Many clients, especially in marginalized communities, rarely, if ever, are directly asked about their reproductive goals. This may be attributed to time constraints or lack of provider skill. Perhaps it also reflects provider bias about who should and who should not have children, and assumptions based on patient demographics like socioeconomic status, age, gender, sexual orientation or relationship status. If reproductive goals are brought up, it is frequently in the context of “planning” and a binary frame that neither acknowledges nor respects the nuanced nature of people’s attitudes and feelings about their own reproduction. PATH is intentionally worded in a way that allows the patient to interpret the questions within their own context. This affords an opportunity for patients to consider, often for the first time, their reproductive goals and facilitates an honest, shared-decision making dialogue between patients and their providers.
Comprehensive reproductive health begins and ends with a person’s agency over their own reproductive life. In an ideal world, healthcare providers would bring “the science” to interactions with patients, while patients would bring preferences based on their own values. In this equation, providers would not contribute their own personal values to counseling, and patients would be free to explore their own attitudes and ask questions free of judgement and bias. However, we know that this is not always the case, and historically certain groups of people have been deemed “worthy” of parenting, while others have been systematically ignored or had their reproductive decisions made for them.
What is PATH?
Healthcare providers can change this paradigm, and support comprehensive reproductive health, by applying principles of patient-centered care. PATH is designed as a patient-centered framework with a shared-decision making model to be used with patients of any demographic without judgement.
PATH is an acronym: PA (parenting/pregnancy attitudes), T (Timing), and H(How important delaying pregnancy is). PATH asks the following three questions:
1) “Do you think you might like to have (more) children at some point?”
2) “When do you think that might be?”
3) “How important is it to you to prevent pregnancy (until then)?”
Follow up questions include:
"Since you have said_____ would you like to talk about ways to be prepared for a healthy pregnancy?"
"Do you have a sense of what’s important to you about your birth control?"
"How would that be for you?"
"Has that ever happened before?"
"How did you manage it?"
PATH facilitates active listening on the part of the provider which is paramount for patient-centered care and ultimately to ensure that patient’s voices are heard. Principles of patient-centered care applied with PATH inform equitable interactions that aim to help patients gain clarity about their reproductive goals, and support them in realizing those goals.
Shared Decision Making
There is consensus in the current medical literature that when patients are choosing among more than one reasonable option, such as when choosing a contraceptive method, providers should assist their patients in making these decisions by helping them to identify their preferences in the context of their values and by providing them with relevant information in a way that the patient can understand and integrate.
A shared decision-making approach is associated with high levels of patient satisfaction in a wide variety of clinical settings including contraceptive counseling. It has been shown to increase a patient’s engagement in self-care as well as improve patient outcomes and health status. The quality of interpersonal care associated with shared decision-making approaches applied to contraception counseling is associated with increased satisfaction with method choice.
As stated in an article published about PATH entitled Beyond intent: exploring the association of contraceptive choice with questions about Pregnancy Attitudes, Timing, and How Important is pregnancy prevention:
“The goal of client-centered contraceptive counseling is a shared decision-making process.
The process is designed to identify contraceptive methods that are in line
with patient preferences, goals and values as well as meeting emotional and
physical health needs and addressing financial limitations. Clinicians provide information
regarding method efficacy, side effects, duration of typical use, etc. While this information
can inform a client’s decision to initiate a specific method, that
decision is entirely theirs to make” (Geist, et al., 2019).”
PATH offers the opportunity for providers and their patients to collaborate on clarifying the patient’s reproductive goals, and to come up with next steps for that patient, taking into account a variety of life circumstances. Each patient is different, so there is not a one-size fits all solution to counseling. The PATH framework is designed to honor these differences and incorporates a variety of techniques to tailor the counseling conversation to each patient.
Planned VS. Unplanned Pregnancy
Considering parenting preferences in a binary, “intended versus unintended” or “planned vs. unplanned” frame, leaves out a spectrum of thoughts, feelings, and attitudes regarding parenting and pregnancy. Feelings about parenting and acceptability regarding pregnancy may be viewed with ambivalence, uncertainty, or indifference. Each of these attitudes are worth considering and are not inherently problematic. Human beings have internal motivations that inform actions, decisions and behaviors. Rather than problematizing the choices, PATH seeks to support someone as they clarify and express the internal motivations that drive their choices.
PATH focuses on desire to have a child rather than on pregnancy for several reasons. Perhaps most importantly, questioning that focuses on desire for pregnancy excludes people without a uterus or who are not capable of or interested in pregnancy for themselves. None of these exclusions mean that the excluded person would not want to have a child, but these people otherwise would be excluded from the conversation. Also, in general, someone’s attitude regarding the acceptability of pregnancy is directly related to their thoughts and feelings about having a child.
Certainly a person’s sentiment about pregnancy could influence their thoughts or feelings about having a child and PATH allows for that with the last question. An example of this could be that a person unsure or concerned about fertility may not strongly avoid pregnancy, in part, in order to gain reassurance about fertility. This apparent ambivalence can be addressed within a PATH framework so as to support rather than judge the person who is simultaneously holding two seemingly inconsistent desires. A binary frame does not allow for consideration of this nuance. If the nuance is not invited into the conversation, it is unlikely that someone’s internal motivations will be clarified.
Add to this the fact that attitudes change over time. Even when someone expresses a strong desire to avoid or to get pregnant during one visit, these desires may shift as health, relationships, financial situations, and life opportunities change.
The framework we describe is versatile. The nuance with which the questions are asked is intentional, and allows for patients with lived experiences entirely different from provider experiences to be heard, affirmed, and supported by compassionate health care professionals.
The Debut of PATH
PATH is currently being implemented in a variety of ways to create health equity nationwide, and continues to expand its reach with newfound partnerships. In Planned Parenthood of Orange and San Bernardino Counties, in Southern California, the framework of patient-centered reproductive goals and contraception counseling has been set as a top priority, and all 70 providers at PPOSBC are receiving comprehensive training, and incorporating the PATH framework in their daily practice.
PATH is part of a state-wide initiative in Utah, where it is being tested in a patient-facing survey and also being rolled out during trainings for providers to use in face to face interactions with patients.
Lisa Callegari, MD is using PATH adapted into MyPath, which is a comprehensive patient-facing reproductive health survey in the electronic health record system used in Veteran’s Affairs (VA) to all women of reproductive age who have childbearing capacity.
The PATH framework has been adopted by the Health Department of Nashville, Tennessee as the model for discussing reproductive health, and is being taught to providers with the intention of improving health equity, reproductive justice, and maternal and child health outcomes. This initiative began in Nashville and is being rolled out in a statewide initiative across Tennessee.
PATH hopes to address the needed shift in how we as health care and public health professionals, approach reproductive health. Rather than claiming that unintended pregnancy is a crisis, we can move forward with the goal of advancing rights through the lens of reproductive justice, ensuring all individuals have the knowledge, access to services, and freedom to decide the number, spacing, and timing of their children.