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Am J Obstet Gynecol. 2019 Nov 30. pii: S0002-9378(19)32692-4. doi: 10.1016/j.ajog.2019.11.1271. [Epub ahead of print]

The history of tiered-effectiveness contraceptive counseling and the importance of patient-centered family planning care.

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Department of Obstetrics, Gynecology and Women's Health, Rutgers-New Jersey Medical School, Newark, NJ. Electronic address:
Guttmacher Institute, New York, NY.


Public health workers, clinicians, and researchers have tried to increase long-acting reversible contraceptive (LARC) use by changing contraceptive counseling between patients and providers. Several major health organizations now recommend tiered-effectiveness counseling, in which the most effective methods are explained first so that patients can use information about the relative efficacy of contraceptive methods to make an informed choice. Some scholars and practitioners have raised concerns that, given histories of inequitable treatment and coercion in reproductive health care, tiered-effectiveness counseling may undermine patient autonomy and choice. This Clinical Opinion examines the development of tiered-effectiveness contraceptive counseling, how its rise mirrored the focus on promoting LARC to decrease the unintended pregnancy rate, and key considerations and the potential conflicts of a LARC-first model with patient-centered care. Finally, we discuss how reproductive justice and shared decision making can guide efforts to provide patient-centered contraceptive care.


IUD; LARC; choice; coercion; contraception; implant; reproductive justice; shared decision making; tiered counseling

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