Communication in reproductive health: Intimate topics and challenging conversations

The field of reproductive health encompasses diverse areas that touch on many of the core issues faced by humanity, including the ability to reproduce, the capacity to limit reproduction when it is not desired, and our nature as sexual beings. Communication about these issues, whether in the clinical setting or among friends, family, or in society at large, presents unique challenges due to the complex societal and personal contexts of these discussions. Communication on sexual and reproductive health topics is also important—and a challenge—across a wide range of medical practice, and an area in which physicians and other health professionals often need training.

In this special issue of Patient Education and Counseling on communication about reproductive health, we present a variety of papers that address communication issues ranging from miscarriage to abortion to HIV/AIDS. A call for papers for this special issue was published in PEC in August 2009. We received 42 proposals and accepted 24 for publication. Papers are presented in six general categories: sexuality, contraception, abortion, infertility and assisted reproduction, pregnancy and childbearing, and HIV/AIDS. They represent work performed across four continents and include randomized controlled trials, observational studies, qualitative research, and literature reviews.

Together, the papers in this special issue draw attention to the importance and value of appropriate counseling and effective communication in this challenging area. Despite the diversity of topics, this special issue reflects a consensus that client-centered approaches are both right in principle and promising in practice. Specifically what client-centered counseling should look like is not yet clear, however. Many of these papers address that question. They either assess specific approaches or gather information that would inform client-centered communication strategies. A number of studies test ways to support or structure counseling in hopes of overcoming providers’ and clients’ reluctance to raise and discuss these issues. As should be expected, some approaches yield demonstrable effects; others do not.

1. Education on sexuality

Wherever reproductive health is concerned, sex is often the elephant in the living room: everyone knows it is there, but no one wants to talk about it. Two studies look at communication aids designed to make talking about sex easier for providers and their adolescent patients. Van der Stege et al. [1] in the Netherlands look at a board game, called SecZ TaLK, for a group whose sexuality often goes unaddressed—young people living with chronic conditions and disabilities. In interviews health care professionals who used the game say that they would recommend it. Among young people, more favorable opinions of the game come from girls than from boys, from younger youth, and from youth in an outpatient clinic rather than in other settings. In the UK MacDowall [2] has helped develop and test an electronic consultation aid called Talking of Sex. Young patients exposed to the aid were slightly more likely to bring up sex during consultations. Also, discussions of preventive practices such as condom use were more common. Van der Kwaak et al. [3] draw on four studies in Africa on sexuality counseling and HIV counseling and a desk review. They find that trust and respect between client and provider are crucial to successful counseling. They identify, as a framework for evaluating provider–client communication, nine dynamics that relate to the agency of client and provider in a specific setting.

2. Communication about contraception

Appropriate communication, both within and outside of the health care system, is essential for people to make autonomous and informed decisions about contraceptive use. Individuals’ experience of such communication—or lack of it—has important implications personally, interpersonally, and from a public health perspective. In this section we present ten papers addressing communication about family planning.

Two papers use observational methods to investigate how communication in the health care setting influences contraceptive use. First, Dehlendorf et al. [4] examine the preferences of women seen in a US abortion clinic for control over the decision about which contraceptive method to use. While more women desired autonomous decision-making about contraception than they did about their general health care, 50% of women did desire some involvement of their health care provider in the choice of contraception. Indeed, in a US cohort study Harper et al. [5] find that health care providers can have substantial influence on young women’s contraceptive decision-making.

Attempting to capitalize on the role of providers, several studies employed experimental methods to investigate how to improve family planning counseling in the clinical setting. Two contributions address use of the flip chart developed by the World Health Organization as an aid to family planning counseling. Johnson et al. [6] provide a comprehensive overview of the development of this tool. They also report on field tests in developing countries, which have indicated improvements in client-centered counseling associated with use of the tool. In the US Langston et al. [7] performed a randomized controlled trial using a modified version of the flip chart. This study did not find that adding the standardized use of this tool to doctors’ individualized counseling increased the choice or continuation of highly effective contraceptive methods.

Two studies investigated training of providers as a means to improve access to and quality of family planning services. In an intervention study by Liamila et al. [8], an educational intervention at nine pharmacies in Kenya encouraged staff to provide wider reproductive health services to users of emergency contraception. In a comparison with eight control pharmacies, they found no effect on the provision of reproductive health services, including education about sexually transmitted infections or about other contraceptive methods. In contrast, Subramanian et al. [9] report success in Ghana improving communication regarding vasectomy. Provider education combined with community outreach and a mass media campaign was associated with increased uptake and acceptability of vasectomy services.

A continuing question is whether better communication between client and provider can change a client’s contraceptive behavior. Abdel-Tawab and Ramarao [10] critically review the literature addressing this question. Findings have been inconclusive, they report. The authors attribute this to a variety of factors related to research methodology and to the unique nature of contraceptive counseling and contraceptive use. Hall et al. [11] explore the challenges of research in this area more specifically, with a review and discussion of the challenges associated with measuring clients’ knowledge about oral contraceptive pills. Without the capacity to accurately measure factors associated with contraceptive use, our ability to document the effects of counseling and counseling interventions will be limited. The authors suggest future research that could ameliorate this problem, including the use of more rigorous psychometric evaluations and consideration of the role of health literacy.

Clearly, there are many influences on contraceptive use beyond the health care setting. Two papers illustrate the utility of interventions in the community to improve contraceptive use. In rural India community health workers conducted an educational campaign, informed by qualitative research, that sought to encourage use of contraceptives and to increase birth spacing. Sebastian and Khan [12] find greater use of contraceptives for spacing in the area that received the intervention than in an area that did not. Yue et al. [13] address the importance of considering sexual partners in the discussion of contraception in Nepal. They use qualitative and quantitative methods to explore the relationship between spousal communication about family planning and use of a modern contraceptive method.

3. Counseling on abortion

Two US studies reflect the continuing sensitivity of abortion decisions even where the procedure is legal and generally available. Most US women who have abortions go to specialized clinics for care. Through in-depth interviews Weitz and Cockrill [14] found that women chose an abortion provider for a variety of reasons. Most women assumed that their general practitioners did not perform abortions. In search of techniques that might improve abortion counseling, Upadhyay et al. [15] conducted a literature review to identify practices used in emotional care that have proved to support coping or to improve psychological adjustment. They uncover nine such patient-centered techniques. A number of these techniques, in fact, are applied in other studies in this special issue.

4. Counseling on infertility and assisted reproduction

Van den Broeck et al. [16] point to the integral role of counseling in the management of infertility. The authors offer an overview of the theory and interventions involved in this specialized form of counseling. Reassurance is often crucial. Van Balen and Bos [17] review studies in which new reproductive technology has enabled the fertile member of an infertile couple to pass one set of genes to their child. Reassuringly, the authors find no evidence that the psychological adjustment of these children differs from that of children conceived naturally, with both parents’ genes. Infertile couples often seek reassurance from peers as well as from professionals. The Internet is one place that they go to find peers. Based on interviews in the UK Hinton et al. [18] conclude that online infertility networks offer emotional support, normalization, and reassurance that can help people deal with the stresses and isolation that they feel.

5. Communication about pregnancy and childbearing

Four papers address pregnancy and childbirth from diverse angles, all pointing to the importance of good communication between health care providers and their patients. De Haan [19] reports that, in rural areas of Kyrgyzstan and Tajikistan, training helped health care providers shift from directive to client-centered approaches to their patients. At the same time, a health education program in health facilities improved preparedness for childbirth among women and their families. In interviews in Belgium, Aujoulat [20] found a diversity of reproductive health education needs among teenage mothers and young pregnant women. These needs vary with life stage and whether the young woman is isolated or has family support.

Two studies find room for improvement in counseling for women with early pregnancy failure and for women with unplanned pregnancies. Based on a review of the literature, Wallace et al. [21] note that women have strong and diverse preferences for management of early pregnancy failure, but current practice may not respond to these preferences. They present a model of counseling that employs principles of shared decision-making, and they offer a checklist to elicit patients’ preferences, priorities, and concerns. Meiksin et al. [22], observing first prenatal care visits of US women with unplanned pregnancies, find that the woman’s feelings are usually discussed. Referrals to counseling and social services are few, however, and discussions of future birth control options are even rarer.

6. Clinical communication about HIV and AIDS

Communication about HIV presents unique challenges because HIV is both sexually transmitted and life-threatening. In this section three papers explore the experiences of individuals with clinical communication about HIV. Sheon et al. [23] use conversation analysis to investigate communication during HIV test counseling in the United States, both before and after a structural intervention designed to facilitate this counseling. This piece illuminates the various components of communication that make up counseling in this context. Also, it indicates that structural interventions can overcome some of the barriers to effective communication about issues of sexuality. Malta et al. [24] use qualitative methods to conduct an in-depth exploration of HIV-positive Brazilian women’s interactions with health care professionals about contraception and other reproductive health issues. They find that the reproductive life goals and sexual health of women with HIV are often neglected in their clinical care.

7. Conclusion

As these papers indicate, frank and open discussion of reproductive health issues is both crucial and challenging. In the clinical setting, how to provide client-centered care through careful attention to clients’ preferences deserves further exploration. There is room for improvement both in care itself and in our methods for studying its effects. In broader society, encouraging discussion of reproductive issues between partners and within communities has the demonstrated potential to enhance the health and well-being of both individuals and communities.

Much remains to be learned about how to promote healthy and responsible sexuality and reproductive behavior around the world. Continuing research, including research on themes and concepts represented here, is essential. Furthermore, reproductive health communication has often pioneered client-centered approaches. Thus, progress in reproductive health communication may well inform counseling and communication across the entire range of personal and public health issues.

We would like to thank for their valuable contribution to this issue: Ann Glasier (Family Planning and Well-being Service, Edinburgh, UK), Ann Marie Ryan (Elsevier), and Dr. Adriaan Visser (editor special issues).