Center for Women´s Health and Wellness
Improving Women’s Health through Reproductive Life Planning
UNCG’s Center for Women’s Health and Wellness and Moses Cone Internal Medicine Program Partnership Project
The Center for Women’s Health and Wellness (CWHW) at UNCG is collaborating with Moses Cone Internal Medicine Clinic on a study to promote women ‘s reproductive health by improve patient- physician communication and educating women on reproductive life planning.
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Background
Many women seek care from both primary care providers, such as family practitioners and internists, and from gynecologists. This separation of reproductive from non-reproductive health care has resulted in many women of reproductive age not receiving appropriate preventive health care. Partly in response to this national problem, many comprehensive primary health care centers opened around the country and in the mid-to late 1990s the National Institutes of Health funded the establishment of 18 academic health centers. Part of the mission of these centers was to develop "one-stop" shopping for women's health care. Evaluations of these programs found that women seeking care at these clinics were more satisfied with their care and had received significantly more screening tests and counseling services as compared to women accessing traditional care from multiple providers.
Studies indicate that women who obtain care from such women’s health centers were more likely to receive gender specific health preventive counseling on gender specific health services such as hormone replacement therapy, dietary calcium intake, breast exam, pap smear, and contraceptive counseling.
However, most women do not have access to an academic health center or one based on an integrative model and many women seek care only from one provider. Research suggests that that low income and minority women tend to frequent only one healthcare provider. Access and affordability of care are among the reasons given. Moreover, women who utilize general medicine specialists, rather than gynecologists, tend to have more chronic illnesses and functional limitations. Because of these reported differences in services provided and in the population served, there is a need for interventions that increase the quality of the reproductive health care received by women who seek care only from internal medicine clinics.
Purpose of this study
With this in mind, we conducted a patient survey and medical record review to identify the extent to which women seeking care in this one internal medicine clinic were receive appropriate reproductive health care. We found that most women had received a pap smear within the past two years (at this or another clinic), most had not received contraceptive counseling, and most of the fertile reproductive age women were not using contraception.
We conducted follow-up focus groups with patients, nurses and physicians (mostly residents) to identify factors that might account for this and strategies to improve women’s reproductive care.
The following are findings from this formative research revealed a number of patient, provider and organizational barriers to effective reproductive health care.
- Patients’ want more individualized health information and need strategies to improve their abilities and willingness to communicate with their physicians.
- Patients do not believe they are often given the information they need to understand their own health and to make good decisions
- Patients are being treated for complicated health problems and time is limited
- Physicians believe that their patients have limited knowledge of their own health problems and treatments and are not interested in prevention
- Physicians would like patients to be more proactive
- Physicians need more training in reproductive health
- The organization needs to be committed to prevention from the “top down”
- The organization needs a clear division of responsibility among providers
Framework for Prevention
Our data indicated two key factors to consider in planning an intervention:
- Patients want more direction and more information about their own health and physicians want more active, informed patients.
- We need an intervention that addresses change at three different levels: organizational, provider and patients.
At the organizational level we need an organizational philosophy that commits the organizations and providers to offering preventive care, better procedures (but not flow charts), and a division of clinical responsibilities
At the provider level we need more education for residents in women’s reproductive care and strategies that increase their commitment to prevention.
At the patient level, we need an intervention that increases women’s knowledge about their own health, treatments and medications', and increases the extent to which they initiate conversations with their doctors and engage in responsibility for their own preventive care.
Reproductive Life Planning
How many women that you know have created a reproductive life plan with complete details of:
- When their children will be conceived
- How they will avoid pregnancy until they are ready
- How they can prepared their bodies for pregnancy
When you look at these questions, you probably cannot think of many women who have or will do this. This is why the Center for Women's Health and Wellness is collaborating with Moses Cone Internal Medicine Clinic on a study that improves women's "preconceptual" health through reproductive life planning (RLP).
Preconception health is defined by the CDC as “a woman’s health before she becomes pregnant” and it focuses on “the conditions and risk factors that could affect a woman if she becomes pregnant,” while considering the health of the fetus or infant as well. Preconception care thus considers a variety of topics that help to promote a healthy pregnancy for both the mother and the infant, including folic acid counseling, vaccinations, managing health conditions, etc.
A reproductive life plan is one of the recommendations of the CDC to improve preconception health and health care in the United States and “is a set of personal goals about having (or not having children),” including the means by which the goals will be met. The CDC recommends that “each woman, man and couple should be encouraged to have a reproductive life plan.” This includes setting goals on when children will be conceived and how contraceptives will be used prior to that time, all while emphasizing personal values and resources available to the individual.
For several years, CWHW has been collaborating with Moses Cone Internal Medicine to improve physician-patient communication and women's reproductive health care. Stephanie Landsman, CWHW graduate assistant and MPH student in Public Health Education is taking this project one step further by developing a RLP educational workbook, which is tailored to meet the need of women with differing reproductive goals. As her capstone experience, Stephanie worked with faculty and residents at Moses Cone Internal Medicine and other experts in the field to develop and field test a workbook that could help improve physician-patient communication regarding RLP.
The workbook first asks the women their pregnancy intentions in the near future. The women are then directed to a section of the workbook based on their intentions to become or to prevent pregnancy. The women are provided with information about, and the opportunity to consider their own lives and situations as related to:
- Avoiding pregnancy if desired
- Avoiding Sexually Transmitted Diseases
- Getting pregnant when/if desired.
- Preparing for a healthy pregnancy when/ if desired
- The importance of screening for cervical cancer
- Identifying unsafe relationships
- Personal health assessment
- Communicating with providers
Although Stephanie is graduating, the work she has started will be continued with other students who are interested in reproductive life planning. Next steps will include and evaluation of the workbook's acceptability to women and an evaluation of the extent to which this intervention helps to improve women's reproductive health care.