion as a family planning option can improve patient experience and decision-making.⁷ The study suggested that patients preferred to be presented with options routinely, and including abortion as an option, was found to be acceptable and least coercive.⁷ This destigmatized unwanted pregnancy and normalized abortion as an option in family planning.

What I do now

I now routinely take the opportunity when reviewing family planning options for people who are at risk of becoming pregnant and do not want to be pregnant to review emergency contraception and abortion as options in family planning. We will collectively recognize, given the abundance of options in family planning, that not all options may be available or acceptable to people in support of their comprehensive reproductive health.

The emergency contraception pill is a last-chance option to prevent pregnancy if a person does not wish to do so in the context of contraceptive failure or no use of contraception.⁸ The emergency contraceptive pill options delay ovulation to prevent a pregnancy.⁵ Ulipristal acetate 30 mg is currently available by prescription only.³ When patients choose a method, I will offer, in addition to their chosen contraception, a prescription for ulipristal acetate should they find themselves in a situation of contraceptive failure or non-use to still try and prevent pregnancy.

I phrase it as:

“We know no method of preventing pregnancy is 100%, sometimes people find themselves in a situation where despite best efforts contraception fails or is not used. There is a pill that one can take to still try and prevent pregnancy in such situations. Do you think this option can be helpful to you/Is this an option you are interested in?”

Abortion is an acceptable family planning option for some people who do not wish to be pregnant. I now routinely bring up abortion as part of family planning counselling.

I phrase it as:

“Sometimes people will experience an unintended or unwanted pregnancy. For people who do not want to be pregnant, there are various options for family planning and one of them is abortion. This is acceptable for some people and not for others. Some people find that learning about all options will help them understand and decide what are or are not acceptable options to them and this may be helpful in choosing family planning options.”

In collective solidarity for comprehensive reproductive health reflecting effectiveness of the method, and the values, needs, and preferences of the person, I call upon us to reflect on our practices and offer our patients, we have the privilege of caring for, all their options in family planning.

It’s what I talk about when I talk about family planning.

Handout

View and download the handout you can use in practice – Mechanisms of action and effectiveness of contraceptive methods.⁹ Download PDF.

Please note: A handout including information on emergency contraceptive pills is in development and will be shared here in due course.

Resources for patients

• Bedsider.org: I write this website on the backside of the prescription. It is an evidence-based up-to-date website that is very user friendly in the way information is organized. Particularly, troubleshooting contraception or starting/stopping contraception is helpful for patients to reference aside from calling up their friendly neighborhood pharmacist. I also explain that it is an American website so some features are not available in Canada. For example, the double rod implant is not an option, pricing is not relevant, and the service provider search functions are only for those in the United States.

Resources for providers

Free eLearning modules:

• We All Have a Role to Play: Increasing Access to Abortion Care in Canada (aussi disponible en français)
• Emergency Contraception Update

References

1. College of Physicians and Surgeons of British Columbia. BC patients get free access to many contraceptives. College Connector. Published April 2023. Accessed April 21, 2023. https://www.cpsbc.ca/news/publications/college-connector/2023-V11-02/04 (View)
2. Allen D, Hunter MS, Wood S, Beeson T. One Key Question^®: first things first in reproductive health. Matern Child Health J. 2017;21(3):387-392. doi:10.1007/s10995-017-2283-2 (View with UBC)
3. Chan MC, Munro S, Schummers L, et al. Dispensing and practice use patterns, facilitators and barriers for uptake of ulipristal acetate emergency contraception in British Columbia: a mixed-methods study. CMAJ Open. 2021;9(4):1097-1104. doi:10.9778/cmajo.202001933 (View)
4. Shen J, Che Y, Showell E, Chen K, Cheng L. Interventions for emergency contraception. Cochrane Database Syst Rev. 2019;2019(1). doi:10.1002/14651858.CD001324.pub6 (View)
5. Canadian contraception consensus chapter 3: emergency contraception. J Obstet Gynaecol Can. 2015;37(10):S20-S28. doi:10.1016/S1701-2163(16)39372-0 (View)
6. Glasier AF, Cameron ST, Fine PM, et al. Ulipristal acetate versus levonorgestrel for emergency contraception: a randomised non-inferiority trial and meta-analysis. Lancet. 2010;375(9714):555-562. doi:10.1016/S0140-6736(10)60101-8 (View or View with UBC)
7. Dianat S, Silverstein IA, Holt K, Steinauer J, Dehlendorf C. Breaking the silence in the primary care office: patients’ attitudes toward discussing abortion during contraceptive counseling. Contracept X. 2020;2:100029. doi:10.1016/J.CONX.2020.100029 (View)
8. Trussell J, Raymond EG, Cleland K. Emergency contraception: a last chance to prevent unintended pregnancy. Contemp Readings in Law Soc Justice. 2014;6:7-38. https://heinonline.org/HOL/Page?handle=hein.journals/conreadlsj6&id=813&div=100&collection=journals. Accessed April 22, 2020. (View with UBC)
9. World Health Organization Department of Sexual and Reproductive Health and Research (WHO/SRH), Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (CCP). Family planning: a global handbook for providers (2022 update). https://fphandbook.org/. Published 2022. Accessed October 9, 2024. (View or View PDF)

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What I talk about when I talk about family planning

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