1202

The rate of unplanned pregnancy in the United States

remains high. A study performed by the Alan Guttmacher
Institute showed that 49% of all pregnancies in the United
States were unintended; 46% of those pregnancies re-
sulted in live births and 54% in induced abortions.
1
Unin-
tended pregnancies can result in serious personal,
socioeconomic, and public health consequences.
Multiple reasons have been suggested for the contin-
ued rate of unintended pregnancy. These include a lack
of patient education, ineffective contraceptive methods,
inconsistent use of contraception, unplanned sexual ac-
tivity, and contraceptive failure. Improvement of contra-
ceptive education has the potential to positively impact
rates of contraceptive failure, inconsistent contraceptive
use, and subsequently, rates of unintended pregnancy. An
individuals education and knowledge level of concep-
tion and contraception may influence the rate of unin-
tended pregnancies within a population. An appropriate
time to ensure exposure to educational material is during
the postpartum period of hospitalized women.
Health care providers are not fully using the postpar-
tum hospitalization period to promote contraception.
After the delivery, additional written literature may pro-
vide women with more valuable information than verbal
counseling alone.
2
In our university setting after the de-
livery, the women come from a variety of backgrounds,
and many of the women have had little or no prenatal
care or exposure to contraceptive counseling. The pa-
tients are seen in the postpartum period by a variety of
providers (including medical students, residents, mid-
wives, and faculty members), and the postpartum con-
traceptive counseling quality is highly variable and
difficult to control. Minimal pamphlets on various con-
traceptive options, but no comprehensive information,
are available currently to distribute in the postpartum
period. An hypothesis-driven cohort study that measured
baseline satisfaction levels and confidence in contracep-
tion decisions was performed in mothers after the deliv-
ery before and after the distribution of standardized
comprehensive written information about contracep-
tion. We proposed that the addition of comprehensive,
complete written information on all contraceptive op-
tions would increase the patients ability to make an in-
formed decision regarding the choice of postpartum
birth control.
Material and methods
Consent to survey hospitalized patients during the
postpartum period at Oregon Health and Sciences Uni-
versity was received from the institutional review board.
All English- and Spanish-speaking parturients during
April and May 2002 were invited to participate by com-
From the Department of Obstetrics and Gynecology, Oregon Health and
Science University.
Reprint requests: Lisa K Johnson, MD, 3181 SW Sam Jackson Park
Road L466,Portland, OR 97201. E-mail johnsoli@ohsu.edu
2003, Mosby, Inc. All rights reserved.
0002-9378/2003 $30.00 + 0
doi:10.1067/mob.2003.308
Patient satisfaction and the impact of written material about
postpartum contraceptive decisions
Lisa K. Johnson, MD, Alison Edelman, MD, and Jeffrey Jensen MD, MPH
Portland, Ore
OBJECTIVE: The purpose of this study was to evaluate the impact of written educational material about pa-
tient satisfaction and decision-making regarding postpartum contraception.
STUDY DESIGN: Baseline patient satisfaction and effectiveness of contraceptive counseling on a postpar-
tum unit was evaluated with the use of a self-administered questionnaire. Data were compared with patients
who received additional comprehensive written educational material during their postpartum hospitalization.
RESULTS: A total of 109 women participated in the study (control subjects, 53; intervention group, 56). De-
mographics and patient satisfaction with contraceptive counseling were similar between groups. Thirty-four
percent of the control subjects reported having received some sort of written information; all women in the in-
tervention group received a standardized comprehensive booklet of information during their postpartum stay
(P < .01). Among the women who received written information, the intervention group was more likely to
state that written material contributed to their ultimate choice in birth control (P < .01).
CONCLUSION: The postpartum distribution of written material about contraceptive options increases a womans
ability to make an informed decision regarding birth control. (Am J Obstet Gynecol 2003;188:1202-4.)
Key words: Contraception, postpartum, patient satisfaction
Volume 188, Number 5 Johnson, Edelman, and Jensen 1203
Am J Obstet Gynecol
pleting an anonymous self-administered questionnaire.
After the baseline collection of data during April, a stan-
dardized, comprehensive information booklet about con-
traceptive options in English and Spanish was given out
to all parturients on the postpartum unit during May. All
subjects during both months completed identical ques-
tionnaires. Basic demographic information was obtained
from each patient. Satisfaction of antenatal and postpar-
tum contraceptive counseling was assessed with a 100-mm
visual analog scale (most satisfied, 0 mm; dissatisfied, 100
mm). Patients reported the type of counseling received
(whether verbal and/or written) and how much the
counseling contributed to their ultimate choice of con-
traceptive.
The primary outcome was whether written informa-
tion better enabled patients to reach decisions about
contraceptive options. The visual analog scale scores
were analyzed with the use of the t test. Categoric and
ordinal data were analyzed with the
2
test and Mann-
Whitney U test. All comparisons were performed on a
desktop computer running SPSS (version 9.0; SPSS Inc,
Chicago, Ill) for Windows (Microsoft Corporation, Red-
mond, Wash).
Results
There were a total of 198 and 203 deliveries during the
baseline and intervention collection periods, respectively.
A total of 109 (27.1%) women participated, 53 women
(27%) in the baseline group and 56 women (27.6%) in
the intervention group. There were no significant differ-
ences in the baseline characteristics of the two groups.
The average age was 25.9 (SD) 6.23 years in the baseline
group and 25.3 6.68 years in the intervention group (P
= .646). Approximately 45% of the women in both groups
were Hispanic (P = .661); the median education level was
equal (high school, some college; P = .287).
Forty-two women (79.2%) in the baseline group and
46 women (82.1%) in the intervention group stated that
they received contraceptive counseling by their health
care providers during their prenatal care (P = .701).
Mean satisfaction of prenatal counseling in the baseline
group was 2.45 cm and 2.72 cm in the intervention
group (P = .654). Thirty-seven women (69.8%) in the
baseline group and 38 women (67.9%) in the interven-
tion group reported postpartum contraceptive counsel-
ing by a health care provider (P = .825). Patient
satisfaction with postpartum counseling was 3.24 cm in
the baseline group and 2.48 cm in the intervention
group (P = 2.6). Only 18 women (34%) in the baseline
group reported having received any written information
during their postpartum hospitalization compared with
56 women (100%) of the intervention group (P < .01).
Among those women who reported the receipt of written
information, women in the intervention group were
more likely to state that this information helped con-
tribute to their ultimate choice in birth control (1.16 vs
4.02 women, P < .01).
Comment
We conceived this project to address the hypothesis that
increasing a patients knowledge of contraception could
increase the patients satisfaction with postpartum contra-
ceptive decision making. Although the ultimate aim of
this intervention is to decrease the incidence of unin-
tended pregnancies, this exact outcome was not studied.
However, our results indicate that the provision of high-
quality, standardized information to women improves the
satisfaction with counseling. This, in turn, may translate
to improved satisfaction with contraceptive choice.
Although antenatal contraceptive counseling is impor-
tant, readdressing the issue with patients in the postpar-
tum setting remains essential. In 2000, researchers at
Wayne State University examined contraceptive decision
making among a population of low-income pregnant
women in Detroit.
3
They discovered that women were not
using the method of contraception consistently that they
planned to use in the prenatal period. Although antena-
tal counseling is imperative, readdressing the issue in the
postpartum period may help to reinforce a decision re-
garding birth control and improve patient satisfaction
and continuation rates.
An evaluation of verbal postpartum counseling was per-
formed in Scotland in 1996.
4
Eight-four percent of the
women reported having a discussion regarding contra-
ception while in the postpartum unit. Fifty percent of
these women, however, had a negative opinion of the
conversation. The most common complaint was that the
discussion was given as a necessary routine undertaken
with reluctance by the physician and that only 50% of the
population was discharged with a method of contracep-
tion. Researchers from this study concluded that the post-
partum unit was not the appropriate setting for
contraceptive counseling, but no other intervention was
evaluated. Many patients may feel, in fact, that these post-
partum conversations are not adequate and that they may
need additional time or information to make a decision.
In 1999, a study in Finland examined the relative im-
portance of various sources of contraceptive informa-
tion.
2
Both women and men were asked to rate their
knowledge of contraceptive methods and from what in-
formation source this information had been obtained.
Both sexes stated that most of their contraceptive knowl-
edge came from written literature rather than from physi-
cian contact. This outcome was surprising, given that this
population (unlike the United States) has excellent ac-
cess to health care.
Both the content and quality of counseling can vary be-
tween providers, and it is difficult to control a patients
perceptions and understanding of the interaction. The
postpartum period can be a difficult time to undertake
1204 Johnson, Edelman, and Jensen May 2003
Am J Obstet Gynecol
what should be considered an important conversation. Pa-
tients are fatigued and often distracted, and physicians
may be rushed and not able to take the time needed to an-
swer a multitude of questions. Most patients who are de-
livered at our university hospital site receive prenatal care
from a variety of practitioners at surrounding satellite clin-
ics. Therefore, it is difficult to assess the amount and the
quality of the information that they receive during the an-
tepartum period. In the same vein, it is difficult for us to
control the counseling that these women receive while
they are hospitalized after the delivery. The cases are fol-
lowed by a variety of providers that include students, resi-
dents, midwives, and attending physicians. Without
having 1 person see all of these patients for study pur-
poses, it is impossible to control this variable. However, in
our study population, both groups of patients reported
similar exposure to and satisfaction with the counseling
that they received, both before and after the delivery.
We chose to focus on providing patients with concise,
comprehensive written information that they can review
at their own pace and narrow down the options that may
be right for them. One problem we have faced consis-
tently is the lack of written information that is available
on the postpartum unit. Although individual brochures
have been used occasionally, never has there been an ad-
equate source of comprehensive written information. By
creating and distributing such a resource, this variable
was easier to control. As we hypothesized, our patients re-
ported a much higher level of satisfaction with this source
of information and an increased ability to make an in-
formed decision about their choice of birth control.
Limitations of the study include the lack of a direct com-
parison between individual counseling methods by a
provider and written information. By focusing on written
information, we intended to study a practical strategy that
was designed to overcome the limitations of multiple
providers at different training levels in the dissemination of
contraceptive counseling at discharge. Although patients
generally reported being satisfied overall with their antena-
tal and postpartum counseling, the value of this counseling
compared with written information was not evaluated. Al-
though satisfaction with contraceptive counseling im-
proved among subjects in the intervention group, the
impact on compliance with the chosen method of birth
control and the subsequent rate of unintended pregnancy
were beyond the scope of this investigation. However, the
positive findings in this study may prove to be a valuable
starting point for further studies of the subject.
REFERENCES
1. Henshaw S. Unintended pregnancy in the United States. Fam
Plann Perspect 1998;30:24-46.
2. Virjo I, Kirkkola AL, Isokoski M, Mattila K. Contraceptive meth-
ods: knowledge sources rated by women and men. Contracep-
tion 1999;59:257-63.
3. Miller VL, Laken MA, Ager J, Essenmacher L. Contraceptive de-
cision making among Medicaid-eligible women. J Commun
Health 2000;25:473-80.
4. Glasier AF, Logan J, McGlew TJ. Who gives advice about post-
partum contraception? Contraception 1996;53:217-20.