Prominent racial/ethnic and socioeconomic disparities in rates of unintended pregnancy, abortion, and unintended births exist in the United States. These disparities can contribute to the cycle of disadvantage experienced by specific demographic groups when women are unable to control their fertility as desired. In this review we consider three factors which contribute to disparities in family planning outcomes: patient preferences and behaviors, health care system factors, and provider related factors. Through addressing barriers to access to family planning services, including abortion and contraception, and working to ensure that all women receive patient-centered reproductive health care, health care providers and policy makers can substantially improve the ability of women from all racial/ethnic and socioeconomic backgrounds to make informed decisions about their fertility. KeywordsHealth disparities; Unintended Pregnancy; Family Planning; Contraception; Abortion The ability to plan if and when to have children is fundamental to the health of women and critical to the equal functioning of women in society. 1 In the United States, rates of unintended pregnancy (including both mistimed and undesired pregnancies), unintended birth, abortion, and adolescent pregnancy differ across racial, ethnic, and socioeconomic lines. These disparities have profound short-term and long-term consequences for women, their children, and society. Women with unintended pregnancies that are continued to term are more likely to receive inadequate or delayed prenatal care and have poorer health outcomes such as infant low birth weight, infant mortality, and maternal mortality and morbidity. 2-7 Children resulting from unplanned pregnancies have been found to be more likely to experience developmental delay and have poorer relationships with their mother.8 These risks of unintended birth are magnified in adolescent mothers, who experience increased risk for pregnancy complications and are often forced to make compromises in education and employment opportunities that

Background Little is known about what women value in their interactions with family planning providers and in decision making about contraception. Study Design We conducted semistructured interviews with 42 black, white and Latina patients. Transcripts were coded using modified grounded theory. Results While women wanted control over the ultimate selection of a method, most also wanted their provider to participate in the decision-making process in a way that emphasized the women’s values and preferences. Women desired an intimate, friend-like relationship with their providers and also wanted to receive comprehensive information about options, particularly about side effects. More black and Spanish-speaking Latinas, as compared to whites and English-speaking Latinas, felt that providers should only share their opinion if it is elicited by a patient or if they make their rationale clear to the patient. Conclusion While, in the absence of medical contraindications, decision making about contraception has often been conceptualized as a woman’s autonomous decision, our data indicate that providers of contraceptive counseling can participate in the decision-making process within limits. Differences in preferences seen by race/ethnicity illustrate one example of the importance of individualizing counseling to match women’s preferences.

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Patient-centered care requires different approaches depending on the clinical situation. Motivational interviewing and shared decision making provide practical and well-described methods to accomplish patient-centered care in the context of situations where medical evidence supports specific behavior changes and the most appropriate action is dependent on the patient's preferences. Many clinical consultations may require elements of both approaches, however. This article describes these 2 approaches-one to address ambivalence to medically indicated behavior change and the other to support patients in making health care decisions in cases where there is more than one reasonable option-and discusses how clinicians can draw on these approaches alone and in combination to achieve patient-centered care across the range of health care problems. Patient-centered care has been found to be associated with improved patient outcomes, including improved self-management, patient satisfaction, and medication adherence, and some studies have found evidence for improved clinical outcomes. 2,3 Data from surveys and qualitative and observational research indicate that clinicians often do not take patients' perspectives into account; rather, clinicians often promote or recommend specific treatments rather than consider patients' preferences during the decision-making process. [4][5][6][7] Clinicians are commonly challenged by the diversity of situations that arise in practice when they attempt to implement patient-centered care. For example, providing patient-centered care for a patient at the end of life is very different from counseling a patient with a long-term health condition or providing advice about preventative care. Each situation has different psychosocial, cultural, and medical implications. A key factor is the degree to which a clinical situation has acceptable alternative courses of action, ie, situations of equipoise, 8 or whether there is clear evidence for a preferred course of action. For the patient electing to have a mastectomy or lumpectomy in early breast cancer, equipoise exists about the long-term outcomes. Evidence for a preferred course of action is found for the overweight smoker with diabetes who is encouraged to consider quitting.Clearly, different situations require different communication approaches, and patient-centered approaches for each of these situations have been delineated during the last few decades. We wish to focus this article on 2 specific methods, namely, shared decision making and motivational interviewing. As researchers and practitioners, we also wish to share our experience with both. In this article, we provide guidance for how to apply Glyn Elwyn, MD patient-centered approaches across a range of clinical problems. In doing so, we explore the definitions of shared decision making and motivational interviewing and summarize the evidence on their use. We also consider the overlap between the 2 approaches and discuss how practitioners can flexibly combine them to improve thei...