School of Public Health

One Key Question: Would You Like to Become Pregnant in the Next Year?

July 2016
Author: Malka Main

The One Key Question Initiative is a new pregnancy intention screening program that health care providers can integrate into their services (training and an implementation toolkit are available by request on their website.) While the program aims to reduce the number of unplanned pregnancies some health care providers feel the program’s “One Key Question” may not go far enough.

Preconception health is invisible. Only half of reproductive-age women receive counseling that links their health behaviors to future pregnancy and birth outcomes.1 The disparate domains of women’s health services – prenatal and primary care - address existing states of health, missing key moments in a woman’s life to address fluctuating pregnancy intentions or likelihoods. Prenatal care alone is not enough to ensure healthy babies.1,2,3 While part of a child’s untold future health is genetically influenced, other parts are informed by the condition of the mother’s body well before conception. In this country, half of pregnancies are unplanned4 and our babies are being born too soon, too small, and sometimes even too sick to survive.2,5,6

THE ONE KEY QUESTION

“We deal with women as pregnant or non-pregnant. It’s either contraception or prenatal care and we are surprised when they show up pregnant,” said Michele Stranger-Hunter, Executive Director of the Oregon Foundation for Reproductive Health. During a project to promote the prescription of emergency contraception during primary care visits, Stranger-Hunter discovered providers did not discuss contraception with their reproductive-age patients. She said the primary care providers assumed these patients talked about their preconception health with some other provider in some other space. Rather than further fragment women’s health care, Stranger-Hunter found a way to embed preconception care into primary care visits.

Stranger-Hunter and her team devised a single question to detect and address pregnancy intention. “Would you like to become pregnant in the next year?” the provider asks the patient during a routine annual visit. The patient may respond in one of four ways and Stranger-Hunter’s team developed specific actions providers should take for each of those responses. If the patient answers “yes,” the provider offers preconception education and care. Patients who respond “no” receive contraceptive counseling. When women say they are “unsure” or are “okay with whatever happens,” the provider offers both preconception education and contraceptive counseling.

THE ONE KEY QUESTION CONVERSATION: WILL IT WORK?

Almost half the women who express this type of passive indecision are not taking contraception.7 These are the women Stranger-Hunter is most concerned about. “We need to stop assuming that if they are ambivalent, they are going to take their birth control pills,” she said.  “I’m not trying to get the providers to help women resolve their ambivalence; I just want it identified so she can be offered the services she most needs.”

Lisa Callegari, Assistant Professor of Obstetrics and Gynecology at the University of Washington, has some concerns about the One Key Question initiative.

Lisa Callegari, Assistant Professor of Obstetrics and Gynecology at the University of Washington, agrees. “The ambivalent group, those women who have mixed feelings,” she said, “that’s a lot of women…As public health thinkers we want things to be black and white, but in reality a lot of women have complex feelings about pregnancy. By addressing women who have an answer like ‘I’m not sure’ One Key Question has definitely moved toward being more accommodating of those women.”

But Callegari worries that the wording of the question oversimplifies the issues of preconception health. In her research with the Veterans Affairs Health Services Research and Development program she is in the process of developing a set of similar questions for providers to ask patients. “Asking ‘would you like to’ or ‘do you want to,’” she explained, “begs a yes or no [answer]. If you said something like ‘What are your thoughts about becoming pregnant in the future?' Or 'Do you think you might like to become pregnant in the future?' That opens up a door to a range of feelings about pregnancy as opposed to directing people into a yes or no about the next year.”

Stranger-Hunter explained that the wording of the “One Key Question,”is intentional. In fact, she had the question trademarked. She needed to be sure that it would be easily accepted by busy providers who asked for a screening question that could be answered succinctly. But it was potential patients, women themselves, who determined the final wording of One Key Question.

Stranger-Hunter’s team interviewed patients during the first pilot at an Oregon Health & Sciences University community health clinic. They posed several iterations of the question, beginning with “Do you plan to become pregnant?” The women had strong reactions. Many disliked the word “plan.” Stranger-Hunter explained that not only is there a “taboo of planning pregnancy while poor” but some research suggests that ‘planning’ is a white middle class concept. Other women in the focus groups, who were unable to get pregnant, said that any question with the word “plan” or “intend” just felt hurtful.

It was the women in the focus groups who told Stranger-Hunter’s team: “Just ask us what we want.”

The question’s one-year timeframe also concerns Callegari who said this isn’t enough time to address lifestyle changes, such as weight loss and smoking cessation, that support healthy pregnancies and infants. Stranger-Hunter said that women in the focus groups preferred the shorter timeline and added that one year is also the best cut-off for assessing the effectiveness of long-acting reversible contraception methods.

THE IMPORTANCE OF THE PATIENT-PROVIDER RELATIONSHIP

Stranger-Hunter and Callegari agree that preconception care is optimum when there is a positive, open patient-provider relationship. Callegari’s research showed that women do want to talk about reproductive goals in a healthcare setting, but they don’t often feel comfortable bringing it up so it is important for the provider to start the conversation.

“The whole point of One Key Question,” said Stranger-Hunter, “is to start a conversation.” An early unpublished pilot in Washington County reported that One Key Question not only started a conversation it helped providers identify co-occurring conditions such as intimate partner violence, mental health conditions and substance abuse. 

Callegari said that her questions, while more open-ended than Stranger-Hunter’s, may be more intimidating for busy primary care providers. “I am not convinced that I necessarily have the right answer either,” she said. “But people need to be thinking about this and talking about this and there has to be debate. It needs to be tested and evaluated and we need to think about what is the best way to do it.”

Acknowledging that time constraints can limit thoughtful discussion of pregnancy planning during primary care appointments, Callegari said: “It may be that some of this counseling could happen with other members of a health care team or patient-centered medical home, such as health coaches.”

Stranger-Hunter agrees. This is the guidance her team gives to clinics who want to integrate One Key Question into their primary care practice. Either offer the follow-up services directly during the visit, ask the patient to schedule a return visit, or refer the patient to another member of the care team for more in-depth counseling and education.

ONE KEY QUESTION GOES NATIONAL AND INTERNATIONAL

Michele Stranger-Hunter, Executive Director of the Oregon Foundation for Reproductive Health, talks about the benefits of One Key Question to Ob-Gyns in Mexico

In Alaska, the Maternal and Child Health (MCH) Program will implement One Key Question as part of their strategy to increase well-woman visit rates.  In this 3-month pilot project, staff of the Women, Infants and Children (WIC) office in Anchorage will ask the One Key Question during initial interviews with mothers who have children under the age of one. Based on their answers, staff will provide referrals to reproductive health nurses at the Municipality of Anchorage, which is just one floor down from the WIC office.  If the project is successful, Alaska MCH will expand this practice to other WIC offices throughout the state.

California and Utah also included One Key Question in their state strategies for improving women’s health and individual clinics in South Carolina, Massachusetts, and Vermont have already adopted the initiative.

It doesn’t stop there. A Scottish version of One Key Question was proposed earlier this year and Stranger-Hunter attended a conference in Mexico last month to train Latin American obstetrician-gynecologists on One Key Question. “It was truly a unique and thrilling experience,” said Stranger-Hunter. Providers from Peru, Ecuador, Guatemala, Brazil and many states in Mexico attended the training. Some providers were concerned that the question would be uncomfortable for women “because of the strong Catholic culture that says sex is for procreation not recreation.” Stranger-Hunter told them this was a topic Latina women discussed in their U.S. focus groups. She described the reaction when she relayed a quote from one of the women: “One Key Question ‘takes the sin out of sex,’” she told them, “and there was an audible ‘Ah!’ in the room.”

Public health providers from Mexico were excited about the new approach to the birth control conversation and physicians from Peru, Ecuador and Guatemala all left with the intention to use One Key Question. 

DOES ONE KEY QUESTION ADDRESS HEALTH DISPARITIES?

Stranger-Hunter recognizes that further evaluation is needed to determine if One Key Question is culturally effective. Her team has successfully conducted focus groups with Latina women, White women, and Asian and Pacific Islander women. But they have had a difficult time convening focus groups of African-American women, a population with the highest rates of unintended pregnancy in the U.S.2 and twice the infant mortality than that of non-Hispanic Whites.5

In African-American communities there is a lived experience of contraceptive coercion and anything that has to do with White providers talking about birth control is suspect,” Stranger-Hunter said. The Oregon Foundation for Reproductive Health is a white, traditional, reproductive rights organization who do not have lived experience as women of color…[We ask ourselves], who are we to lead an effort to reduce maternal and child health disparities among African-American women?”

She wants to learn what she can do to train providers. “I’m open!” she exclaimed. “I’m in process. Building relationships, building trust. This is an important area that needs to be further developed.”

NEXT STEPS FOR ONE KEY QUESTION

There are currently no published studies on the effectiveness of One Key Question, But Stranger-Hunter said that unpublished data from pilot projects in Oregon and Chicago suggest that the implementation of One Key Question increased contraceptive counseling in primary care clinics.

The initiative is only a few years old and it is a difficult one to measure. Outside In, a clinic that serves marginalized populations in Portland, Oregon, was one of the first to adopt One Key Question. They added it to their primary care services in 2013, said clinic manager Timothie Rochon.  With Stranger-Hunter’s knowledge, they adjusted the question to include all reproductive-age patients: “We wanted to be inclusive of our male, transgender and LGB patients as well,” Rochon explained. “Our question looked like this, ‘Do you or your partner want to become pregnant in the next year?”  Rochon said their biggest obstacle has been integrating One Key Question into electronic health record software where they can accurately document and measure its impact.

Folic Acid as a Daily Multivitamin
Because half of all U.S. pregnancies are unplanned, the CDC recommends all women 15-45 years of age take folic acid daily.

But its potential has not gone unnoticed. In an opinion paper earlier this year, the American College of Obstetricians and Gynecologists highlighted One Key Question as an effective way to promote reproductive life planning. And a recent survey from the Milken Institute at the George Washington University’s School of Public Health used One Key Question as a metric to assess women’s pregnancy intention and tailor patient care.7 Their recommendations to community health clinics included adopting the One Key Question protocol. They found that respondents readily answered the question and it helped to identify women in need of reproductive or contraceptive counseling.

Stranger-Hunter said while it would not be easy to prove the question led to a reduction in unplanned pregnancies, it would be possible to assess, within specific clinics, improved birth outcomes and increased use of contraceptive services. She would also like to measure One Key Question’s impact on preconception care, a more complicated task since no one has collected the data to determine a baseline for this type of care.

•••

But that may soon change. The National Preconception Health and Health Care Initiative recently published nine evidence-based preconception wellness measures that health systems can use to establish benchmarks in preconception care.8 These are the first steps towards reversing the invisibility of preconception health and recognizing that the health of woman’s body, well before the point of conception, shapes the health of future generations.  


REFERENCES

  1. Hillemeier MM, Weisman CS, Chase GA, et al. Women’s Preconceptional Health and Use of Health Services: Implications for Preconception Care. Health Services Research, 2008;43(1p1):54-75. doi: 10.1111/j.1475-6773.2007.00741.x
  2. Centers for Disease Control. Infant mortality rates and international rankings. Published 2010. Accessed June 2016
  3. Chuang CH. Pregnancy intention and health behaviors: results from central Pennsylvania women’s health study cohort. Published 2010. Accessed June 2016
  4. Guttmacher Institute. Unintended pregnancy in the United States. Guttmacher Institute website. 2015. Accessed June 2016
  5. World Health Organizations. Born too Soon: Global Action report on preterm Birth. Published 2012. Accessed June 2016
  6. Organization for Economic Cooperation and Development. Low Birth Weight infants. Published 2011. Accessed June 2016
  7. Wood, SF. Patient Experiences with Family Planning in Community Health Centers. Published July 2015. Accessed June 2016
  8. Frayne DJ, Verbiest S, Chelmow D, et al. Health Care System Measures to Advance Preconception Wellness: Consensus Recommendations of the Clinical Workgroup of the National Preconception Health and Health Care Initiative. Obstetrics & Gynecology. 2016;127(5):863-872. doi: 10.1097/AOG.0000000000001379.