Feminist Midwife Scripts: Contraception Options
After requests to detail the language I use in different midwifery care scenarios, I am starting a series of "scripts." With these example texts, I seek to provide a springboard for providers, care seekers, and reproductive health workers to discuss possible best practices for language and approach in different scenarios. I will update each script with language and ideas shared here and on social media to work toward creating an environment of true empowerment, respect, and care in obstetrical and gynecological health.
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In one clinic day, full to the brim with appointments, I typically encounter multiple people who want to start a contraceptive method but aren't sure what all the options are. Or the general differences in how they work. Or they mistakenly think they don't qualify for a method. Someone might say, "I'm thinking about the pill, but I'm not sure." Or, "I used Depo and I gained weight, and I don't know what other options there are." Or, "My mom says I can't use the IUD because I haven't had a baby before, but I want to know about the IUD and the other choices."
This is the perfect opportunity as a care provider to open the conversation, give people all the information they might need to make their own decision, and then start someone on the path to bodily empowerment. A chance for feminist healthcare at its finest!! (Maybe this feels a little save-the-world-y to some, but these conversations make all the difference to many, and build trust and a long relationship with providers!)
To start the conversation by listing everything available, I often do a quick "101 of the methods" script. I do this for everyone, as the full list applies to everyone. Teens get the same list as grand multips. People with a history of multiple abortions get the same list as those without. Queer people and straight people get the same list. Save those important and pesky qualifying medical conditions, every should hear the list of every method.
As you consider the list of options and how you currently counsel people, I encourage you to consider your own values clarification exercise as part of this work. Are there certain methods you personally believe only certain "types" of people should use? Or are there certain "types" of people who you think might not use a method well, and thus you counsel about that method differently to them than you would others? Here are a few examples of values clarification, with considerations included in parentheses: all methods can be used by just about anyone regardless of age (adolescents qualify for LARCs just like everyone else), BMI (read the research and decide for yourself how you'll counsel people), parity (grand multips can choose the rhythm method just like anyone else whose cycle is regular), withdrawal is a real method of contraception (and a lot of people use it so don't disparage it or it shuts down the conversation), etc. Consider what it is as a provider that might sway you against recommending a method for someone. I try to check myself this way: is the method what they want based on outcome/effectiveness/side effects, and do they qualify for it based on medical eligibility. If both of those are a 'yes,' then they get the method. No other factors should be considered. Examine whether your values need to be checked at the door so as to not enforce your own beliefs on someone else's reproductive choice. (Consider, also, that many methods are in-the-works to be provided over-the-counter, and people will likely start determining their own methods with or without us, so let's be open and welcoming to their preferences now!)
A few notes:
Before starting the script, I'll often ask people if they're looking to start a method because they're looking to control their periods, for contraception, or for another reason, so the conversation can be guided slightly that way per their needs.
Never assume heterosexuality. That's all I'll say about that, because I hope that's understood.
Use of contraceptive methods in the postpartum period is a different discussion, due to concerns around the hypercoagulable state and breast milk production. This script is meant for people not in the postpartum period.
The "one key question" method for contraceptive counseling or preconception counseling can work well as long as the provider is aware of their own biases toward/against methods for certain people. Introducing the question and then starting the conversation from there can be helpful for many people initially creating relationships with their clientele.
I'm anticipating comments about discussing the risk for deep venous thrombosis (DVT) for contraceptive methods containing estrogen. Or the bleeding profile for the first three-to-six months of Depo. Or the incredibly low risk of pregnancy but within that a slight risk of ectopic pregnancy with IUDs. I know all of these things. For each and every method below, when the patient starts to lean toward a method, I go into further detail about how that method works, its side effects, common reactions, and risks. This is just a quick overview script to start the conversation.
I personally have zero stock in which method someone chooses, beyond it meeting their needs related to side effect management and, if it's their reason for starting a method, pregnancy prevention.
If someone stops me mid-conversation, and hears something they like, great! I'll stop and completely counsel them on that method. Then I'll say, just so you know the full list and know you can change your method at any time, let me run quickly through the other options.
Some people will shake their head or wave their hand when you start into one method. Respect their desire to move past that method, and gauge whether asking about their experience or what they've heard about that method would be important to their care later on in the conversation.
I will cover discussion about permanent versus reversible contraceptive methods in another post.
The people I serve have a reading level of around the fifth grade, so my scripts typically reflect the actual language I use at the start of the conversation, and then modify based on their understanding.
In my care I constantly seek to normalize choice and outcomes. You'll see this in the script below when I saw "some people like" or "for some people ___ happens." This helps people frame their own experiences (or the experience they may have) in context of community rather than "maybe it's just me," and allows them to realize you're ready for their feedback when things come up.
Almost every appointment I have is book at fifteen minutes. Sometimes double-booked. And I get through this and find time to ask people about their history and their lives. I believe that you can do it, too! (And, screw the fifteen minute requirement anyway.)
I usually start with how often the method is used, from the day-to-day to the long-term. I do not feel that this prioritizes any method over another. However, I have noted that ending the conversation on the long-acting reversible contraceptives (LARCs) generally prompts more discussion about those methods (totally subjective comment here). Fully acknowledging my own work toward being non-coercive in discussing methods (reproductive justice, y'all), every so often I'll switch up the order of methods, and usually I find it doesn't affect the rates of people who choose what they may have already indicated they're leaning toward anyway.
So, now, the script:
"There's the birth control pill, which is a small pill that has hormones in it, and you take it around the same time every day. After three weeks of taking the pill, you get your period, and keep on taking a pill every day. Some people are great at remembering to take pills every day, and some aren't. There's the patch, which is a really strong sticker you put on your body once per week, and your body absorbs the hormones through the sticker. After three weeks of using the patch, you have one week when you don't, and you get your period that week, and restart the patch the next week. Some people find it easier to change something once per week than once per day, while other people have a harder time with that. The patch is the color of white skin-tone. There's the ring, which is a small, flexible, plastic ring that you insert yourself into your vagina, and your body absorbs the hormones that way. You leave it in there for three weeks, including during sex and when you shower. After three weeks, you take it out, get your period, and then put another back in the next week. Some people like being able to insert their own method but not have it be visible on their body like the patch, and others don't like the idea of inserting something on their own.
Then there are the longer term methods. There's the shot that you can get every three months, called Depo. Usually your period gets light or goes away completely. Some people like coming in for their shot every three months, and for others to come into the clinic for a shot interrupts their life too much. There's the implant that goes in your arm and lasts for up to three years, and you can always take it out before that. It's about this big (show distance between fingertips), about the thickness of spaghetti, and here in the clinic we would place it just underneath the skin, sort of like a tuberculosis test, between the two muscles in your bicep (here I point to the area on my own arm). Usually your period gets really light or goes away completely the whole time you have it in. There's the three- and five-year T-shaped devices that go into your uterus, both of which you can take out anytime beforehand. Both cause your periods to get light or go away completely. There's the ten-year T-shaped device that also goes into your uterus, which doesn't have any hormones at all, so your period would come however it does now (here I'll talk about if they're someone who has really irregular periods, they'll still be irregular, or if they're regular they'll still be regular). Once they're in your uterus you shouldn't feel them at all, and your partner shouldn't notice them during sex. With these longer term methods some people really like that they do not have to think about using their method every day, week, or month, and others feel more in control of using the method regularly on their own.
Condoms are very effective contraceptive methods and are the only method that can be used to protect against some sexually transmitted infections. There are also quite a few non-hormonal methods that a lot of people might not talk about. The rhythm method, or natural planning, means that you'd learn more about your monthly cycle and figure out when you release an egg to determine when it's safe to have sex without leading to pregnancy. Some people use this method with the withdrawal, or pull-out method, which means pulling the penis out of the vagina before ejaculation. The diaphragm is a plastic-like covering that you insert into your vagina to cover your cervix, and you can use a cream with it to stop sperm from swimming.
There are multiple kinds of permanent birth control, meaning that the method is not reversible, and we can talk about those if you're interested.
What do you think about that list? I know that's a lot of information and I'm happy to go back over anything or chat about any of those in more detail.
If there's silence, or if they express they're still not sure, or if it seems like more information would be helpful... I'll start into this next portion.
Methods that are easy to start and switch if you don't like them are the pill, patch, and ring, so sometimes people will start with those to see how they feel. Other people know they're not planning pregnancy for a long time or ever, and in their lives find it easier to use a method that is really effective and they don't have to think about. Other people pick a method based on whether or not they want to see their period at all, be able to control when it comes, or how heavy or crampy it might be. Other people choose a method based on how quickly they want their fertility to return. Do any of those reasons sound like why you'd choose a method?"
Looking forward to your thoughts! As always, in the comments please be cognizant of pronouns, assumptions of heteronormativity, gender roles, etc.
In solidarity,
Stephanie