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The rate of unplanned pregnancy in the United Statesremains high. A study performed by the Alan GuttmacherInstitute showed that 49% of all pregnancies in the UnitedStates were unintended; 46% of those pregnancies re-sulted in live births and 54% in induced abortions.1 Unin-tended pregnancies can result in serious personal,socioeconomic, and public health consequences.

Multiple reasons have been suggested for the contin-ued rate of unintended pregnancy. These include a lackof patient education, ineffective contraceptive methods,inconsistent use of contraception, unplanned sexual ac-tivity, and contraceptive failure. Improvement of contra-ceptive education has the potential to positively impactrates of contraceptive failure, inconsistent contraceptiveuse, and subsequently, rates of unintended pregnancy. Anindividual’s education and knowledge level of concep-tion and contraception may influence the rate of unin-tended pregnancies within a population. An appropriatetime to ensure exposure to educational material is duringthe postpartum period of hospitalized women.

Health care providers are not fully using the postpar-tum hospitalization period to promote contraception.

After the delivery, additional written literature may pro-vide women with more valuable information than verbalcounseling alone.2 In our university setting after the de-livery, the women come from a variety of backgrounds,and many of the women have had little or no prenatalcare or exposure to contraceptive counseling. The pa-tients are seen in the postpartum period by a variety ofproviders (including medical students, residents, mid-wives, and faculty members), and the postpartum con-traceptive counseling quality is highly variable anddifficult to control. Minimal pamphlets on various con-traceptive options, but no comprehensive information,are available currently to distribute in the postpartumperiod. An hypothesis-driven cohort study that measuredbaseline satisfaction levels and confidence in contracep-tion decisions was performed in mothers after the deliv-ery before and after the distribution of standardizedcomprehensive written information about contracep-tion. We proposed that the addition of comprehensive,complete written information on all contraceptive op-tions would increase the patient’s ability to make an in-formed decision regarding the choice of postpartumbirth control.

Material and methods

Consent to survey hospitalized patients during thepostpartum period at Oregon Health and Sciences Uni-versity was received from the institutional review board.All English- and Spanish-speaking parturients duringApril and May 2002 were invited to participate by com-

From the Department of Obstetrics and Gynecology, Oregon Health andScience University.Reprint requests: Lisa K Johnson, MD, 3181 SW Sam Jackson ParkRoad L466,Portland, OR 97201. E-mail johnsoli@ohsu.edu© 2003, Mosby, Inc. All rights reserved.0002-9378/2003 $30.00 + 0doi:10.1067/mob.2003.308

Patient satisfaction and the impact of written material aboutpostpartum contraceptive decisions

Lisa K. Johnson, MD, Alison Edelman, MD, and Jeffrey Jensen MD, MPH

Portland, Ore

OBJECTIVE: The purpose of this study was to evaluate the impact of written educational material about pa-tient satisfaction and decision-making regarding postpartum contraception.STUDY DESIGN: Baseline patient satisfaction and effectiveness of contraceptive counseling on a postpar-tum unit was evaluated with the use of a self-administered questionnaire. Data were compared with patientswho received additional comprehensive written educational material during their postpartum hospitalization.RESULTS: A total of 109 women participated in the study (control subjects, 53; intervention group, 56). De-mographics and patient satisfaction with contraceptive counseling were similar between groups. Thirty-fourpercent of the control subjects reported having received some sort of written information; all women in the in-tervention group received a standardized comprehensive booklet of information during their postpartum stay(P < .01). Among the women who received written information, the intervention group was more likely tostate that written material contributed to their ultimate choice in birth control (P < .01).CONCLUSION: The postpartum distribution of written material about contraceptive options increases a woman’sability to make an informed decision regarding birth control. (Am J Obstet Gynecol 2003;188:1202-4.)

Key words: Contraception, postpartum, patient satisfaction

Volume 188, Number 5 Johnson, Edelman, and Jensen 1203Am J Obstet Gynecol

pleting an anonymous self-administered questionnaire.After the baseline collection of data during April, a stan-dardized, comprehensive information booklet about con-traceptive options in English and Spanish was given outto all parturients on the postpartum unit during May. Allsubjects during both months completed identical ques-tionnaires. Basic demographic information was obtainedfrom each patient. Satisfaction of antenatal and postpar-tum contraceptive counseling was assessed with a 100-mmvisual analog scale (most satisfied, 0 mm; dissatisfied, 100mm). Patients reported the type of counseling received(whether verbal and/or written) and how much thecounseling contributed to their ultimate choice of con-traceptive.

The primary outcome was whether written informa-tion better enabled patients to reach decisions aboutcontraceptive options. The visual analog scale scoreswere analyzed with the use of the t test. Categoric andordinal data were analyzed with the χ2 test and Mann-Whitney U test. All comparisons were performed on adesktop computer running SPSS (version 9.0; SPSS Inc,Chicago, Ill) for Windows (Microsoft Corporation, Red-mond, Wash).

Results

There were a total of 198 and 203 deliveries during thebaseline and intervention collection periods, respectively.A total of 109 (27.1%) women participated, 53 women(27%) in the baseline group and 56 women (27.6%) inthe intervention group. There were no significant differ-ences in the baseline characteristics of the two groups.The average age was 25.9 ± (SD) 6.23 years in the baselinegroup and 25.3 ± 6.68 years in the intervention group (P= .646). Approximately 45% of the women in both groupswere Hispanic (P = .661); the median education level wasequal (high school, some college; P = .287).

Forty-two women (79.2%) in the baseline group and46 women (82.1%) in the intervention group stated thatthey received contraceptive counseling by their healthcare providers during their prenatal care (P = .701).Mean satisfaction of prenatal counseling in the baselinegroup was 2.45 cm and 2.72 cm in the interventiongroup (P = .654). Thirty-seven women (69.8%) in thebaseline group and 38 women (67.9%) in the interven-tion group reported postpartum contraceptive counsel-ing by a health care provider (P = .825). Patientsatisfaction with postpartum counseling was 3.24 cm inthe baseline group and 2.48 cm in the interventiongroup (P = 2.6). Only 18 women (34%) in the baselinegroup reported having received any written informationduring their postpartum hospitalization compared with56 women (100%) of the intervention group (P < .01).Among those women who reported the receipt of writteninformation, women in the intervention group weremore likely to state that this information helped con-

tribute to their ultimate choice in birth control (1.16 vs4.02 women, P < .01).

Comment

We conceived this project to address the hypothesis thatincreasing a patient’s knowledge of contraception couldincrease the patient’s satisfaction with postpartum contra-ceptive decision making. Although the ultimate aim ofthis intervention is to decrease the incidence of unin-tended pregnancies, this exact outcome was not studied.However, our results indicate that the provision of high-quality, standardized information to women improves thesatisfaction with counseling. This, in turn, may translateto improved satisfaction with contraceptive choice.

Although antenatal contraceptive counseling is impor-tant, readdressing the issue with patients in the postpar-tum setting remains essential. In 2000, researchers atWayne State University examined contraceptive decisionmaking among a population of low-income pregnantwomen in Detroit.3 They discovered that women were notusing the method of contraception consistently that theyplanned to use in the prenatal period. Although antena-tal counseling is imperative, readdressing the issue in thepostpartum period may help to reinforce a decision re-garding birth control and improve patient satisfactionand continuation rates.

An evaluation of verbal postpartum counseling was per-formed in Scotland in 1996.4 Eight-four percent of thewomen reported having a discussion regarding contra-ception while in the postpartum unit. Fifty percent ofthese women, however, had a negative opinion of theconversation. The most common complaint was that thediscussion was given as a necessary routine undertakenwith reluctance by the physician and that only 50% of thepopulation was discharged with a method of contracep-tion. Researchers from this study concluded that the post-partum unit was not the appropriate setting forcontraceptive counseling, but no other intervention wasevaluated. Many patients may feel, in fact, that these post-partum conversations are not adequate and that they mayneed additional time or information to make a decision.

In 1999, a study in Finland examined the relative im-portance of various sources of contraceptive informa-tion.2 Both women and men were asked to rate theirknowledge of contraceptive methods and from what in-formation source this information had been obtained.Both sexes stated that most of their contraceptive knowl-edge came from written literature rather than from physi-cian contact. This outcome was surprising, given that thispopulation (unlike the United States) has excellent ac-cess to health care.

Both the content and quality of counseling can vary be-tween providers, and it is difficult to control a patient’sperceptions and understanding of the interaction. Thepostpartum period can be a difficult time to undertake

1204 Johnson, Edelman, and Jensen May 2003Am J Obstet Gynecol

what should be considered an important conversation. Pa-tients are fatigued and often distracted, and physiciansmay be rushed and not able to take the time needed to an-swer a multitude of questions. Most patients who are de-livered at our university hospital site receive prenatal carefrom a variety of practitioners at surrounding satellite clin-ics. Therefore, it is difficult to assess the amount and thequality of the information that they receive during the an-tepartum period. In the same vein, it is difficult for us tocontrol the counseling that these women receive whilethey are hospitalized after the delivery. The cases are fol-lowed by a variety of providers that include students, resi-dents, midwives, and attending physicians. Withouthaving 1 person see all of these patients for study pur-poses, it is impossible to control this variable. However, inour study population, both groups of patients reportedsimilar exposure to and satisfaction with the counselingthat they received, both before and after the delivery.

We chose to focus on providing patients with concise,comprehensive written information that they can reviewat their own pace and narrow down the options that maybe right for them. One problem we have faced consis-tently is the lack of written information that is availableon the postpartum unit. Although individual brochureshave been used occasionally, never has there been an ad-equate source of comprehensive written information. Bycreating and distributing such a resource, this variablewas easier to control. As we hypothesized, our patients re-ported a much higher level of satisfaction with this source

of information and an increased ability to make an in-formed decision about their choice of birth control.

Limitations of the study include the lack of a direct com-parison between individual counseling methods by aprovider and written information. By focusing on writteninformation, we intended to study a practical strategy thatwas designed to overcome the limitations of multipleproviders at different training levels in the dissemination ofcontraceptive counseling at discharge. Although patientsgenerally reported being satisfied overall with their antena-tal and postpartum counseling, the value of this counselingcompared with written information was not evaluated. Al-though satisfaction with contraceptive counseling im-proved among subjects in the intervention group, theimpact on compliance with the chosen method of birthcontrol and the subsequent rate of unintended pregnancywere beyond the scope of this investigation. However, thepositive findings in this study may prove to be a valuablestarting point for further studies of the subject.

REFERENCES

1. Henshaw S. Unintended pregnancy in the United States. FamPlann Perspect 1998;30:24-46.

2. Virjo I, Kirkkola AL, Isokoski M, Mattila K. Contraceptive meth-ods: knowledge sources rated by women and men. Contracep-tion 1999;59:257-63.

3. Miller VL, Laken MA, Ager J, Essenmacher L. Contraceptive de-cision making among Medicaid-eligible women. J CommunHealth 2000;25:473-80.

4. Glasier AF, Logan J, McGlew TJ. Who gives advice about post-partum contraception? Contraception 1996;53:217-20.