The problem

Pregnancy causes changes that cascade through a woman’s life and that of her family, and can have large health impacts—especially for those already struggling with chronic disease, poor mental health, or stressful circumstances. We now know that pregnancy timing and circumstances affect not only a prospective mother’s health but also the wellbeing of her children. A woman’s pre-pregnancy status can shape her child’s developmental trajectory and risk of chronic conditions decades later. But in Washington State, 37 percent of pregnancies are unintended, a measure that is included in the Washington State Common Measure Set for Health Care Quality and Cost.  Such a rate does not allow many women and doctors to build preconception resources that support healthy pregnancy, healthy babies, and healthy parenthood.

State-of-the-art contraceptive technologies—long acting “get-it-and-forget-it” IUDs and progestin implants—are 20 times as effective as the Pill. They dramatically reduce mistimed or unwanted pregnancy, as shown by the Colorado Family Planning Initiative, which cut teen births and abortions nearly in half and reduced preterm births.  Professional bodies now recommend implants and IUDs as top-tier protection for most women, including teens and those who are HIV-positive. But busy primary care providers often don’t know whether a patient wants to get pregnant or avoid pregnancy, and so may miss opportunities to help patients.

With unintended pregnancy so common and the consequences so significant, the American College of Obstetricians and Gynecologists now recommends that health care providers touch on reproductive life planning at every visit with reproductive-age women. Clinicians want to help their patients manage health conditions and stack the odds in favor of flourishing children, but are swamped with ever more tasks and topics to cover and ever smaller chunks of time in which to address them all.

The solution

The Oregon Foundation for Reproductive Health, a Portland-based nonprofit, has developed a simple, quick method called One Key Question® (OKQ) to screen routinely for pregnancy intentions in reproductive age patients. The one key question is this: “Would you like to become pregnant in the next year?” The clinician documents one of four patient responses:  Yes, I’m OK either way, I’m not sure, or No, followed by evidenced-based care that supports their answer.

Patients who respond yes receive preconception counseling, which identifies health behaviors change or care that could support a healthy pregnancy. Patients who feel uncertain or ambivalent receive information about preconception care as well as contraception.  A response of no leads to a conversation about family planning options, giving an opportunity to check in on current satisfaction and explore less familiar methods that might better fit. Inexpensive posters and tear sheets from the National Campaign to Prevent Teen and Unintended Pregnancy and a color coded medical eligibility chart from the CDC make it easy to step through family planning options

Results

One Key Question is rapidly becoming a national model. One example is the state of Delaware, where Governor Jack Markell partnered with Upstream USA  to retool contraceptive care statewide, so that women can receive the method of their choice same day, free of charge—including IUDs and implants.  The upgrade, called Delaware CAN, included OKQ screening to identify the preventive reproductive health needs of patients.

In Oregon, OKQ is being deployed in a variety of settings, from home-visiting and WIC to primary care.  A pilot project at One Community Health compared two major health centers, one in which OKQ was implemented and one without. At one month, 64% of electronic medical records for the intervention site documented appropriate screening for pregnancy desires, compared to 12% at the non-intervention site, suggesting that staff were able to incorporate the change into their normal workflow of patient care.

Challenges

Even for clinicians who would like to improve reproductive outcomes for their patients, adopting a screening protocol such as One Key Question can be challenging.

• Sexuality and reproduction can be sensitive topics for providers as well as patients. In particular, those women who are young, poor, ethnic minorities, or in ill health can feel shamed or pressured unless conversations are carefully client-centered. That said, women say that they want their providers to ask.
• At a practical level, incorporating the OKQ algorithm into varying electronic health records continues to be a major barrier for health centers that want to use OKQ in a systematic and routine way.
• Asking about pregnancy intentions can uncover desire for better birth control or for preconception care, requiring staff training or other increases in capacity. (The “Beyond the Pill” program at UCSF offers onsite trainings to clinics wanting to upgrade contraceptive services, with grant funding for those that qualify.)

Keys to success

To ensure program excellence and compatibility of evaluation across settings, the non-profit Oregon Foundation for Reproductive Health trademarked One Key Question and asks for a signed memorandum of understanding prior to implementation. In settings that have adopted OKQ, the following components have been keys to success:

• Conduct comprehensive training with health center team before roll-out
• Integrate screening into current workflow practice
• Renew protocols or referrals for preconception and contraception care
• Develop a plan to evaluate impact of screening on other services provided

To learn more about One Key Question or to sign up for a monthly newsletter, please contact  info@onekeyquestion.org.