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

Figures & data

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.

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.

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.

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)

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