How to Use the PATH Framework
to Discuss Reproductive Goals with Patients
The PATH Framework
(Parenthood/Pregnancy Attitude, Timing, and How important is pregnancy prevention)
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)?
The PATH framework can help clarify your patients’ reproductive goals and needs. PATH is designed to yield a maximal amount of relevant information in an efficient way. Once your patient has verbalized their current attitudes about their own reproduction you can offer conversations about pre-pregnancy care, contraception, and fertility, as appropriate.
PA: "Do you think you might like to have (more) children at some point?"
The "PA question" is designed to clarify respondents' attitudes about parenthood. This may be the first opportunity they have had to seriously reflect on their future in this way. While technically a "yes" or "no" question, it allows for nuanced answers that can encompass respondents' thoughts, feelings, desires, intentions, or plans regarding their reproduction.
Don't Make Assumptions
The "PA question" does not assume that all people want to be parents. It is important not to skip over this and go straight to a timing question unless the person has already expressed a desire to have children (or more children), in which case you would skip the first question.
Are They Already A Parent?
Include the word "more" if the person is already a parent. If the person already has a child or children ask:
"Do you think you might like to have more children at some point?" or "Do you think you might like to have another child at some point?"
Listen for an Expanded Answer
In response to the "PA question," people may give an expanded answer that effectively answers "T" or sometimes even "T" and "H." In this case, do not ask a question that they have already effectively answered, as it would indicate that you were not listening, and could affect rapport.
Examples of when you would skip "T:"
“I’m really not sure, but I can tell you that it’s no time soon if I do.”
“Yes! I definitely want to be a parent someday. I am pretty traditional, and family is one of the most important things in my life. I definitely want to be married first, which I don't see happening for at least four or five years.”
Notice: body language, facial expression, tone of voice. Do they seem to be excited about the idea of being a parent someday (or having another child?), or do they seem "put off" by the idea?
If the answer to the “PA question” is “NO,” skip to the "H Question." There is no need to ask about timing if the person has said they do not desire children in the future.
"No, I really don't think so, I've really got my hands full with the three I've got!"
"I seriously doubt it, I mean I love kids and all, but I think it would be too much to deal with for me."
Any reply other than "NO"
If the person answers anything other than NO, proceed with T.
"I’m not really sure.”
"Yes, absolutely, I would love to be a parent.”
"Somedays yes, somedays no.”
T: "When do you think that might be?”
Asking a question about timing in an open-ended manner allows the person to respond in the way that is most relevant
to them. This may mean they answer in terms of literal time (now, number of months, years, etc.), or in relation to life events (when my son is 3, when I’m out of school), or perhaps both (no sooner than 3 years! I want to get out of school first) or they may answer in a way that doesn’t seem to address timing at all but will let you know what is at the top of the list of things that are important to them (wow, it’s hard to even think when that might be, my boyfriend is pressuring me right now even though I told him I’m not ready). This question recognizes that many people do not hold timing-based reproductive intentions.
There is no need to press for a specific answer in terms of exact length of time, since the goal is to help the person clarify what they want, and to offer appropriate services, it is enough if they express clearly that they would not like to have a child "any time soon."
This question is not meant to match the amount of time that someone wants to prevent pregnancy with the length of use of a contraceptive method because all long-acting methods and short acting methods can be used for as much or as little time as someone likes.
Individualize the Question
If the person’s response to “PA” was something other than a clear yes or no, individualize the question to reflect what the person’s attitude is.
If the person says “I’m really not sure,” you can say “If you were to decide to have a child, when do you think that might be?”
If the person has a medical condition or is on medication that poses a health risk to the person or the pregnancy.
"It is important for people with diabetes to be prepared for a healthy pregnancy by getting their blood sugars in good control and making sure they are on the right medicines before they get pregnant. You have said you would love to have another child at some point, do you think you might like to get pregnant soon?"
When to Skip This Question
Do not ask this question about timing if the answer to "PA" was NO.
Optionally, you may decide to skip this question if the person is a young adolescent and they haven’t told you they are seeking pregnancy.
If person answers "now" or "trying for a while" skip the “H Question,” and ask “are you interested in talking about ways to be prepared for a healthy pregnancy?”
H: “How important is it to you to prevent pregnancy (until then)?”
The “until then” in this question is used only when the person has said they would like (more) children but has not said when or under what circumstances. If they have said anything related to timing (life event, number of months or years) replace until then with a rephrase for what they said about timing.
"How important is it to you to prevent pregnancy until you are out of school?" (...Or fill in with whatever they have told you.)
This question can elicit a person’s orientation towards a potential pregnancy and allow them to think about the acceptability of a pregnancy anytime soon. This provides important context for their views on the importance of contraceptive efficacy and their contraceptive choices.
When to leave off "until then"
If the person has replied that they do not want children (or more children), you would have skipped question T, but it is still important to ask question H. If this is the case, leave off "until then." If they feel strongly about no future children, it is appropriate to offer to discuss permanent contraception.
Benefits of this question:
Helps the person consider what the impact might be for them if a pregnancy occurred before they are ready.
Helps the person clarify their priorities.
Allows a natural transition to offering to discuss pre-pregnancy care if they have indicated that it is not very important to them to prevent pregnancy until they are ready.
Helps guide the conversation towards contraceptive methods that are consistent with their goals and preferences. The conversation can:
Help the person consider whether effectiveness is a characteristic about their contraceptive method that is important to them or that they are seeking.
Introduce a discussion about relative effectiveness of different contraceptive methods.
It is important to have these discussions with patients of all genders and sexual orientations. The PATH framework works the same way for everyone, and you can use the same questions as they are. Or if you prefer, you can change the "H question" to be: "How important is it to you not to cause a pregnancy until then?"
The purpose of the PATH framework is to:
Support a person's reproductive autonomy and agency.
Help people gain clarity about what they want in terms of reproduction so they can make choices that are aligned with their goals.
Re-frame people's thinking to focus on their future rather than their current partner or sexual experiences.
Let the person know that your priority is helping them figure out what is important to them.
Allow the person time to explore their thoughts and feelings about reproduction.
Build rapport by letting them know you are listening.
Inform the provider about the direction of the visit (offering to discuss pre-pregnancy care, fertility support, and contraception).
The purpose of the PATH framework is NOT to:
Give the provider information so they can decide which intervention or contraceptive is best for the patient.
Create a concrete plan that the patient should commit to.
Make the patient feel like they "should" have a "plan."