mHealth technologies for pregnancy prevention: A challenge for patient-centred contraceptive counselling in Dutch general practice

Abstract

Background

A general practitioner (GP) standardly provides contraceptive counselling and care in the Netherlands. Recent years have seen the rise of mobile health technologies that aim to prevent pregnancy based on fertility awareness-based methods (FABMs). We lack high-quality evidence of these methods’ effectiveness and clarity on how healthcare professionals include them in contraceptive counselling.

Objectives

To analyse how Dutch healthcare professionals include pregnancy-prevention mobile health technologies (mHealth contraception) in contraceptive counselling and to propose practice recommendations based on our findings.

Methods

We used ethnographic methods, including semi-structured interviews with nine professionals who were recruited using purposive sampling, 10 observations of contraceptive counselling by four professionals, six observations of teaching sessions in medical training on contraception and reproductive health, one national clinical guideline, and seven Dutch patient decision aids. Data were collected between 2018 and 2021 and analysed inductively using praxiographic and thematic analysis.

Results

In contraceptive counselling and care, professionals tended to blend two approaches: 1) individual patient-tailored treatment and 2) risk minimisation. When interviewed about mHealth contraception, most professionals prioritised risk minimisation and forewent tailored treatment. Some did not consider mHealth contraception or FABMs as contraceptives or deemed them inferior methods.

Conclusion

To minimise risk of unintended pregnancy, professionals hesitated to include mHealth contraception or other FABMs in contraceptive consultations. This may hamper adequate patient-centred counselling for patients with preference for mHealth contraception.

Based on these results, we proposed recommendations that foster a patient-tailored approach to mHealth contraceptives.

ABSTRACT

KEY MESSAGES

• Prioritisation of risk minimisation precluded professionals from including FABMs and mHealth contraception in their counselling.

• For patient-centred counselling, professionals need differentiated information about FABM use and effectiveness through adequate guidelines and training.

Keywords:

• Contraceptive counselling
• non-hormonal contraception
• mHealth technologies
• risk minimisation
• patient-centred care

Introduction

In recent years, Dutch patients’ wariness towards hormonal contraceptives has increased and their usage thereof has decreased [1,2]. Demand for hormone-free alternatives has coincided with the growth of mobile pregnancy-prevention health apps (mHealth contraception). However, high-quality evidence of their effectiveness is lacking [3,4], creating tension between two core clinical values: evidence-based treatment and individual patient-tailored care.

Newly available mHealth technologies consist of self-tracking apps and/or wearable devices that determine fertile days based on older fertility awareness-based methods (FABMs). FABMs aim to identify the menstrual cycle days when intercourse is likely to result in pregnancy [3]. Some FABMs (e.g. rhythm or calendar methods) use cycle length and statistical probabilities of conception in a given cycle to determine fertile days. Others take biomarkers such as basal body temperature, cervical fluid samples, or urinary hormone metabolites to determine fertile days and/or ovulation. Some FABMs deploy multiple biomarkers to identify fertile days more accurately and maximise effectiveness [5].

Systematic review of evidence on the effectiveness of these mHealth contraceptive technologies and other FABMs reveal a lack of high-quality studies [3,4]. Based on moderate-quality studies, the pregnancy rates with typical use range between 2 and 34 per 100 women in a year [3,4]. Research shows that Dutch users use these technologies without the support of their healthcare professionals [6]. They rely on online information, advertisements, and online peer support groups. Pregnancy rates of FABMs (and derivative apps) depend on users’ consistency and motivation to prevent pregnancy [7].

In this landscape, providing good contraceptive care is essential but challenging. Patients need evidence-based information to make contraception decisions. Good counselling is key, since shared decision-making and quality of contraceptive counselling correlate with patient satisfaction, continuation, and adherence [8–12].

A recent qualitative study among Dutch women who wanted to avoid pregnancy yet did not, or did not consistently, use prescribed contraceptives revealed they wanted more extensive counselling on non-hormonal methods [13]. A qualitative study in the UK identified four main motivations for using contraceptive apps: wanting a non-hormonal contraceptive alternative, being attuned to one’s body, increased partner involvement and contraceptive practices suiting their life stage [14]. A qualitative study in the Netherlands showed that users value how contraceptive apps let them visualise, understand and be attuned to their cycle patterns [6].

In the Netherlands, GPs are the first access point to contraceptive care. GPs increasingly integrate eHealth technologies into their practice [15], as eHealth fosters patient-centred care [15,16]. Yet, the use of mHealth contraceptives reflects a new dynamic, as their uptake is patient-initiated, without professional support and chosen based on information obtained through channels other than healthcare professionals [6].

Some guidance on mHealth contraception and other FABMs is included in the 2020 full-version clinical guidelines for contraception by the Dutch College of General Practitioners (NHG) [17]. The NHG summarises available evidence on FABMs and two mHealth solutions but lets professionals decide if and how they integrate the information in contraceptive counselling.

Thus, mHealth contraceptives warrant understanding how these technologies fit within existing contraceptive care practices. Yet, studies on counselling on FABMs and, specifically, mHealth contraception in contraceptive consultations are lacking. Addressing this lacuna, this exploratory study asks: how do professionals in the Netherlands integrate mHealth cycle-tracking technologies or other FABMs in their contraceptive counselling? And how do training and guidelines support their doing so?

Methods

This study belongs to ethnography on the implications of mHealth contraception for women’s health, knowledge and contraceptive care in the Netherlands. That ethnography looks at users’ practices with mHealth contraception [6], and in this article focuses on how these new forms fit into institutionalised contraceptive care.

Ethnography involves small-scale but in-depth qualitative studies in everyday settings [18]. Following an ethnographic approach, this study explored the implications of mHealth contraceptives for institutionalised care by collecting data through semi-structured interviews with professionals (n = 9); analysing national clinical guideline on contraception (n = 1); studying patient decision aids (n = 5); and conducting live observations and recordings of contraceptive consultations (n = 10) and undergraduate and postgraduate medical training sessions (n = 6). The data were collected between 2018 and 2021 and coded inductively. See appendix for an overview of interview participants and collected data. The article aims to map how Dutch professionals learn to provide contraceptive care, how they practice it, and if and how they integrate mHealth contraception or other FABMs in counselling.

Setting

In the Netherlands, GPs are the first access point to contraceptive care for most patients. Gynaecologists and midwives can provide contraceptive care as part of specialised care. Gynaecological care is accessed only through a GP referral; midwifery contraceptive care involves postpartum patients. We focused on general practices, as mHealth contraception users usually seek contraceptive care with their GP as a first point of contact. The graduate and postgraduate medical training that GPs receive is fairly standardised nationwide; the use of the Dutch College of General Practitioners (NHG) guidelines is promoted. Since several years, the Dutch College of Doctor Assistants (NVDA) Academy has trained nurse practitioners (NPs) to provide contraceptive counselling and care within general practice.

The NHG has one clinical guideline on contraceptive care (17), which is frequently accessed digitally. The NHG and other medical websites offer patients contraception information and decision aids.

Selection of participants

Selection criteria.

Interview participants and observations of contraceptive consultations were included if they involved a professional actively providing contraceptive care within general practice. The teaching sessions were part of undergraduate and postgraduate medical training in contraception and reproductive health. Educators of medical training on contraceptive care for graduate and undergraduate medical students where included among interviewees.

Recruitment and sampling.

We used purposeful sample to include a diverse group of professionals (maximum variation sampling [19]). Recruitment targeted some professionals with specialisation in sexual health (n = 4) and/or involvement in training medical students or residents in contraception training (n = 3) and some with no such specialisation and/or involvement in training (n = 6). Among the former group was an NP providing contraceptive counselling and care and a gynaecologist practising in a university medical centre. After observing their lecture, this gynaecologist was approached with the request to discuss their approach to medical training on contraception. Professionals were recruited to reflect practices with diverse patients – including younger urban populations, among whom mHealth contraceptive users constituted a significant demographic – and varying practice philosophies. We included a religious general practice and another that incorporated holistic alternative medicine (which we assessed by information available online) as these professionals could offer potentially diverging views or knowledge of FABMs. Interviewees were approached via email through the professional network of the first author (n = 4), snowball sampling (n = 1) or online search engines or online practitioner’s lists (n = 6). In the latter searches, search terms were used to specify the types of professionals we targeted. Two GPs did not respond to the invitation. All respondents willing to participate were included in the study (n = 9.) Participants received no payment or financial compensation.

Interview procedure

The first author conducted interviews between November 2018 and April 2021. Interviews were semi-structured, lasting between 36 min and 62 min with a median 45-minute duration. They occurred in professionals’ consultation rooms unless conducted via video conferencing due to COVID-19 restrictions (n = 2). The interviewer formulated a topic list informed by literature, NHG guidelines on contraception and observations during training sessions in a Dutch medical school. See appendix for topic list.

The interviewer ordered discussion topics according to input from the professional. The interviewer asked follow-up questions to encourage professionals to clarify contraceptive care assumptions, views and practices. Follow-up questions also stemmed from the interviewer’s personal and professional insights as a medical anthropologist who has studied and used mHealth contraception. The encounter between the interviewer and interviewees brought out differences in perspective and experience between both parties, enriching understanding of the data. Interviews were audio-recorded with a digital voice recorder. Verbatim transcriptions were anonymised.

Observations of consultations

During interviews, the interviewer inquired about later observing the professional’s contraceptive counselling. Two professionals agreed to participate; one provided access to others in the practice and one referred the author to the NP. The first author observed 10 consultations of four professionals between December 2020 and April 2021. Five consultations were observed with the NP, as they held sexual health office hours twice weekly, so multiple consultations could be attended in one visit. Two consultations occurred by phone due to COVID-19 restrictions and were audio-recorded by the professional using an audio set-up for recording consultations in residency training. Recordings were shared through a secure university server. The other nine consultations were observed in person and recorded in field notes.

Observations of medical training

Access to undergraduate and postgraduate medical training was obtained through the first author’s professional network. Six teaching sessions on reproductive care and contraception (lectures, seminars, practical training, e-learning) were observed between September 2018 and February 2021. Three sessions were part of basic medical training; two were part of training for residents who specialise in general practice. Some training sessions occurred online due to COVID-19 restrictions. One training was an NHG e-learning on contraceptive care. Training sessions were recorded in field notes. Slides and/or other digital materials were analysed as part of the data.

Guideline and decision aids

The 2020 NHG clinical guideline for contraceptive care was included in the analysis [17]. This guideline and some GPs referred to patient decision aids, seven of which were analysed as part of the data. Decision aids are online tools in the form of questionnaires that help patients find a contraceptive that suits their needs. Decision aids were accessed through search engines; none was excluded from the data. All decision aids were in Dutch. One was financed and maintained by a for-profit healthcare company; the rest were maintained on a non-profit basis, provided as part of clinical care and/or by government-funded reproductive health organisations.

Data analysis

During data collection, emerging patterns and recurring themes were documented in field notes. Notes were revisited iteratively during data collection and analysis.

We coded the data inductively using a praxiographic approach [20]. Specific care practices were coded in qualitative data analysis software (ATLAS.ti). Professionals’ views on mHealth contraception and FABM were coded thematically. Codes were compiled in code groups. Codes and code groups were compared to and triangulated with patterns and themes identified in field notes.

To improve comparability and validity, relevant codes from different types of data (clinical observations, training observations, interviews and guideline) were mapped out in one code map (see Appendix). This helped crystalise recurring patterns and themes, generating deeper understanding of relationships between data. Different types of data were highly consistent and showed clear patterns enabling triangulation. To ensure saturation, one additional interview, field notes and recordings from three consultations were coded after code mapping, with no new patterns or themes emerging. To improve reliability, all co-authors were asked to compare emerging codes and interpretations with their clinical and/or research experience and field knowledge.

Ethics

The GPs received participant information ahead of interviews. The information was recapitulated before audio recording. Verbal consent of GPs was audio-recorded.

Patients received participant information in writing before clinical consultations or verbally at the start of phone consultations. Consent was obtained verbally before counselling began. Consultations were not audio-recorded to ensure patient privacy except those over the phone. Patients and professionals were informed that they could revoke consent during or after interviews or observations.

Observation during medical training was done with consent from lecturers. Observation of training in large lecture halls was kept covert for attending students. In smaller training groups, the researcher made themselves known but did not obtain consent from individual students.

Observations of consultations and medical training sessions focused on professionals’ and educators’ practices. No personal data from students/residents or individual patients was collected.

The Ethics Advisory Board of the Amsterdam Institute for Social Science Research approved this study (2017-AISSR-7961).

Results

Below, we first describe how the professionals in this study approached contraceptive counselling in practice. Here, we see how professionals negotiated between tailored treatment and risk minimisation in contraceptive care. We observe the two approaches existing in tension with one another both in the cases of patients preferring hormone-free methods as well as in the case of mHealth contraception. This resulted in professionals challenging patients’ preferences for hormone-free methods and excluding mHealth contraception and other FABMs from their care offering. We identify several obstacles to tailored counselling on mHealth contraceptive technologies and FABMs.

Tailoring treatment and risk minimisation

We found that professionals used two approaches during contraceptive counselling, which we categorised as tailoring treatment and risk minimisation. Table 1 summarises the approaches’ main characteristics. See Table A6 (Appendix) for an illustration of the approaches with a selection of data, including quotes and examples from the field.

Table 1. Two approaches to contraceptive care in Dutch general practice.

Approach	Tailoring treatment	Risk minimisation
Involves	Asking what contraceptive choice patient has in mind Advising patient to use decision aid Finding out patient values and lifestyle Discussing contraceptive history and experienced side effects with patient Discussing possible alternatives that may suit patient Taking a try-and-see approach: try a contraceptive, see how it suits the patient, evaluate and, if necessary, change methods	Determining contraindications for use of method Using safety guidelines during insertion of contraceptives (e.g. minimising risk of infection, measuring fundal height to ensure safe placement) Discussing if patient is aware of usage guidelines Stressing or providing tips for consistent use (e.g. committing to taking a pill daily at the same time) Providing short-term prescriptions to ensure proper evaluation after start of use
Goal	Finding the contraceptive method that best suits patient’s preferences, lifestyle, values	Minimising the chance of unintended pregnancy or other adverse risks (e.g. thrombosis, expulsion, uterine perforation, user errors)
Style	Patient-centred dialogue style, supportive in patient’s decision-making process	Statistical reasoning, protocol work, assessing patient understanding and abilities, gatekeeping
Ideal contraceptive	The contraceptive that best suits the patient’s situation; the ideal contraceptive may change if patient’s situation or preferences change	A contraceptive that is safe and has the lowest possible typical use rate – that is, a foolproof contraceptive unaffected by possible user errors

Analysis based on data from interviews, consultations, medical training, contraceptive guideline and decision aids. See Table A6 (Appendix) or data excerpts illustrating the two approaches.

Tailoring treatment entails activities, techniques and technologies professionals use to determine which contraceptive method best suits patients’ preferences, lifestyles and values. Risk minimisation entails activities, techniques and technologies professionals use to minimise the risk of adverse outcomes. In the observed care practices, the approaches blended into and complemented each other: professionals tailored care to patients’ individual situations and preferences while ensuring prescribed contraceptives were safe (e.g. minimising risks of complications and unintended pregnancy). Sometimes, when the approaches existed in tension, risk minimisation predominated. When interviewed about mHealth contraception and other FABMs, most professionals tended to give priority to risk minimisation and forewent tailoring treatment.

Preference for professional-dependent contraceptives: Predominant risk minimisation

When risk minimisation predominated, professionals expressed preference for long-lasting professional-dependent contraceptives. For example, in an undergraduate training session, a lecturer distinguished between ‘good contraceptives’ and ‘bad contraceptives.’ This distinction was based on typical use pregnancy rates. Although pregnancy rates of most common medically prescribed contraceptive methods is low with perfect use, pregnancy rates with typical use are higher in methods requiring daily user administration.

According to this lecturer, oral contraceptive pills (OCPs) were ‘bad’ contraceptives, as were condoms, because they were user dependent. ‘Good’ contraceptives were methods that could be inserted in the patient and thus work effectively regardless of external circumstances.

Look, an Implanon you insert, a Mirena or a Kyleena [IUD] you insert, as a doctor. A copper IUD: you insert. So those are things that…that are in there. (interview 1, lecturer/gynaecologist)

This illustrates the risk minimisation approach when it predominates, whereby a good contraceptive is foolproof and thus withstands the irregularities of life. Concern over possible user mistakes when taking OCPs compelled predominant risk minimisation and the preference for foolproof contraceptive methods. Professionals stressed the inconsistency in OCP use:

Taking…the [oral contraceptive] pill…[patients] don’t understand enough about that. (interview 1, gynaecologist)

And

People, in fact, do all sorts of things with their [contraceptive] pills…and keep thinking: things will turn out fine. (interview 6, GP)

Tailoring treatment for patients preferring hormone-free methods

Most professionals (n = 7) mentioned patients’ growing wariness towards hormonal contraceptives and/or patients’ preference for hormone-free contraceptives. Some professionals invalidated patients’ wariness of hormones and their side effects and argued that:

nowadays everything is attributed to [hormonal contraception]…mood swings,…weight gain,…headaches,…so they have the [false] idea that [these complaints] are related to the pill. (interview 7, GP)

And

[patients] are very much anti-hormone, even though, of course the body itself also makes hormones. (interview 4, GP)

Some professionals attributed patients’ preferences for hormone-free contraceptives to social media trends and misinformation. These invalidations were consistent with other studies’ findings about professionals’ attitudes towards patients’ concerns about side effects [21].

Professionals linked this invalidation to the pregnancy risks involved, as illustrated in this statement:

That [argument] about hormones, I don’t really take that seriously from people because of course the alternative, pregnancy, involves a lot more hormones. (interview 3, GP)

Here, this professional considered hormone-free contraception as an alternative to pregnancy rather than as an alternative to other forms of contraception.

mHealth contraceptives considered ‘bad’ or ‘not contraceptives’

Almost all professionals (n = 7) used predominant risk minimisation when interviewed about mHealth contraception. Professionals characterised them as ‘tricky,’ ‘risky’ and ‘dangerous.’ Patients’ inconsistent method adherence was foregrounded by statements such as:

And if taking the [OC] pill doesn’t work, then I imagine that [a method with] a thermometer won’t work whatsoever. (interview 5, GP)

Professionals emphasised factors that could diminish effectiveness of mHealth contraception, such as those detailed in Table 2.

Table 2. Factors that could diminish effectiveness according to Dutch professionals in interviews.

	Diminishing factor	Excerpt example
1	Patients’ limited abilities to use methods effectively	‘Why are we talking about this when you know that we have two, three million illiterate people in the Netherlands?’ (interview, 3 GP)
2	Patients’ irregular lifestyle impeding ability to use methods consistently	‘Highly educated, smart women who are well informed also have a busy life and are certainly not up for checking an app like that seriously.’ (interview 3, GP)
3	Patients’ or their partners’ inability to abstain or use protection during fertile days	‘Yeah, in the heat of the moment, you won’t be checking an app.’ (interview 1, gynaecologist)
4	Cycle irregularities or cycle-length variance	‘Every woman’s cycle is different, right? Not everyone has a very steady cycle or a very steady rhythm.’ (interview 7, GP)
5	Factors that could influence a particular cycle, such as stress	‘All these apps don’t account for stress, nutrition, travel abroad – to the other side of the Equator, the position of the moon, or who knows what.’ (interview 3, resident in training)
6	Factors that could influence temperature measurements	‘In daily life, there are already so many more influences that can disrupt your [body] temperature, like going out a night drinking, or um, at some point, I don’t know, wearing pyjamas that are too warm.’ (interview 3, resident in training)

Table 3. Obstacles to tailored counselling on mHealth contraception in Dutch general practice.

1	A lack of high-quality evidence on the effectiveness of different mHealth contraception and other FABMs.
2	Of available evidence, the undifferentiated typical use rate of 24 was the most prominent to underpin professionals’ views on FABMs, warranting a risk minimisation approach.
3	Professionals did not consider FABMs as contraceptive methods, but rather methods to achieve pregnancy.
4	Professionals considered FABMs as ‘not a medical issue’, therefore falling outside the scope of their responsibilities.
5	Professionals assumed most/all patients lack ability to learn a FABM.
6	Professionals assumed most/all patients lack ability to consistently apply a FABM.
7	Professionals assumed most/all FABMs do not adjust for possible factors that could influence ovulation or biomarkers and their measurement.
8	Professionals invalidated patient preferences for hormone-free contraceptives.

Obstacles identified in analysis of interviews, consultations, medical training, contraceptive guideline and decision aids.

Some professionals did not consider FABMs or mHealth contraception as a form of contraception at all, underscored by statements, such as

That’s a method you use for the opposite reason: to get pregnant. (interview 1, gynaecologist)

And

All those things on the market [mHealth contraception] are really just to…enable you to get pregnant and not to prevent pregnancy. (interview 3, GP)

mHealth contraceptives beyond the scope of general practice

Some professionals considered the use of FABMs or mHealth contraception as outside their scope of responsibility. ‘You know…it’s not a medical issue, actually,’ said a GP (interview 4), where ‘medical issue[s]’ pertain to methods professionals can prescribe.

Consistent with this demarcation of their professional domain, some professionals expressed that people choosing these contraceptive methods made such decisions without professional help.

Women who are very conscious about these things, they actually have [using these methods] figured out, they don’t really need me. […] This super-smart category, they don’t come here, they know what to do, they just do it. (interview 5, GP)

These methods’ user dependence implied independence from the professional, unlike prescribed user-dependent contraceptives such as OCPs, for which the professional functions as a gatekeeper.

At the same time, some professionals emphasised the value of access to trustworthy evidence and/or counselling on these methods. Their perception that patients were drifting away from professionals in this respect was identified as a problem.

As a GP, I think you should always try to connect with what is going on with patients because otherwise you will lose them. And that’s maybe what’s somewhat happening now. (interview 3, resident in training)

Most professionals were unaware of evidence on FABMs in NHG guidelines. Most classified all FABMs as ineffective without citing pregnancy rates or citing a pregnancy rate between 20 and 24 per 100 women in a year. This aligns with expectations as the NHG guideline’s Table 4 with effectiveness rates does not differentiate the typical use pregnancy rates of different FABMs. Rather, it uses the aggregated typical use pregnancy rates for all FABMs. One GP was aware of more differentiated NHG evidence on the effectiveness of FABMs, yet could not locate it during the interview and remarked on the NHG guidelines’ inaccessibility.

Table 4. Recommendations to foster tailored counselling on mHealth contraceptives in Dutch general practice.

	Guidelines
1	Within the available evidence, effectiveness rates of FABMs and mHealth contraception methods can be better distinguished.	One FABM is not as effective as the other: pregnancy rates with typical use range between 2 and 34 per 100 women in a year [3,4]. To counsel patients with different needs, having access to differentiated information on various FABMs is paramount.
2	The differentiated evidence already included in NHG guidelines can be made more accessible.	In the 2020 digital version of the guideline, accessing differentiated evidence takes ample clicks and scrolls, while no table provides an overview of evidence. To prevent the conflation of different methods, implement ways to make this information more easily accessible.
3	The differentiated requirements of methods can be made more accessible in guidelines and/or training.	Knowing what a user of a method is expected to do daily and knowing method requirements concerning cycle-length variance (if applicable) enable professionals to counsel patients on possible suitable options. For patient-centred counselling, make this differentiated information accessible to professionals. A BMJ Clinical Update [4] provides an interactive example of such differentiated information.
	Clinical care
4	Tailoring to the needs of individual patients concerning FABMs and mHealth contraception can help lower the risk of unintended pregnancies.	As typical use pregnancy rates of FABMs and mHealth contraception range between 2 and 34 per 100 women in a year [3,4], it is useful to explore with patients what pregnancy risk they find acceptable. Consider if the method of choice matches the level of protection required or if an alternative may be better suited. Consider how patients view their own level of commitment to reach or approach perfect use should they prefer a FABMs or mHealth contraception. In addition, professionals can support patients by helping them understand how they can minimise user errors and inconsistencies, as well as if (and if so, how) they can deal with possible irregularities in their cycle. Most certified FABM counsellors provide such guidance (see e.g. [22,23].
	Education and training
5	As mHealth contraceptives continue emerging, these methods require more attention in medical education and training.	As the development of mHealth technologies outpaces curriculum development, education can focus on teaching principles of the most common evidence-based FABMs, relevant biomarkers these methods use, and user involvement needed to execute them. In the eyes of professionals, this increased educational attention may merit the decision to include these methods within contraceptive care. This can support professionals in serving as a linchpin by providing information on contraception, including emerging mHealth solutions, and ultimately preventing uninformed or misinformed decision-making by patients.
	Decision aids
6	Decision aids comparing FABMs and mHealth contraception can support patients in their decision-making.	Users of mHealth contraception rely on online information and social media advertisements [6]. This information is not always evidence-based; meanwhile, an overview and comparison of different FABMs and mHealth contraceptive technologies is lacking. A decision aid to compare methods can help patients by providing information specific to each method, such as requirements for use, typical and perfect use rates, the learning curve for usage, and patients’ considerations of digital data-sharing and privacy. This can contribute to informed decision-making by patients.

Recommendations are based on the analysis of interviews, consultations, medical training, contraceptive guideline and decision aids.

Obstacles to tailored counselling on FABMs and mHealth contraception

We identify assumptions, views and arguments leading professionals to forgo tailoring treatment on FABMs and mHealth contraception in Dutch general practices, as detailed in Table 3.

Discussion

Main findings

This study analyses how Dutch professionals integrate mHealth cycle-tracking technologies or other FABMs in contraceptive counselling and how training and guidelines support them in doing so. It addresses tension in evidence-based medicine between providing the most effective care based on evidence and tailoring care to an individual patient’s preferences and situation.

When interviewed about FABMs and mHealth contraception, professionals tended to prioritise risk minimisation and forewent tailoring treatment. Professionals hesitated to include these methods in counselling because they considered them risky.

Strengths and limitations

This study was limited regarding geographical scope, professionals and observed consultations. It also hinged on the first author’s personal and professional insights as a medical anthropologist who has studied and used mHealth contraception. As common in ethnography, data saturation was ensured by including and triangulating different data types. Despite our limited sample, the ethnographic approach and the first author’s positionality allowed a more in-depth analysis of how mHealth technologies pose new challenges for contraceptive care. The analysis uncovered the dynamics underlying professionals’ hesitance to include mHealth contraception, thereby hampering patient-centred counselling.

The observed contraceptive consultations did not include examples of patients specifically requesting counselling on FABMs or mHealth contraception; analysis of counselling on these methods was, therefore, infeasible. Contraceptive consultations excluding such examples could indicate that these are not the most common contraceptive requests or that patients with such requests find information through channels other than care professionals. Further research is needed to understand how professionals navigate the tension between tailoring treatment and risk minimisation while counselling on mHealth contraception.

Despite this study’s small scale, we identify the necessity to respond to the emergence of mHealth contraceptives in medical education, training, guidelines and practice. Future research is needed to elaborate an adequate response to mHealth contraceptives.

Comparison to existing literature

Recent studies have identified barriers to good patient-centred contraceptive counselling [8,10,24], such as professionals’ lack of knowledge on methods, time constraints, limited tailored communication skills and professional-dominated counselling. Several studies have highlighted tension between professional preferences for the most effective methods and individual patient-tailored care [25–27]. Comparing these studies, we found that as new mHealth technologies emerge, barriers to good, patient-centred counselling persist. Tension between professional preferences and individual patient-tailored care seems to intensify as professionals tend to forgo a tailoring approach when discussing mHealth contraceptives and/or patients’ preferences for non-hormonal methods [25–27].

A recent qualitative study among Dutch women who wanted to avoid pregnancy yet did not or did not consistently use prescribed contraceptives revealed that these patients relied on condoms, withdrawal, the calendar method (often deployed via apps) and/or a combination thereof [13]. These patients expressed wanting more extensive counselling on non-hormonal methods. Our study contributes to these findings by showing that professionals are hesitant to counsel on these methods because they wish to minimise risk of unintended pregnancy. In line with other evidence [21,28], some professionals tended to delegitimise women’s preferences for hormone-free contraception and their worries about side-effects.

Compared to literature on eHealth or mHealth solutions as auxiliary to traditional care in general practice [15,16,29,30], our study raises new questions. Literature on mHealth in general practice calls for increased education for professionals as well as critical ethical reflection by professionals and policymakers to understand how mHealth solutions can be implemented safely and effectively [15,16,29,30]. After all, if a digital solution is not proven safe, the professional is underprepared or the intervention is not well-integrated in general practice, it may not improve care quality.

Yet, what if the mHealth solution is not professional-initiated or policy-prescribed but rather taken up by patients? How, then, can we improve care quality? While understandable from a risk-prevention perspective, advising against the use of these technologies or considering them beyond the scope of general practice may not prevent patients from using them. How can we ensure patients are well-informed in their decision-making and well-equipped to use methods correctly and consistently, thereby decreasing unintended pregnancy rates? This article accordingly encourages patient-centred questions such as: How can we support patients in choosing between different FABMs and mHealth contraception? How can we help those choosing mHealth contraception or an FABM to achieve perfect use or an approximation thereof? For which patients in which situations would which method be a preferable option? As patients are already taking up these methods, good care may mean supporting their choice to use them in a well-informed way based on available evidence.

Implications

This study takes starts with the need for patients to have evidence-based information and patient-centred counselling when making reproductive health decisions. With mHealth contraceptives proliferating and patients expressing preferences for non-hormonal contraception, the need for good counselling is paramount. Professionals thus need to be knowledgeable about different FABMs and mHealth solutions.

We have identified several obstacles to patient-centred counselling on mHealth contraceptives. A key impediment to patient-centred counselling on mHealth contraceptives and other FABMs is the lack of high-quality evidence. High-quality research on mHealth contraceptives is thus needed. While we await high-quality evidence on mHealth contraceptives, we suggest practical recommendations to foster tailored counselling, as compiled in Table 4.

Conclusion

Professionals in this study hesitated to include FABMs and mHealth contraception in their counselling. Most considered them as risky, inferior contraceptives, not contraceptives at all, and/or ‘not a medical issue.’ When interviewed about mHealth contraception, professionals tended to prioritise risk minimisation and forego tailoring treatment. This may hamper adequate patient-centred counselling for patients with preference for FABMs and mHealth contraception. Based on these results, we proposed recommendations that foster a patient-tailored approach to mHealth contraceptives.

Acknowledgements

This article would not have been possible without participation of healthcare professionals, practice assistants and educators. We thank those who participated for their time and effort. We thank the patients who allowed us to observe their consultations for their courage and willingness. We thank the reviewers and editors of this journal for their invaluable feedback to improve the manuscript in various version. Thank you Mirjam Dijkxhoorn, Karina Hof and Machiel Keestra for your inspiring input and support in improving the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Appendix

Figure A1. Code map.

Table A1. Demographic and professional data of interview participants (n = 9).

Characteristics		Mean (SD)
Years of practice		18 (13)
		Number
Gender	Female	4
	Male	5
Profession	General practitioner	7
	Gynaecologist	1
	Nurse practitioner	1
	Lecturer	3
	Specialised in sexual health	4
Practice location	Urban	4
	Semi-urban	5

Table A2. Details on observed consultations (n = 10).

Care professional	Topic	Type of consultation	Recorded in
GP	Oral contraceptives, first consult	Face-to-face	Field notes
GP resident	Restarting oral contraceptive	Phone	Audio recording
GP resident	Implanon after APLA	Phone	Audio recording
GP	Change from OCP to IUD	Face-to-face	Field notes
GP	OCP, first consultation	Face-to-face	Field notes
NP	IUD removal	Face-to-face	Field notes
NP	Evaluation of new OCP prescription	Phone	Field notes
NP	Follow-up after IUD placement	Face-to-face	Field notes
NP	Evaluation of new OCP prescription	Face-to-face	Field notes
NP	IUD removal	Face-to-face	Field notes

Table A3. Details on observed training sessions (n = 6).

Type	Topic	Level	Location
Lecture	Contraception	Undergraduate	Academic hospital lecture hall
Anatomy lesson	Male and female pelvis	Undergraduate	Academic hospital anatomy lab
Lecture	Unexplained subfertility	Undergraduate	Academic hospital lecture hall
Seminar	Bleeding problems and menstrual disorders	Postgraduate vocational	Video conference (due to COVID-19 restrictions)
Seminar	IUD counselling and placement	Postgraduate vocational	Video conference (due to COVID-19 restrictions)
E-learning	Contraception continuing education	Postgraduate continuing	E-learning

Table A4. Details of guideline (n = 1) and decision aids (n = 5).

Organisation	URL	Sampled
Guideline on contraception
Dutch College of General Practitioners (NHG)	https://richtlijnen.nhg.org/standaarden/anticonceptie#volledige-tekst	Version 2.1, May 2020
Decision aids
Public health organisation focusing on reproductive health	https://seksualiteit.nl/anticonceptietool/	2021
Public health organisation focusing on reproductive health	https://sense.info/nl/condoom-pil-en-meer/welke-anticonceptie-kies-jij/anticonceptie-keuzehulp	2021
Dutch College of General Practitioners (NHG)	https://www.thuisarts.nl/zwangerschap-voorkomen/ik-wil-voorkomen-dat-ik-zwanger-word-wat-kan-ik-kiezen#welk-voorbehoedmiddel-past-bij-mij	2021
Pharmaceutical company	https://www.anticonceptie.nl/	2021
General practice	https://www.keuzehulpanticonceptie.nl/	2021

Table A5. Interview guide.

Theme 1. you as a professional

Can you give me some general background information about you as a person and as a professional (age, years of practice experience, why you became a health care professional)? How would your patients describe you as a doctor?

Theme 2: The contraceptive consultation

Can you describe to me how a contraceptive consult typically goes? For example, based on your last consultation, very concretely: how did the consultation go, what was discussed, and what did you do to provide this patient care? What kind of tools or techniques do you employ when providing contraceptive care? For example, do you employ paper tools, digital tools and dialogue techniques when interacting with patients? Can you give an example of a consultation that went particularly well or badly, in your opinion? If so, how did this consultation go? What went well or poorly?

Theme 3: Methods taking fertile days into account

Do you counsel on methods (digital or otherwise) that take fertile days into account? What is your approach to methods that take fertile days into account? What does a consultation about this usually look like?

Theme 4. Use of guideline

When was the last time you consulted the NHG guidelines on contraception? What prompted this, and can you describe how you used it at the time? Are there other documents, guidelines, information sources or tools that you use in your consultations?

Theme 5. Observation of consultations or training (if applicable)

When interviews occurred after or between consultation observations, the consultations provided additional material for interview questions. The same held for observations of medical trainings and interviews. The interviewer adjusted according to each interview’s circumstance.

Table A6. Data excerpts illustrating two approaches to contraceptive care in Dutch general practice.

	Tailoring treatment	Risk minimisation
Guideline	‘For contraception requests, investigate preference, anticipated compliance, and personal situation.’ (NHG guideline)	‘Consider obesity, smoking, and exposure to second-hand smoke when assessing individual risk of VTE [venous thromboembolism].’ ‘When choosing methods such as combination pills or the progestogen-only pill, note the importance of consistency for effectiveness.’ (NHG guideline)
Education	Lecturer presents cases for students to practise counselling on contraceptive methods based on patient’s situation. (observation, seminar for residents in training on contraceptive counselling)	Lecturer describes in detail how to insert IUDs and stress the medical procedures to ensure risk minimisation, such as measuring probe length to ensure IUDs are inserted in the uterine cavity (minimising expulsion risk, observation, seminar for residents in training on contraceptive counselling)
Decision aids	Decision aids include questions such as: ‘Do you suffer from heavy, prolonged, or painful periods?’ or ‘To what extent do you want to think about contraception?’ Based on patients’ answers, tools provide one or more suitable contraceptive methods that fit the patients’ situation and preferences.	Some decision aids also ask questions regarding contraindications for use, such as: ‘Have you or family members had thrombosis yourself?’
Interviews	‘You hope… you can help people… like, now how can we make sure we can match the right methods to your life situation…. You choose… a certain method. Then we are going to evaluate that… after three months. If turns out not to work, we just move on to something else.’ (interview 8, NP)	‘And what I always do last [during a consultation], is really just the technique. And that’s about: how do you use that pill, so that it also works well, that that also achieves your Pearl Index….Because people do ALL sorts of things with pills….But especially with oral contraception, of course, you just have to use it precisely and properly. And, um, so that needs explanation. Then I talk about: postponing [menstruation] on holiday [by skipping the placebo pills], forgetting to take the pill, starting at the end of the cycle, things like that.’ (interview 6, GP)
Observations	Professional stresses to patients in consultations that they need to feel content and comfortable using their chosen methods, but that they can never know what side effects may appear. Professional plans an evaluation with each patient and makes time to discuss their experience using the method, addressing effects on mood, libido, physical complaints, daily administration, among others (field notes of observed consultations)	Professional (GP resident in training) asks patient: ‘And just to make sure the pill is safe for you: do you smoke?…And is there any history of thrombosis in your family?…. And does breast cancer run in the family?’ (transcript of recorded phone consultation)