Introduction to Reproductive Life Planning and Motivational Interviewing

Meghan Benson, MPH, CHES
Director of Community Education
Meghan.Benson@ppwi.org
608-251-6587
Anne Brosowsky-Roth
Community Education Resource Specialist
Anne.Brosowsky@ppwi.org
414-289-3767
Reproductive Life Planning &
Motivational Interviewing
Safe Healthy Strong 2014
Pre-Conference Institute
August 6, 2014
UW-Milwaukee Zilber School of Public Health

About
PLANNED PARENTHOOD
 Annual reproductive health exams
 Birth control (including EC & condoms)
Copyright © 2013 Planned Parenthood of Wisconsin, Inc.
 Cancer screening
 Colposcopy
 STI testing & treatment
 HIV testing & risk-reduction education
 Pregnancy testing & all-options education
 Abortion care
 Referrals for other health & social services

Conflict of Interest
Statement
 Meghan Benson
• I have received no support or commercial funding for
this presentation, or for any products mentioned
herein.
 Anne Brosowsky-Roth
• I have received no support or commercial funding for
this presentation, or for any products mentioned
herein.
Copyright © 2013. Planned Parenthood of Wisconsin, Inc.

Agenda
9 – 9:30 a.m. Welcome & Introductions
9: 30 – 10:30 a.m. What is Reproductive Life
Planning
10:30 – 10:45 a.m. BREAK
10:45 – 12:15 p.m. Contraceptive Efficacy
12:15 – 1:15 p.m. LUNCH
1:15 – 3:15 p.m. Motivational Interviewing
3:15 - 3:30 p.m. BREAK
3:30 – 4:30 p.m. Case Studies & Role Play
4:30 – 5:30 PM Questions | Comments | Wrap up

Objectives
 List the core components of a reproductive life plan.
 Define the terms “perfect use” and “typical use” in relation to
contraception & explain how this fits into the WHO “Tiers of
Contraceptive Efficacy” framework.
 Examine why Motivational Interviewing (MI) is an effective tool for
fostering behavior change.
 Express the main features of an MI approach to counseling.
 Demonstrate how to develop a Reproductive Life Plan with a patient or
client using MI tools.

2006 CDC Guidelines for
Interconception Care
Goal: to improve the chances that an infant will be
born healthy by addressing any issues prior to
conception
 Increase KNOWLEGE, attitudes and behaviors of
men and women before conception takes place
 Increase ACCESS to health services
 Improve INTERVENTIONS after an adverse
pregnancy outcome
 Reduce DISPARITIES in adverse pregnancy outcomes

Unintended
pregnancy in the US
Source: the Contraceptive Choice Project

Title X FY 2014 Program
Priorities
1. Assuring the delivery of quality family planning and related preventive health services…
2. Providing access to a broad range of acceptable and effective family planning methods
and related preventive health services…
3. Assessing clients’ reproductive life plan as part of determining
the need for family planning services, and providing
preconception services as appropriate
4. Addressing the comprehensive family planning and other health needs of individuals,
families, and communities through outreach to hard-to-reach and/or vulnerable
populations…
5. Identifying specific strategies for adapting delivery of family planning and reproductive
health services to a changing health care environment…
US Department of Health and Human Services: Office of Population Affairs

Links between
childbearing and poverty
 Lower educational
attainment in women
 Reduced future earning
potential
 Singe-parent families
more likely to live in
poverty
 Increased healthcare
costs

Does intent matter?
Women experiencing unintended
pregnancy tend to:
 Delay prenatal care
 Be at greater risk of physical
abuse while pregnant
 Have higher rates of negative
health outcomes during and
after pregnancy.
Children who result from
unintended pregnancy may:
 Have poorer physical and
mental health outcomes
Source: Child Trends Institute. The Consequences of
Unintended Childbearing, White Paper. (2007)

Pregnancy and
“intendedness”
Pregnancies by Intention Status
Intended
Mistimed
Unwanted
Source: Alan Guttmacher Institute. Facts in Brief: Facts on Unintended Pregnancy in the United States (January 2012)
.
Unintended pregnancies
account for about 49%* of all
pregnancies. They include
pregnancies that were:
• Mistimed 29%
• Unwanted 19%
*these numbers do not add up to 100% due to
rounding.
Nearly 50% of unintended
pregnancies occurred in a
month that couples used a
method of contraception.

The RLP assessment…
 Patient centered
 Empowering for the participant
 Includes key basic questions that
allow the client to elaborate
 Invites goal setting and action
steps (Motivational Interviewing)
 SHORT!
Source: Deliberations of the Ad Hoc Committee of PCCHC Select Panel on Reproductive Life Planning, Washington, DC,
November 23, 2009.

Reproductive Life
Planning - RLP
RLP is client-based
assessment of their own
goals to determine where
childbearing fits into
 Education
 Work/Career
 (Any?) Future Children
 When?
 How many?
 How often?
So they can create a plan
to meet those goals.

RLP at the Most Basic
1. Do you want to have a (another) baby?
2. Are you having sex and is there a chance you
could get pregnant or get someone pregnant?
3. If you don’t want a baby right now, what are
you doing (or planning to do) to keep from
getting pregnant or getting someone
pregnant?

BIRTH CONTROL:
WHAT DO YOU KNOW?

More effective
Less than 1 pregnancy
per 100
women each year
Less than
1 per 100
Implant IUDs
Female
sterilization
Male
Sterilization
2 – 9
per 100 LAM
Breastfeeding Depo Shot The Pill The Patch Nuva Ring
15-24
per 100
Diaphragm External condom Internal condom Withdrawal Cervical cap
About 25
per 100 Emergency
Contraception
Fertility
Awareness Spermicides The sponge
Less effective
About 25 pregnancies
per 100
women each year
COMPARING BIRTH CONTROL
EFFECTIVENESS
Source: Adapted from WHO, 2007 and ARHP Method Match.

Health Behavior Change

Health Behavior
 Health behaviors are impacted by many,
intersecting and overlapping variables
 Mutable and immutable factors
 Factors related to individual, family, community,
environment, culture, society, and various institutions
(i.e. schools, health care, legal system, etc…)

Consider the Context of
Health Behavior

Health Behavior Change
 Health behaviors are complex with factors at many
levels contributing to both behavior intention and
ultimately behavior
 Causation and even correlation can be challenging
to demonstrate between various factors and health
behaviors
 This makes health behavior change hard – for
everyone!

Health Behavior Theory
 Unified Theory of Behavior
 Jaccard, J. and Levitz, N. (2013). Parent-based interventions to reduce
adolescent problem behaviors: New directions for self-regulation
approaches In G. Oettingen and P. Gollwitzer (Eds.) Self-regulation in
adolescence. New York: Cambridge University Press.
 Jaccard, J. and Levitz, N. (2013). Counseling adolescents about
contraception: toward the development of an evidence-based
protocol for contraceptive counselors. Journal of Adolescent Health,
52, S6-S13.
 Transtheoretical Model of Behavior Change or
“Stages of Change” Model

Unified Theory of
Behavior
 Determinants of Behavior Intention

Unified Theory of
Behavior
 Moderators of Intention-Behavior Relationship

Transtheoretical Model of
Behavior Change

Questions?

Role-play 1
1. Get into pairs. One person is the
counselor, the other the client.
2. Counselors: You ONLY have 2 minutes to
explain to your clients why they should
use birth control.
3. Clients: Listen carefully to your
counselors.

Motivational
Interviewing (MI)
MOTIVATIONAL
INTERVIEWING is a quick,
effective, and client-centered
technique that allows clients
to define their own goals and
make their own choices by
helping them identify what is
personally meaningful in
their own lives.

MI + RLP
A set of skills you can use to help your clients
motivate themselves for success.

More Information on
Motivational Interviewing
 Today, we will focus on utilizing MI skills in the
context of Reproductive Life Planning
 For further MI resources & training –
 Motivational Interviewing Network of Trainers:
http://www.motivationalinterviewing.org/motivational-interviewing-
resources
 Professional Certificate in MI:
http://continuingstudies.wisc.edu/certificates/motivatio
nal-interviewing

What is Motivational
Interviewing (MI)?
A collaborative, goal-oriented method of
COMMUNICATION
Strengthens an individual’s motivation and
movement toward a goal by exploring the THEIR
OWN arguments for change

Benefits of MI for
Providers
 Reduces frustration with
our clients (and with
ourselves).
 Removes our own ego
from the education or
counseling process.
 Releases us from
responsibility if a client
doesn’t follow through.

Benefits of MI for
Clients

Guiding Principles
of MI
Resist the righting reflex
Understand your client’s
motivations
Listen to your client
Empower your client

Behavioral
Characteristics of MI
 Understand from the CLIENT’S frame of reference
 Express ACCEPTANCE and AFFIRMATION
 Elicit and SELECTIVELY REINFORCE the CLIENT’S:
 Own motivations
 Problems and concerns
 Change talk (desire, ability, reasons, need to change)

The Spirit of MI
 RESPECTFUL
 OPTIMISTIC
 EMPATHETIC
 COLLABORATIVE

Another way of stating
the principles of MI –
 Roll with resistance – don’t argue
 Express empathy – use reflective listening
 Develop discrepancy – elicit change talk
 Support self-efficacy – it’s ultimately the
client’s responsibility

Behavioral Characteristics
of MI
 INCREASE client’s COMMITMENT to change
 E-P-E: Elicit – Provide – Elicit
 ELICIT client’s ideas and needs
 PROVIDE information and advice
 Ask permission, unless client asked for advice
 ELICIT client’s reactions and commitment to change

Role Play 2
1. Divide into the same pairs you were in for the
previous activity.
2. Stay in the same role.
3. Client: You have 2 minutes to explain to the
counselor all the reasons that you think you
should use birth control.
4. Counselor: Listen carefully to your clients.

Expect – and accept –
Ambivalence
On one hand,
I want to be successful.
REWARDS
On the other hand,
all kinds of things stand
in the way of making
that happen.
OBSTACLES

It doesn’t mean the
client doesn’t care…
REWARDS
If I’m careful about using birth
control:
• I won’t get pregnant [get
someone pregnant] until I want to.
OBSTACLES
.
But..
• There’s too many side effects.
• It’s too expensive.
• I can’t get to the clinic.
• My partner doesn’t want me to use it.
• I’m not having sex right now anyway.

Ready, Willing, Able
 Individuals won’t even attempt to change their
behavior if it seems impossible.
 Use a scale to gauge readiness, willingness, or
ability to change.
Confidence Ruler
1 2 3 4 5 6 7 8 9 10
Least Most

On one hand…
Client: A “3.”
Facilitator: Why not a “1” or a “2”?
Client: I know I’m not ready for a baby, and I
don’t know if my boyfriend would be a
great father. I guess having a baby
wouldn’t be the worst thing in the world,
and we would have to figure it out.
Facilitator: Why do you think this number isn’t
higher?
Client: I want to be sure I’m ready first.

Example

Don’t jump ahead!
 Affirm the individual’s
freedom of choice and self-direction.
 Monitor for readiness.
 Don’t push for a
commitment when the
individual isn’t ready for it.

The Flow of
Change Talk
Intervention
(MI)
Client
assesses
their
own
GOALS
Client
commits
to work
on goals
and
makes a
PLAN
CLIENT
ACHIEVES
GOALS or
MODIFIES
BEHAVIORS

Recognizing
Change Talk
D = Desire for Change – “I want to…”
A = Ability to Change – “I could…”
R = Reasons for Change – “I would…if…”
N = Need for Change – “I have to…”
A = Activation – Person is ready, willing or preparing.
C = Commitment to Change – “I’m going to…”/“I will…”
T = Taking Steps – “I’ve started to…”/“I am…”

Eliciting Information With OARS
• Open-ended questions
• Affirmations
• Reflections
• Summaries

Open-Ended Questions/
Statements
 Require more than a one word (yes or no) answer.
 Elicit more of a person’s thoughts and feelings
about a behavior.
Close-ended questions Open-Ended Questions
How many children do you plan to
have?
What are your thoughts about
having children in the future?
Do you use birth control? How do you feel about using birth
control?
Do you talk with your partner about
preventing pregnancy?
Tell me how you and your partner
talk about preventing pregnancy.

Affirmations
 Emphasize strengths.
 Nurture competency.
 Focus on descriptions.
 Be genuine!
What affirmations can you offer
a client who’s been diagnosed
with an STI?

Reflective Listening
 Reflections don’t have to
be perfect (they can even
be wrong!)
 Feeling understood can
make a client more open
to considering change.
 YOU choose what to
reflect to the client!
Reflective statements lead
to better understanding.

Types of Reflections
A. SIMPLE
 Repeat
 Rephrase
B. COMPLEX
 Double-sided (AND not BUT)
 Paraphrase
 Metaphor
 Continue the thought
C. AMPLIFIED
 Exaggerate
 Understate

Summaries
 Collect the material
that has been
offered.
 Link something that
was just said with
something that was
said earlier.
 Transition to the
next topic.

Rolling with
Resistance
 Use amplified reflections
 Shift the focus
 Reframe
 Agreement – with a twist
 Stress personal choice
 Side with the negative

Thoughts, ideas, questions?

Are you ready?
What resources would you need to implement
a discussion of RLP with your clients?

Resources
(CDC) Reproductive Life Plan Tool for Health Professionals
http://www.cdc.gov/preconception/documents/RLP
HealthProviders.pdf
(CDC) Reproductive Life Plan Worksheet for Patients
http://www.cdc.gov/preconception/documents/
ReproductiveLifePlan-Worksheet.pdf
(WI DHS) BadgerCare Family Planning Only Services
www.dhs.wisconsin.gov/badgercareplus/fpw.htm
(information available in English/Spanish/Hmong)

Resources
 Planned Parenthood of Wisconsin, Inc. (locate health
centers, online information about sexual and
reproductive health) www.ppwi.org
 Bedsider.org (contraceptive info, personalized
method comparison tool, appointment/birth control
reminders)
 ARHP (Association of Reproductive Health
Professionals) My Method Match Patient Tool
arhp.org/methodmatch

Selected References
 Alan Guttmacher Institute: Facts on Unintended Pregnancy in the United States
(January 2012) guttmacher.org/pubs/FB-Unintended-Pregnancy-US.pdf
 Child Trends Institute. The Consequences of Unintended Childbearing, White Paper.
(2007) www.childtrends.org/Files//Child_Trends-
2007_05_01_FR_Consequences.pdf
 The Choice Project. choiceproject.wustl.edu
 The World Bank. “Poverty Reduction. Does Family Planning Matter?” (2005)
siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/28
1627-1095698140167/GreenePovertyReductionFinal.pdf
 (CDC) Recommendations to Improve Preconception Health and Health Care in the
United States (2006) www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm

Selected References
 Frey KA, Navarro SM, Kotelchuck M, Lu MC. (2008) The clinical
content of preconception care: preconception care for men.
American J ObstetGynecol. 2008 Dec;199(6 Suppl 2):S389-95
 Frost JL and Linberg L (2012) “Reasons for Using Contraception:
Perspectives of US Women Seeking Care at Specialized Family
Planning Clinics.” Contraception. Epub ahead of print, 27
September 2012.
 Sanders L. (2009) “Reproductive Life Plans: Initiating the Dialogue
With Women.” MCN: Journal of Maternal and Child Nursing.
36(4)342-347.

Introduction to Reproductive Life Planning and Motivational Interviewing

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