contraceptive counseling

Policy and Economics Brief
Executive Summary
The Department of Health of Human Services has a mandate to increase the proportion of wanted pregnancies by 10% by 2020, which means reducing unwanted pregnancies. While there are a number of different options for achieving this, the one that is most proven in terms of the literature is structured contraceptive counseling. As our clinic has a mandate to safeguard the health of the women in our community, and as unwanted pregnancies have a variety of adverse impacts, particularly on vulnerable populations, we should offer structured contraceptive counseling. To do so would allow us to reduce the number of unwanted pregnancies among our patients, improving their health and economic outcomes. Further, the economics of such counseling are exceptionally positive. As with a lot of preventative medicine, structured contraceptive counseling costs little in terms of either fixed or ongoing costs. Furthermore, because it diverts patients away from unwanted pregnancy, it lowers the demand on our services, which will in turn have a net opportunity benefit, rather than an opportunity cost.
Background and Significance
Reducing the unintended pregnancy rate in the United States is a national public health goal, driven by the Department of Health and Human Services, which aims to see an increase by 10% in the proportion of pregnancies that are intended between 2010 and 2020 (Guttmacher Institute, 2016). In 2011, 45% of pregnancies in the US were unintended. There are significant social, economic and health consequences to unintended pregnancies, and these are the issues that are driving the campaign to increase the proportion of intended pregnancies. In particular, it has been found that unintended pregnancy is correlated with lower rates of positive health behaviors during the prenatal period (Lindberg et al, 2015). The consequences are more strongly negative the younger the mother is. For teen mothers, unintended pregnancy is associated with increased dropout rates, living in poverty and reliance on public assistance (Logan et al, 2007). There are also mental health consequences for the mother later in life associated with unplanned pregnancy (Herd, et al, 2016).
There are social and economic consequences as well as the health consequences. Some of the documented negative social and economic consequences are reduced quality of life, diminished workforce efficiency. Furthermore, public health care systems often bear the burden of the cost, largely because unintended pregnancies often lead to poverty, or occur more frequently in low income communities (Guttmacher Institute, 2016). 64% of births from unintended pregnancies were publicly funded, compared with 48% of all births and 35% of births resulting from planned pregnancies (Sonfield, et al, 2011). Across social, economic and health measures, none have been found to improve with unplanned pregnancy. This is the background against which HHS has instituted its policy to reduce the number of unplanned pregnancies.
The HHS mandate, and the public health consequences, are the drivers of the policy being proposed in this document. It has been documented that abstinence programs are ineffective at delaying the onset of intercourse or at reducing the number of unplanned pregnancies (DiCenso, et al, 2002). By contrast, women who receive contraceptive counseling are more likely to report the use of contraceptives post-counseling (Lee, et al, 2011). Contraceptive counseling increases the knowledge of different forms of contraception, leading to an increase in the adoption of intrauterine devices and subdermal implants, compared with women who received unstructured contraceptive counseling (Madden, 2013). These results show that the best means of reducing unintended pregnancies, and therefore avoiding the health, social and economic costs, is to implement structured contraceptive counseling.
Our roles as health care providers is to use the best available medical evidence to guide our decision-making. When we do this, we will achieve superior health outcomes, and better serve our communities. As health care administrators, we seek to lower the cost of health care, and reduce the barriers to accessing health care. When we can do this at the same time as we are providing superior health care, this is a fantastic achievement. In the case of structured contraceptive counseling, the evidence is clear. Not only does contraceptive counseling of all types correlate with superior health and economic outcomes, but it lowers the cost of care for the provider, and structured contraceptive counseling is the best available form of contraceptive counseling, according the literature.
Position Statement
As an outpatient OB/GYN clinic, we serve women of childbearing age specifically. This constituency comes from all corners of our community, through a variety of payers, and we serve them all. The objectives by which we operate our clinic, and treat our patients, should only be to look after the best interests of women. While some may come to us with high confidence, we are often on the front lines serving marginalized women, teenagers, women of color, and other vulnerable populations. These are the populations most at risk for things like unwanted pregnancy, and in the greatest need of our help.
We believe that pregnancy and parenthood are among the greatest things that a woman can experience, but we also believe these it should be her choice whether or not to have these experiences. We believe that it is a fundamental right of every woman to have full control and sovereignty over her own body.
These beliefs should be evident in everything that we do. First and foremost, we serve as experts, who can leverage our education and experience to provide knowledge, insight and guidance for the women who walk through our doors. It is not possible to simply pose as experts, we must perform as experts every single day. Part of being an expert means aligning current practice with the best available evidence on medical practice.
Recent research supports the use of structured contraceptive counseling as a means of both improving health for vulnerable communities and for improving the social and economic health of our society as a whole. Our facility will also benefit from adopting this practice, because of the impacts that it has on the overall cost environment. The upfront costs are just a fraction of what it costs our facility in the long run.
We should adopt structured contraceptive counseling as a matter of policy because it fits our mandate of providing low-cost access to health care for women in our community. It fulfills our mandate of lowering the health risks to the women in our community, and by extension to their children as well. We should adopt structured contraceptive counseling because it provides superior results in terms of both health care behaviors and outcomes for the women in our community that alternative programs. Abstinence counseling has no impact on adult women and minimal if any impact on teen girls. Unstructured contraceptive counseling has some positive impact but less than structured contraceptive counselling.
The benefits afforded by structured contraceptive counselling arise specifically because of the structured nature. The structure allows the counsellor to control the conversation in a way that allows the patient to hear all of the options that are available. The patient can then make an informed decision about her body. The structure of the counseling also allows for the consistent delivery of counseling services to the community. In all fields both in and out of health care, consistent service delivery is associated with superior results.
Structured contraceptive counseling also fits within the general mandate of our specialization. As an OB/GYN clinic, all aspects of female health are within our mandate. Structured contraceptive counseling is preventative medicine, and many of the most effective health care measures that we can take are preventative in nature. Unwanted pregnancy is one of the things that is easy to prevent. While pregnancy is not necessarily a negative health event, the research clearly indicates that it is associated with a number of negative health outcomes, both in the short run for mother and child, and in the long run for the mother as well. As such, preventing unwanted pregnancy can and does fall within the scope of care for an OB/GYN clinic.
Furthermore, adopting this policy would be the best option we can utilize for helping to meet the HHS objective to increase the proportion of pregnancies that are planned. Clinics such as our deal with many vulnerable women, who are less likely to have access to these services. We also have as patients many other women who might have access to other health care options, but choose us for our specialized knowledge in this particular area of female health.
We are the experts in this area, and we have access to the best knowledge that exists in our field of study. It is our duty as health care providers – our duty to our patients, to our community, and to all of our other stakeholders, to fulfill our obligations to deliver the best possible care, based on the best available evidence. That obligation therefore includes the delivery of structured contraceptive counseling to our patients as part of our program to reduce the instance of unwanted pregnancy among our patients.
Economic Analysis
There are several types of costs associated with instituting a new program. These include the fixed costs of program delivery, the opportunity costs associated with using those resources, and the costs associated with serving high volumes. These cost categories will each be discussed in detail in this section.
The cost of service delivery can be divided into the fixed costs associated with service delivery, and the volume-based costs, known in accounting as variable costs. These costs are the costs that change with the volume of patients served. Fixed costs include things like the facility, the staff that are hired to administer the program, and any equipment costs that might be incurred. In general, this program's major cost component in terms of fixed costs is the counselor. It is believed that a full-time counselor will be needed to administer this program. The counselor will need to be added to our staff, and this cost will constitute the major fixed cost. Other fixed costs will be predominantly associated with maintaining a page on the clinic's website dedicated to the counselling program. Such costs are expected to be marginal at best.
The volume-based costs associated with this program are the cost of the different materials that are used in the counselling process. This includes printed materials that are provided to the patients. There is limited need for medical equipment for this counseling, though there may be an increase in patients who are referred to some of the other services that we offer. Those costs – or revenues – would not be included in an analysis of the structured contraceptive counselling program because they require further action on the part of the patient for a referral. If anything, patients leaving the program to seek out new prescriptions or for medical testing probably represent a revenue opportunity, rather than a new cost. Volume-based costs might also include any additional marketing costs that are incurred in order to promote the new program to the community.
There are also opportunity costs associated with the structured contraceptive counseling program. An opportunity cost is a resource that will be utilized for this program that would otherwise have been utilized for something else. Opportunity costs therefore only refer to the new use of existing resources, rather than the use of new resources. Use of new resources would be classified either as a fixed cost or a volume-based cost.
Some opportunity costs that might arise as the result of this program are the use of existing administrative staff, and real estate, to run the counseling program. The structured contraceptive counseling program will hire a new counselor, but will not require a new full-time administrator, at least in the short run. Thus, the current administrative staff will be called upon to assist in the scheduling of appointments, and maintenance of health and payment records associated with the new structured contraceptive counseling program. The time that this staff dedicates to this project will either take away from the efficiency at which they complete their other existing duties, or will diminish their ability to take on new future unknown duties, both of which might constitute an opportunity cost.
The same can also be said for the physical space that the program will require. While the clinic might already have this space, and be paying rent on it, this space can be used for any number of different purposes. The ability of the clinic to use this space for any other activity will be diminished as the result of adopting the structured contraceptive counseling program.
The total cost of implementing the structured contraceptive counseling program, taking into account fixed costs, volume-based costs and opportunity costs, is quite small, especially when considered in relation to the benefits. For example, the extra health care that is required for unwanted pregnancies is substantial for a clinic such as ours. The hours of staff and physician time, for example, required to treat patients will be reduced. The cost burden associated with treating those who cannot afford care will be reduced. The resources used to provide health care to the women in our community, in general, will be reduced, as there will be fewer unwanted pregnancies.
By putting control over pregnancy in the hands of the women who walk through our doors, we will be reducing our own costs, in terms of financial costs, labor costs, and other resources costs. While there is opportunity cost associated with the resources used for the counseling,, there are opportunity benefits associated with the program as well. In business terms, structured contraceptive counseling has a positive return on investment (ROI), both in economic terms and in terms of community and social health as well.

Conclusion
The best available evidence shows that structured contraceptive counseling is the best means by which we can reduce unwanted pregnancies. Reducing unwanted pregnancies is a stated national health goal, and has positive impacts on the social and economic well-being of the affected women and families. As such, providing this service fits within our mandate to our community and to our patients. The costs associated with implementing a structured contraceptive counseling program are relatively low, and they are likely minimal in comparison to the benefits that that program will deliver to both our clinic and to the women whom we serve. It is therefore recommended that we adopt as a matter of policy to implement a program to provide structured contraceptive counseling services at our OB/GYN clinic.

References

DiCenso, A., Guyatt, G., Willan, A., Griffith, L. (2002) Interventions to reduce unintended pregnancies among adolescents: Systematic review of randomized controlled trials. British Medical Journal. Vol. 324 (7351) 1426.

Guttmacher Institute (2016) Unintended pregnancy in the United States. Guttmacher Institute. Retrieved May 3, 2018 from https://www.guttmacher.org/fact-sheet/unintended-pregnancy-united-states

Herd, P., Higgins, J., Sicinski, K., & Merkurieva, I. (2016) The implications of unwanted pregnancies for mental health later in life. American Journal of Public Health. Vol. 106 (3) 421-429.

Lee, J., Parisi, S., Akers, A., Borrerro, S., & Schwarz, E. (2011) The impact of contraceptive counseling in primary care contraceptive use. Journal of General Internal Medicine. Vol. 26 (7) 731-736.

Lindberg, L., Zimet, I., Kost, K. & Lincoln, A. (2016). Pregnancy intentions and maternal and child health: A analysis of longitudinal data in Oklahoma. Maternal and Child Health Journal. Vol. 19 (5) 1087-1096.

Logan, C., Holcombe, E., Manlove, J. & Ryan, S. (2016) The consequences of unintended childbearing. The National Campaign to Prevent Teen and Unplanned Pregnancy. White paper. Retrieved May 3, 2018 from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.365.2689&rep=rep1&type=pdf

Madden, T., Mullersman, J., Omvig, K., Secura, G., & Peipert, J. (2013) Structured contraceptive counseling provided by Contraceptive CHOICE Project. Contraception. Vol. 88 (2) 243-249.

Sonfield, A., Kost, K., Benson, R., & Fisher, L. (2011). The public costs of births resulting from unintended pregnancies: National and state-level estimates. Perspectives on Sexual and Reproductive Health. Vol. 43 (2) 94-101.