Contraceptive counseling is a common healthcare experience in the U.S.¹ The National Survey of Family Growth, a nationally representative survey of women of reproductive age, has found that more than 50% of sexually active women report receiving a family planning service related to birth control in the past 12 months.¹ Contraceptive counseling delivered during this care presents a key opportunity for healthcare providers to help clients achieve their personal reproductive goals, as well as contribute to clients, improved relationships with providers and the healthcare system. Quality contraceptive counseling has been found to be associated with contraceptive continuation² and to help build trust between clients and providers.³ In addition, provision of quality, client-centered counseling that focuses on client experiences, values, and preferences is an ethical goal in and of itself.⁴

Providing Quality Family Planning Services (QFP), published by the Centers for Disease Control and Prevention (CDC) and the Office of Population Affairs in 2014, identifies client centeredness as a core aspect of quality care.⁵ The QFP defines client-centered care as “care [that] is respectful of, and responsive to, individual client preferences, needs, and values; client values guide all clinical decisions.” The National Academy of Medicine’s recognition of the importance of patient centeredness throughout health care⁶ informed the QFP’s emphasis on client centeredness. Client-centered care is particularly important in contraceptive counseling because of the personal nature of reproductive decisions and the complex individual, social, and cultural factors that may influence contraceptive method selection and use.

Research suggests a need for improvement in the provision of client-centered contraceptive counseling. Women have reported dissatisfaction with contraceptive counseling in general, and specifically with the information and decision support they receive.^3,7–9 Understanding client preferences for contraceptive counseling and tailoring the interaction accordingly is essential to providing client-centered care. Efforts in this area are especially important considering challenges that may hinder the delivery of client-centered care, such as time constraints and competing medical priorities during visits.¹⁰

To inform recommendations included in the QFP, CDC and Office of Population Affairs conducted a series of systematic reviews on contraceptive counseling and education during 2010–2011. Efforts to update this series began in 2015. Building on the value QFP places on client-centered family planning care, the updated series includes explicit attention to client preferences for contraceptive counseling. The objective of this report is to summarize the evidence on these client preferences.

The methodology for conducting this systematic review was similar to the approach used in the reviews in the prior series and has been described elsewhere.¹¹ Briefly, six key questions (KQs) were developed (Appendix Table 1, available online) and an analytic framework applied to show the relationships between the population, intervention, and outcomes of interest (Figure 1). KQs 1–5 were included in the prior review on contraceptive counseling¹² and are addressed elsewhere in this issue. KQ 6, which asks, “What are clients’ preferences with regard to contraceptive counseling approaches in the family planning setting?” was added during this review update process, in keeping with QFP’s emphasis on the importance of client-centered care. Although KQs 1–5 address the outcomes and implementation of counseling interventions, KQ 6 is a unique addition in its explicit focus on describing client preferences. This review describes the evidence for KQ 6.

For the review series, 16 electronic bibliographic databases were searched for studies related to KQs 1–6 published from March 2011 through November 2016. Because KQ 6 was not included in the prior review, a limited search was conducted of ten electronic bibliographic databases for earlier research published from October 1992 through February 2011 (six of the 16 databases used for the latter time period were unavailable because of institutional barriers). October 1992 was selected as the beginning date because that is when the Food and Drug Administration approved injectable contraception for use, marking a shift in the range of available contraceptive options, and thus a potential change in counseling preferences. Although fewer databases were used for the limited search, the conclusion was drawn that these databases were sufficient, given that the six excluded databases had not yielded any relevant articles in the search of literature in the latter time period.

Search terms were developed for the updated review series (Appendix Table 2, available online), which were used to identify potential articles related to KQs 1–6 from March 2011 through November 2016; the search terms were revised to be specific to KQ 6 in the search of literature published prior to 2011.

For the review series, a search was conducted of literature related to all KQs 1–6 published March 2011 or later. This review included only those articles addressing KQ 6. The search for literature related to all KQs 1–6 yielded 24,953 citations (Figure 2). Of these, 10,157 were excluded as duplicates. Titles and abstracts were reviewed for 14,796 citations, and 14,591 were excluded, primarily because they described research conducted outside the U.S. or similar setting, were unrelated to family planning, were not original research, or did not describe a contraceptive counseling intervention or client preferences. Full-text articles were reviewed for 205 records. Seventeen articles were identified as addressing KQ 6, in that they described aspects of care for which clients expressed a preference or which were associated with greater patient satisfaction or perceived quality of care. Another review in this issue examines outcomes associated with youth-friendly services.¹⁵ Although there is a minor overlap in findings (specifically regarding the importance of positive provider interactions and confidential services for youth), these two reviews provide uniquely useful bodies of evidence on (1) any family planning services designed specifically for youth and (2) preferences for contraceptive counseling among clients across the reproductive age range (15–45 years).

In the search for literature relevant to KQ 6 published prior to 2011, results included 13,313 citations (Figure 2). Of these, 3,375 were excluded as duplicates, and 9,938 citations were included in the review of titles and abstracts. Of these, 9,880 citations were excluded, primarily for the same reasons citations were excluded in the search of literature published since 2011. There were 58 full-text articles reviewed; the nine articles that met inclusion criteria were abstracted and results were integrated with results of 17 articles published since 2011, for a total of 26 articles describing client preferences published from October 1992 through November 2016. Two articles describe results from the same study and are discussed together in Evidence Synthesis.^16,17

Appendix Table 3 (available online) describes key characteristics, research questions, results, design, and study quality of the 26 included articles. Twelve studies (from 13 articles) used qualitative methods to understand client preferences for contraceptive counseling, with sample sizes ranging from 14 to 42 women.^3,16–27 Five studies used quantitative surveys to obtain descriptive information of counseling preferences (sample sizes ranging from 57 to 1,852 women).^28–32 Three studies used surveys to examine associations between various factors and client preference, satisfaction, or perception of high quality of care (sample sizes ranging from 748 to 1,741 women).^9,33,34 Four studies used mixed methods. Three of these studies had qualitative components and a survey or questionnaire (sample sizes ranging from 15 to 59 women),^7,35,36 and one study used additional data from a chart review (n=7,801 women).³⁷ One clinical trial of a counseling intervention (n=814 women) assessed client preferences as a secondary outcome.³⁸ Female clients or potential clients of family planning services were the population for all studies, with nine studies assessing preferences of adolescent clients specifically.^{18,20,21,23,24,27,29,36,37} Other studies focused on women seeking prenatal and postpartum care,^16,17,30 Latina immigrant women,¹⁹ young women who had experienced pregnancy,”⁵⁶ college students,²¹ homeless women,³⁵ women seeking abortion/^8,31 and women or adolescents seeking emergency care.^20,29,38 Four studies sought to assess differences in preferences between Latina, black, and white participants.^3,9,25,31

Seventeen studies (from 18 articles) were conducted in urban settings in the u.s.^3,16–20,^{22–25,29–31,35–38} Three studies about adolescents were conducted in secondary school settings,^23,27,37 and one study was conducted on a suburban college campus.²¹ Six studies had geographically diverse samples (including urban, suburban, and rural participants) in multiple states or counties in the U.S.,^{7,9,28,32–34} including two with nationally representative samples.^9,32 Two studies were conducted in midsized cities in Western Europe.^26,27 Studies generally had moderate risk for bias and low generalizability to the predefined target population of women of reproductive age in the U.S.

During evidence synthesis, it was inductively determined that results aligned with four domains for client preferences. Results are organized according to these domains. Three domains are derived from Dehlendorf et al.,³ including (1) contraceptive information received in counseling; (2) the decision-making process; and (3) the relationship between providers and clients. An additional domain was addressed by a subset of studies: (4) the context in which contraceptive counseling is delivered (e.g., where, when, and with whom counseling conversations occur). Findings are described by domain and subdomain below. Table 1 depicts article findings by domain and subdomain.

This review included 26 articles describing 25 studies related to client preferences for contraceptive counseling, including 17 articles published in March 2011 or later. A growing number of studies have addressed this topic in the years since 2011, in keeping with an increasing focus on patient centeredness in health care generally⁴¹ and family planning specifically.⁵

Eighteen studies (from 19 articles) provided information on clients, preferences for receiving contraceptive information.^{3,7,16–20,22–25,27,29,30,32–35,38} Results emphasized the value of comprehensive, personalized information to meet the needs and preferences of clients, including but not limited to information on side effects and method efficacy. This evidence suggests that to improve the client centeredness of counseling, providers might use tailored approaches to elucidate what information is most valuable to clients and deliver personalized counseling. Customizing the discussion in this way may also address time constraints that may affect counseling quality.¹⁰ Future research should explore how tailored approaches, such as decision aids and standardized questions to elicit client preferences, may impact patient experience.

Clients had varied preferences for modes of communication. Clients generally valued receiving written or electronic information supplementing verbal information.^{3,16–18,20,22,25,27,35} Visual aids were also useful to clients.^{16–18,23–25,34,35} The availability of multiple forms of written and visual information before, during, and after visits may accommodate clients, various preferences.

Twelve studies (from 13 articles) reported preferences related to the contraceptive decision-making process.^{37,16–19,22,23,25,26,31,34,35} Clients valued respect for their autonomy in making the final decision about contraception^16,23,25,31 and emphasized dislike for provider pressure.^{3,7,17,19,20,22,23,25,35} This domain may be particularly salient for women of color, given that racial/ethnic bias in the promotion of highly effective methods, such as LARC, has been documented⁴² and that two included studies report perceived racial/ethnic discrimination in contraceptive counseling among women of color.^17,19 Finally, multiple studies documented some clients desired some provider engagement in the decision-making process, with emphasis on the client making the final decision.^{3,16,19,23,34} This finding is consistent with results from a study published after the end date for this review (November 30, 2016), which found that patients who reported experiencing shared decision making were most satisfied with their counseling, compared with those who reported making the contraceptive decision by themselves, or who reported the provider making the decision.⁴³

Twelve studies (from 13 articles) indicated client preferences for positive interpersonal dynamics with their providers.^{3,9,16–21,23–25,36,37} Confidentiality was also important in the counseling relationship, especially to adolescents.^{19–21,23,36,37} Although a positive relationship between medical professionals and those they care for is of value in all aspects of medical care, these results underscore their particular importance in the context of the personal and intimate decision-making process around contraception.

Finally, 11 studies included information on the context in which counseling is provided.^{9,16,21,25–30,32,37} Clients had varied preferences for the context of care, including receiving counseling inside or outside of school settings,^23,27,³⁷ in family planning or more general care settings,^{9,21,26,27,29,32} from female providers,^9,25–27 and alongside other reproductive healthcare services.^16,28,30 These results point to the importance of having diverse family planning providers and environments to meet clients’ needs.

Contraceptive care in the prenatal and postpartum period was well received by clients.^16,30 Contraceptive counseling on the day of abortion was not desired by a majority of clients in one study.²⁸ Future research could explore how best to meet the contraceptive needs of clients seeking abortion and when contraceptive counseling is best provided in that context.

A strength of this review is its comprehensive inclusion of studies of any design. This allowed for the inclusion of a diverse range of studies on client preferences for counseling, many including rich qualitative data. When synthesized in a review, this information offers insights to inform future programmatic efforts, interventions, and research.

The included studies document client preferences regarding the content of quality contraceptive counseling, including comprehensive, personalized information provision; decision-making support that prioritizes client autonomy; positive interpersonal relationships with providers; and diverse preferences for the context in which contraceptive counseling is provided. The included studies provide rich evidence that may inform future programs, interventions, and research, enhancing the experience of contraceptive counseling for family planning clients in the U.S.