Shared Decision Making in Contraception

Reproductive intentions are a person's plans and wishes about whether, when and how many children to have. Shared decision making is the process in which clinician and patient consider medical evidence and personal values together to reach a choice that the patient owns. Asking about intentions routinely identifies patients who need contraception, those who want preconception care, and those who are ambivalent.

Why intentions matter. They determine the most suitable method duration, the importance of rapid return to fertility, the need for preconception optimisation of chronic disease and the timing of teratogen-safe treatment.

Ambivalence. Many patients are unsure whether they want a pregnancy. Ambivalence is common and valid; it is associated with inconsistent use and should be explored, not dismissed.

Screening question. Ask every patient of reproductive age a simple question such as "Would you like to become pregnant in the next year?" The response directs care.

Preconception folic acid. Folic acid 400 micrograms orally daily from at least 1 month before conception through 12 weeks of pregnancy; 5 mg daily for those with a previous neural tube defect, diabetes, antiseizure treatment, sickle cell disease or obesity.

Medical conditions affecting timing. Diabetes, hypertension, epilepsy, HIV, sickle cell disease, cardiac disease, kidney disease and autoimmune disease benefit from planned pregnancy after optimisation and medication change. Effective contraception until optimisation is achieved is part of disease management.

Shared decision making steps.

• Invite participation: make clear there is a choice and the patient's preferences matter.

• Present options with their benefits, risks and uncertainties in plain numbers.

• Explore what matters to the patient.

• Reach a decision together, or agree on time to decide while providing an interim method.

• Review the choice at follow up.

Linking intentions to methods.

• Pregnancy desired within 1 year: short-acting methods or long-acting reversible methods with prompt return of fertility; avoid DMPA where a quick return to fertility matters.

• Spacing of 2 or more years: implants or IUDs are effective and cost effective.

• No more children: long-acting reversible methods and permanent methods are both appropriate; discuss reversibility and regret.

Postpartum and postabortion. Discuss intentions and methods during antenatal care and before discharge, since ovulation may return before the first period.

Common errors.

• Assuming intentions from age, marital status or parity.

• Pushing permanent methods in young patients without exploring future plans.

• Neglecting to discuss teratogenic risks in patients on medicines such as valproate.

Changing intentions. Intentions change with relationships, health and circumstances. Revisit them at each visit.

Special groups. Adolescents and people living with HIV have the same right to plan pregnancy as other patients; those wishing to conceive need preconception care, viral load suppression and partner testing.

Referral and escalation. Refer patients with chronic disease who want pregnancy for specialist preconception review. Refer patients with subfertility after 12 months of regular unprotected intercourse, or 6 months if aged over 35, for evaluation.