AN INDEPENDENT VOICE FOR NURSING
Reproductive Life Planning: A Concept Analysis Fuqin Liu, PhD, RN, Jennifer Parmerter, BSN, RN, and Marcia Straughn, MS, RN, CNE Fuqin Liu, PhD, RN, is Assistant Professor, Texas Woman’s University College of Nursing, Denton, TX; Jennifer Parmerter, BSN, RN, is Graduate Student, Texas Woman’s University College of Nursing, Denton, TX; and Marcia Straughn, MS, RN, CNE, is PhD Student, Texas Woman’s University College of Nursing, Denton, TX. Keywords Concept analysis, family planning, preconception care, reproductive life planning Correspondence Fuqin Liu, PhD, RN, Texas Woman’s University College of Nursing, Arts and Sciences Building, Room 118, 1216 Oakland Street, Denton, TX 76204-5498 E-mail: fl[email protected] Disclosure: The authors have no conflicts of interest to disclose.
Liu
BACKGROUND. In 2006, the U.S. Centers for Disease Control and Prevention issued 10 recommendations on preconception care, which included the statement that reproductive life planning should be considered an individual’s responsibility across his or her life span. PURPOSE. The purpose of this article is to provide a concept analysis of reproductive life planning using Walker and Avant’s method as an organizing framework. METHODS. Search engines were employed to review the existing knowledge base of the concept of reproductive life planning. FINDINGS. The findings suggest that reproductive life planning is integral to preconception care and family planning. Attributes, antecedents, and consequences associated with reproductive life planning are discussed. Model, borderline, and contrary cases are also provided to illustrate the concept. PRACTICE IMPLICATIONS. A reproductive life plan can serve as a framework for promoting reproductive health across the life span of both men and women. Healthcare providers must assess the individual’s ability to understand and utilize educational resources to ensure full and effective participation in reproductive life planning.
Parmerter
Straughn
Introduction In 2006, the U.S. Centers for Disease Control and Prevention (CDC) issued 10 recommendations on preconception care, which included the statement that reproductive life planning should be considered an
individual’s responsibility across his or her life span (Johnson et al., 2006). Specifically, the CDC recommends that every man, woman, and couple of sexual maturity should have a reproductive life plan. The CDC defines a reproductive life plan as a set of personal goals related to a conscious decision about whether to bear 55
© 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
Reproductive Life Planning children (Johnson et al., 2006). Reproductive life planning is a relatively new concept, and as such needs to be properly and effectively disseminated and applied by nurses and other healthcare providers in clinical care settings. The purpose of this concept analysis is to present a theoretical understanding of reproductive life planning and to explore its clinical relevancy. Method A comprehensive literature review was conducted using the Cumulative Index to Nursing and Allied Health Literature, Medline, PsycINFO, ProQuest, the World Wide Web, and reference lists of related Figure 1. The Eight Steps of Concept Analysis (Walker & Avant, 2011)
F. Liu et al. journal articles with a time line of 2000–2014. Keywords used were reproductive life plan, reproductive life planning, reproductive life goals, and reproductive life tool. The search was limited to English-language articles only. Using these terms and limiters, 20 articles were located. Additionally, four white papers and two conference proceedings were included in the analysis. We also selectively included five recent partner violence-related studies in the analysis. We believe that this body of literature is critical to the discussion of women’s reproductive control in the context of reproductive life planning. Walker and Avant’s (2011) eight-step method (Figure 1) of analysis was used to examine the concept of the reproductive life planning. A summary of the attributes, antecedents, and consequences of the concept of reproductive life planning is presented in Figure 2. Uses of the Concept
1. Select a concept 2. Determine the aims or purpose of the analysis 3. Identify all of the possible uses of the concept 4. Determine the defining attributes 5. Identify model cases 6. Identify borderline, related, contrary, invented, and illegitimate cases 7. Identify antecedents and consequences 8. Define empirical referents
The concept of reproductive life planning is found in literature in which the primary focus is preconception care, and the two terms are often used synonymously. As a part of a list of recommendations intended to improve preconception health, the CDC introduced the concept of reproductive life planning and recommended that all women, men, and couples of sexual maturity create a reproductive life plan (Johnson et al., 2006). After the introduction of the term, the concept received attention in the literature. Wade, Herrman,
Figure 2. Attributes, Antecedents, and Consequences of Reproductive Life Planning
56 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
Reproductive Life Planning
F. Liu et al. and McBeth-Snyder (2012) included reproductive life planning as a component of preconception care; however, they did not present a theoretical understanding of reproductive life planning. With regard to its clinical usage, the literature has adopted the concept and used it in the context of a reproductive life planning tool (Moos et al., 2008; Wade et al., 2012). The concept of reproductive life planning is instrumental to nurses when developing guidelines to assist individuals in planning for reproductive health and responsibility (Files et al., 2011). Mittal, Dandekar, and Hessler (2014) found that reproductive life planning is effective in assisting women with chronic disease in making constructive and informed decisions in regard to contraception and pregnancy planning. Reproductive life planning is also considered an intervention for improving birth outcomes (Malnory & Johnson, 2011). Sanders (2009) discusses the introduction of reproductive life planning to a primarily female population. Further, its significance at different stages of the reproductive life cycle has been addressed, with particular attention to women in adolescence or middle age, along with the associated risks and potential outcomes of unintended pregnancy at those respective phases of life (Barry, 2011; Coffey & Shorten, 2014; Sanders, 2009). Attributes Multiple attributes are associated with reproductive life planning. The first attribute, as recommended by the CDC, is that reproductive life planning is inclusive of both sexes (Frey, Navarro, Kotelchuck, & Lu, 2008; Johnson et al., 2006; Posner, Johnson, Parker, Atrash, & Biermann, 2006). However, a stringent interpretation of this attribute may pose concerns among women who report pregnancy coercion and birth control sabotage by their partners, known as reproductive coercion (Barry, 2011; Miller et al., 2010, 2014). As would be expected, women are placed at the center of the proposed conceptual model of preconception care (Posner et al., 2006). Nevertheless, in reproductive life planning, the role of the male and the female should be addressed separately, with each as an individual and as part of a couple (Barry, 2011; Frey et al., 2008; Posner et al., 2006). The second attribute, also recommended by the CDC, is responsibility (Johnson et al., 2006). A reproductive life plan consists of an individual’s intent and plans in regard to the number and timing of pregnancies (Files et al., 2011; Johnson et al.,
2006), and is an individual’s responsibility across his or her life span (Johnson et al., 2006). Thus, the third attribute is that it is a lifelong plan. It is appropriate to initiate reproductive life planning at the beginning of an individual’s reproductive years and to continue until reproduction is no longer possible. In this way, reproductive life planning spans decades and various reproductive stages, including preconception, pregnancy, and interconception (Malnory & Johnson, 2011). Preconception health is a larger framework in which reproductive life planning functions as a tool for life planning (Johnson et al., 2006). Specifically, reproductive life planning can be used to initiate discussion and education about reproductive health (Sanders, 2009). Hence, the fourth attribute is communication. Nurses and healthcare providers frequently have the opportunity to introduce reproductive life planning with simple questions about desires and plans in regard to the number of children, spacing of children, and life and family goals. Lu (2007) recommends that a discussion of reproductive life planning be included in every routine office visit, with the aim of developing a reproductive time line. A reproductive life plan is not static but can and should change as the individual’s goals and experiences change (American College of Nurse-Midwives, 2011; Files et al., 2011). This fifth attribute, flexibility, allows individuals to take life circumstances into consideration. Medical and social services are needed to help clarify the reproductive life goals of an individual, especially in cases in which the individual is high risk for poor pregnancy outcomes (Lind, Godfrey, Rankin, & Handler, 2014). An individual’s life circumstances are unique, and as such the reproductive life plan is personalized for each individual or couple. Thus, the sixth attribute of reproductive life planning is personalization. Accordingly, reproductive life planning is patient-centered (Bello, Adkins, Stulberg, & Rao, 2013).
Presentation of Cases Model Case A model case provides an example of the concept and demonstrates all defining attributes of the concept, that is, serves as a pure exemplar (Walker & Avant, 2011). For a model case, consider the following constructed example. 57
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Reproductive Life Planning A teenager is beginning to date and determines that she wants to delay sexual activity. She discusses her plans with her boyfriend and determines that she intends to remain abstinent but will use contraceptive protection when she chooses to become sexually active. She plans to complete college and to establish a career and marriage before starting a family. She wants to decide on the number of children she will have, taking into consideration her future husband’s wishes and input. During a routine wellness exam, she shares her decisions with her healthcare provider, who counsels her to maintain a healthy lifestyle to promote health and wellness, and discusses which form of contraception is most appropriate for her lifestyle and goals when she decides that the time is right to have sexual relations. After the visit, she accesses the reproductive life planning tool found on the CDC web site and formally writes her intentions. This model case exemplifies reproductive life planning with inclusion of all attributes in each situation. Borderline A borderline case is an example of a case in which some, but not all, defining attributes of the concept are demonstrated (Walker & Avant, 2011). Borderline cases are inconsistent in some way with one or more of the defining attributes of the concept. For a borderline case, consider the following constructed example. An 18-year-old male is headed off to college. He decides that he will probably not “settle down” for a long time because he wants to date extensively while attaining his education. He wants to eventually marry and to have four children by the time he and his wife are 40. He is sexually active. He receives advice on methods of conception from his primary care provider during a routine office visit. However, he expresses his intention to request that his sexual partner take responsibility for contraception, and thus to rely on her for protection. This case is considered borderline because it does not contain all of the attributes of reproductive life planning. Specifically, the attribute of responsibility for contraception is missing. Contrary A contrary case is one in which none of the defining attributes are met, or is a case that is “not the concept” (Walker & Avant, 2011). For a contrary case, consider the following constructed example. 58 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
F. Liu et al. A 16-year-old female high school student from a rural community has dated a classmate for a year. She begins sexual relations with her boyfriend without any discussion or decision in regard to contraception. She believes that she cannot get pregnant due to her age and irregular menses. Although she goes to a family healthcare provider regularly, she avoids answering any sexual- or family planning-related questions asked by the provider. She has verbalized no plans beyond high school graduation; she assumes that she will work locally until she gets married. This case is considered contrary because it contains none of the defining attributes of reproductive life planning. Antecedents Antecedents are those circumstances that occur before the introduction and use of the reproductive life plan. Antecedents for reproductive life planning include having reproductive potential, a perception of need, and the ability to understand and execute a reproductive life plan. These antecedents are relevant to reproductive life planning, regardless of lifestyle or sexual orientation (Files et al., 2011; Lu, 2007). Any man or woman, in achieving sexual maturity, is an appropriate candidate for a reproductive life plan. Having reproductive potential is an important antecedent because it means that the desire to have children has the potential to be actualized during the reproductive life span. There are times, however, when the discussion of having a reproductive life plan may not be as pertinent, such as when an individual has been diagnosed with infertility. Nonetheless, reproductive life planning may still be applicable to a couple for whom one partner has a confirmed diagnosis of infertility. Whether the focus is on individuals or couples, perception of need is another reason for developing a reproductive plan. Such a need is closely linked to one’s awareness of the risks of unintended pregnancies and undesired pregnancy outcomes. Healthcare providers are well positioned to increase awareness of the need for reproductive planning (Atrash et al., 2008). For example, an individual may not have considered reproductive planning or considered the possibility of an unintended pregnancy, and thus is an appropriate candidate with whom to initiate the reproductive life plan (Bello et al., 2013). Healthcare providers must recognize the lack of reproductive planning to initiate a conversation or intervention (Chuang et al., 2012). Often, the intervention
Reproductive Life Planning
F. Liu et al. involves the provider’s reframing his or her thinking while providing counseling and reproductive-related education to the patient (Atrash et al., 2008). To understand and execute a reproductive life plan, the individual must have the ability to understand the information and options for making informed decisions (Malnory & Johnson, 2011). Thus, health literacy is an important antecedent of reproductive life planning. The healthcare provider needs to assess what the individual knows about reproductive health, appraise the patient’s health literacy, and make alterations to educational interventions at a level appropriate for the individual (Sanders, 2009). Consequences Reproductive life planning is a precursor to family planning, which includes inquiry into appropriate and effective contraceptive methods (Files et al., 2011). In setting a time line for reproduction, the individual or couple provides critical information to the healthcare provider that guides the choice for suitable contraception based on the reproductive life plan. Individuals may not have access to appropriate contraception, however, for financial or social reasons. Regardless of the life situation of a woman, the provision of reproductive life planning-based information can increase knowledge of a woman’s choices and how to achieve them (Noyes & Savin, 2012a, 2012b; Stern, Larsson, Kristiansson, & Tyden, 2013). As such, reproductive life planning is a precursor to preconception care, a framework in which risks and behaviors that are potentially harmful to the mother or infant are addressed, which guides the individual to optimal pregnancy outcomes (Biermann, Dunlop, Brady, Dubin, & Brann, 2006; Files et al., 2011; Witt & Kelly, 2014). Finally, for both men and women, reproductive life planning can lead to a sense of empowerment and control of the future (Malnory & Johnson, 2011; Stern et al., 2013).
question: “Do you plan to have any (more) children at any time in your future?” Then, there is a series of questions that follow, based on whether the patient responds “yes” or “no.” This tool is available on the CDC web site (CDC, 2014a). Additionally, the CDC (2014b) provides a publicly available reproductive life plan worksheet. The Women’s Health Branch of the Colorado Department of Public Health and Environment developed, piloted, and evaluated a reproductive life plan booklet (Thomson & Archer, 2012). The objective for developing the tool was to provide women of reproductive age with educational materials that present preconception health concepts as easy-to-understand steps for healthy behavior, including pregnancy planning. The booklet is available on their web site (Thomson & Archer, 2012). Another publicly available booklet created by a state agency is Plan Your Health, Life Your Life, published by the Utah state government (Utah Department of Health, 2009). Further, based on the work done by the Preconception Health Council of California, Mittal et al. (2014) developed a modified version of a reproductive life plan to include additional sections specific to counseling patients with diabetes, obesity, and/or hypertension. The revised reproductive life plan is retrievable via a web link provided in the article. Although various reproductive life planning tools are available, none has explicitly addressed the needs of women who are affected by intimate partner violence. Clark, Allen, Goyal, Raker, and Gottlieb (2014) reported that male behavior to control the fertility of female partners in an abusive relationship is common. Further, fear of violent consequences can become a barrier to women practicing contraception themselves (Williams, Larsen, & McCloskey, 2008) and to negotiating condom use with their partner (Mittal, Senn, & Carey, 2013). The control and climate of fear seen in abusive relationships warrant further refinement of the existing reproductive life planning tools to address the issue of fertility control and safety concerns.
Empirical Referents
Implications for Nursing Practice
The CDC Preconception Care Workgroup and the Select Panel on Preconception Care suggest developing, evaluating, and disseminating reproductive life planning tools for women and men that are ageappropriate, culturally relevant, and cover both general health topics and specific risk behaviors. The CDC RLP Tool for Health Professionals begins with the
Many women have the potential to make uninformed decisions on contraception, which can lead to unplanned pregnancy. Notably, nurses are in a pivotal position to introduce women to the idea of reproductive life planning and to facilitate the development of such a plan. Nurses are advised to modify a reproductive life plan to fit the unique needs of an individual 59
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Reproductive Life Planning (Coffey & Shorten, 2014). To this end, they must assess the individual’s ability to understand and execute reproductive life planning (Sanders, 2009), as well as her access to reliable birth control methods. For example, Dunlop, Logue, Miranda, and Narayan (2010) found that almost half of their study sample, who reported never wanting a child or not wanting a child for at least 1 year, were at risk for unintended pregnancy, based on their reported contraceptive practices. In cases in which reproductive coercion occurs with partner violence, the nurse should work with the prescriber to select contraceptive methods that cannot be tampered with or sabotaged, such as subdermal implants (American College of Obstetricians and Gynecologists, 2013; Secura, Allsworth, Madden, Mullersman, & Peipert, 2010). Nurses should also take an active role in statewide initiatives related to preconception care and reproductive life planning (Noyes & Savin, 2012a, 2012b). Finally, nurse leaders, educators, and researchers can promote the use of reproductive life planning as a necessary and integral component of the individual’s health continuum (Steiner, Finocchario-Kessler, & Dariotis, 2013; Witt & Kelly, 2014).
Conclusion This concept analysis was undertaken to present a theoretical understanding of reproductive life planning. Based on a small body of available literature, we conducted the analysis and proposed a set of antecedents, attributes, and consequences associated with reproductive life planning. However, as new evidence adds to the topic, this set of antecedents, attributes, and consequences should be expanded. A limitation of this analysis is that we referenced heavily the landmark report by Johnson et al. (2006) when considering the attributes of the concept. Thus, once the available literature grows, the concept of reproductive life planning should be revisited. Despite this limitation, this concept analysis has yielded important implications. Nurses should incorporate reproductive life planning across the healthcare spectrum, for both men and women of reproduction age, regardless of life situation or sexual orientation. Notably, a reproductive life plan can serve as a framework for promoting better pregnancy outcomes. Nevertheless, refinement of existing reproductive life planning tools is needed to address the unique challenges of an abusive relationship. 60 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
F. Liu et al. Acknowledgment. We would like to thank Dr. Donna Scott Tilley at Texas Woman’s University College of Nursing for providing feedback on the manuscript. References American College of Nurse-Midwives. (2011). Planning your family: Developing a reproductive life plan. Journal of Midwifery & Women’s Health, 56(5), 535–536. doi:10.1111/j.1542-2011.2011.00057.x American College of Obstetricians and Gynecologists. (2013). ACOG Committee opinion no. 554: Reproductive and sexual coercion. Obstetrics & Gynecology, 121(2, Pt. 1), 411–415. Atrash, H., Jack, B. W., Johnson, K., Coonrod, D. V., Moos, M. K., Stubblefield, P. G., . . . Reddy, U. M. (2008). Where is the “W”oman in MCH? American Journal of Obstetrics and Gynecology, 199(6), 259–265. Barry, M. (2011). Preconception care at the edges of the reproductive lifespan. Nursing for Women’s Health, 15(1), 68–74. doi:10.1111/j.1751-486X.2011.01613.x Bello, J. K., Adkins, K., Stulberg, D. B., & Rao, G. (2013). Perceptions of a reproductive health self-assessment tool (RH-SAT) in an urban community health center. Patient Education & Counseling, 93(3), 655–663. doi:10.1016/ j.pec.2013.09.004 Biermann, J., Dunlop, A. L., Brady, C., Dubin, C., & Brann, A., Jr. (2006). Promising practices in preconception care for women at risk for poor health and pregnancy outcomes. Maternal & Child Health Journal, 10(5), S21– S28. Centers for Disease Control and Prevention. (2014a). Preconception health and health care reproductive life plan tool for health professionals. Retrieved from http://www.cdc.gov/ preconception/documents/rlphealthproviders.pdf Centers for Disease Control and Prevention. (2014b). Preconception health and health care: My reproductive life plan. Retrieved from http://www.cdc.gov/preconception/ documents/reproductivelifeplan-worksheet.pdf Chuang, C. H., Hwang, S. W., McCall-Hosenfeld, J., Rosenwasser, L., Hillemeier, M. M., & Weisman, C. S. (2012). Primary care physicians’ perceptions of barriers to preventive reproductive health care in rural communities. Perspectives on Sexual & Reproductive Health, 44(2), 78–83. doi:10.1363/4407812 Clark, L., Allen, R., Goyal, V., Raker, C., & Gottlieb, A. (2014). Reproductive coercion and co-occurring intimate partner violence in obstetrics and gynecology patients. American Journal of Obstetrics & Gynecology, 210(1), 42.e1– 42.a8. doi:10.1016/j.ajog.2013.09.019 Coffey, K., & Shorten, A. (2014). The challenge of preconception counseling: Using reproductive life planning in primary care. Journal of American Association of Nurse Practitioners, 26(5), 255–262. doi:10.1002/23276924.12054 Dunlop, A. L., Logue, K. M., Miranda, M. C., & Narayan, D. A. (2010). Integrating reproductive planning with primary health care: An exploration among low-income,
F. Liu et al. minority women and men. Sexual and Reproductive Healthcare, 1, 37–43. Files, J. A., Frey, K. A., David, P. S., Hunt, K. S., Noble, B. N., & Mayer, A. P. (2011). Developing a reproductive life plan. Journal of Midwifery & Women’s Health, 56(5), 468– 474. doi:10.1111/j.1542-2011.2011.00048.x Frey, K. A., Navarro, S. M., Kotelchuck, M., & Lu, M. C. (2008). The clinical content of preconception care: Preconception care for men. American Journal of Obstetrics and Gynecology, 199(6 Suppl. 1), S389–S395. doi:10.1016/ j.ajog.2008.10.024 Johnson, K., Posner, S. F., Biermann, J., Cordero, J. F., Atrash, H. K., Parker, C. S., . . . Curtis, M. G. (2006). Recommendations to improve preconception health and health care—United States: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. Morbidity & Mortality Weekly Report, 55(RR–6), 1–22. Lind, C. E., Godfrey, E. M., Rankin, K. M., & Handler, A. S. (2014). Likelihood of emergency contraception use among African-American women at risk of adverse birth outcomes. Maternal and Child Health Journal, 18(5), 1190– 1195. doi:10.1007/s10995-013-1349-z Lu, M. C. (2007). Recommendations for preconception care. American Family Physician, 76(3), 397–400. Malnory, M. E., & Johnson, T. S. (2011). The reproductive life plan as a strategy to decrease poor birth outcomes. Journal of Obstetric, Gynecologic & Neonatal Nursing, 40(1), 109–121. doi:10.1111/j.1552-6909.2010.01203.x Miller, E., Decker, M. R., McCauley, H. L., Tancredi, D. J., Levenson, R. R., Waldman, J., . . . Silverman, J. G. (2010). Pregnancy coercion, intimate partner violence and unintended pregnancy. Contraception, 81(4), 316– 322. doi:10.1016/j.contraception.2009.12.004 Miller, E., McCauley, H. L., Tancredi, D. J., Decker, M. R., Anderson, H., & Silverman, J. G. (2014). Recent reproductive coercion and unintended pregnancy among female family planning clients. Contraception, 89, 122–128. doi:10.1016/j.contraception.2013.10.011 Mittal, M., Senn, T. E., & Carey, M. P. (2013). Fear of violent consequences and condom use among women attending an STD clinic. Women and Health, 53(8), 795–807. doi:10.1080/03630242.2013.847890 Mittal, P., Dandekar, A., & Hessler, D. (2014). Use of a modified reproductive life plan to improve awareness of preconception health in women with chronic disease. Permanente Journal, 18(2), 28–32. doi:10.7812/TPP/13146 Moos, M. K., Dunlop, A. L., Jack, B. W., Nelson, L., Coonrod, D. V., Long, R., & Gardiner, P. M. (2008). Healthier women, healthier reproductive outcomes: Recommendations for the routine care of all women of reproductive age. American Journal of Obstetrics & Gynecology, 199(6), S280–S289. Noyes, S. S., & Savin, M. K. (2012a). My life, my plan: Delaware’s reproductive life planning for teens. Journal of Obstetric, Gynecologic, & Neonatal Nursing (Convention Proceedings), 41(1), S3. doi:10.1111/j.1552-6909.2012.01358_5.x
Reproductive Life Planning Noyes, S. S., & Savin, M. K. (2012b). Set your mind. Set your goals: Delaware’s reproductive life plan for young women. Journal of Obstetric, Gynecologic, & Neonatal Nursing (Convention Proceedings), 41(1), S4. doi:10.1111/j.15526909.2012.01358_6.x Posner, S. F., Johnson, K., Parker, C., Atrash, H., & Biermann, J. (2006). The national summit on preconception care: A summary of concepts and recommendations. Maternal and Child Health Journal, 10(Suppl. 1), S197– S205. doi:10.1007/s10995-006-0107-x Sanders, L. B. (2009). Reproductive life plans: Initiating the dialogue with women. American Journal of Maternal Child Nursing, 34(6), 342–349. doi:10.1097/01.NMC .0000363681.97443.c4 Secura, G., Allsworth, J., Madden, T., Mullersman, J., & Peipert, J. (2010). The contraceptive CHOICE project: Reducing barriers to long-acting reversible contraception. American Journal of Obstetrics & Gynecology, 203(2), 115.e1– 115.e7. doi:10.1016/j.ajog.2010.04.017 Steiner, R. J., Finocchario-Kessler, S., & Dariotis, J. K. (2013). Engaging HIV care providers in conversations with their reproductive-age patients about fertility desires and intentions: A historical review of the HIV epidemic in the United States. American Journal of Public Health, 103(8), 1357–1366. doi:10.2105/AJPH.2013 .301265 Stern, J., Larsson, M., Kristiansson, P., & Tyden, T. (2013). Introducing reproductive life plan-based information in contraceptive counseling: An RCT. Human Reproduction, 28(9), 2450–2461. doi:10.1093/humrep/det279 Thomson, K., & Archer, L. (2012). Formative evaluation of a reproductive life plan tool. Retrieved from http://www.colorado.gov/cs/Satellite?blobcol=urldata& blobheadername1=Content-Disposition& blobheadername2=Content-Type&blobheadervalue1= inline%3B+filename%3D%22Formative+Evaluation+ of+a+Reproductive+Life+Plan+Tool.pdf%22& blobheadervalue2=application%2Fpdf&blobkey= id&blobtable=MungoBlobs&blobwhere=1251848592179& ssbinary=true Utah Department of Health. (2009, September). Plan your health, live your life. Retrieved from http:// health.utah.gov/mihp/pdf/Teen_RLP_082709.pdf Wade, G. H., Herrman, J., & McBeth-Snyder, L. (2012). A preconception care program for women in a college setting. American Journal of Maternal Child Nursing, 37(3), 164–172. doi:10.1097/NMC.0b013e31824b59c7 Walker, L. O., & Avant, K. C. (2011). Strategies for theory construction in nursing (5th ed.). Upper Saddle River, NJ: Pearson Education. Williams, C. M., Larsen, U., & McCloskey, L. A. (2008). Intimate partner violence and women’s contraceptive use. Violence Against Women, 14(12), 1382–1396. doi:10.1177/1077801208325187 Witt, J. S., & Kelly, P. J. (2014). Choice, not chance: Reproductive life plan assessment as a clinical management framework. Women’s Healthcare: A Clinical Journal for NPs, 2(1), 45–47.
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Reproductive Life Planning: A Concept Analysis Fuqin Liu, PhD, RN, Jennifer Parmerter, BSN, RN, and Marcia Straughn, MS, RN, CNE Fuqin Liu, PhD, RN, is Assistant Professor, Texas Woman’s University College of Nursing, Denton, TX; Jennifer Parmerter, BSN, RN, is Graduate Student, Texas Woman’s University College of Nursing, Denton, TX; and Marcia Straughn, MS, RN, CNE, is PhD Student, Texas Woman’s University College of Nursing, Denton, TX. Keywords Concept analysis, family planning, preconception care, reproductive life planning Correspondence Fuqin Liu, PhD, RN, Texas Woman’s University College of Nursing, Arts and Sciences Building, Room 118, 1216 Oakland Street, Denton, TX 76204-5498 E-mail: fl[email protected] Disclosure: The authors have no conflicts of interest to disclose.
Liu
BACKGROUND. In 2006, the U.S. Centers for Disease Control and Prevention issued 10 recommendations on preconception care, which included the statement that reproductive life planning should be considered an individual’s responsibility across his or her life span. PURPOSE. The purpose of this article is to provide a concept analysis of reproductive life planning using Walker and Avant’s method as an organizing framework. METHODS. Search engines were employed to review the existing knowledge base of the concept of reproductive life planning. FINDINGS. The findings suggest that reproductive life planning is integral to preconception care and family planning. Attributes, antecedents, and consequences associated with reproductive life planning are discussed. Model, borderline, and contrary cases are also provided to illustrate the concept. PRACTICE IMPLICATIONS. A reproductive life plan can serve as a framework for promoting reproductive health across the life span of both men and women. Healthcare providers must assess the individual’s ability to understand and utilize educational resources to ensure full and effective participation in reproductive life planning.
Parmerter
Straughn
Introduction In 2006, the U.S. Centers for Disease Control and Prevention (CDC) issued 10 recommendations on preconception care, which included the statement that reproductive life planning should be considered an
individual’s responsibility across his or her life span (Johnson et al., 2006). Specifically, the CDC recommends that every man, woman, and couple of sexual maturity should have a reproductive life plan. The CDC defines a reproductive life plan as a set of personal goals related to a conscious decision about whether to bear 55
© 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
Reproductive Life Planning children (Johnson et al., 2006). Reproductive life planning is a relatively new concept, and as such needs to be properly and effectively disseminated and applied by nurses and other healthcare providers in clinical care settings. The purpose of this concept analysis is to present a theoretical understanding of reproductive life planning and to explore its clinical relevancy. Method A comprehensive literature review was conducted using the Cumulative Index to Nursing and Allied Health Literature, Medline, PsycINFO, ProQuest, the World Wide Web, and reference lists of related Figure 1. The Eight Steps of Concept Analysis (Walker & Avant, 2011)
F. Liu et al. journal articles with a time line of 2000–2014. Keywords used were reproductive life plan, reproductive life planning, reproductive life goals, and reproductive life tool. The search was limited to English-language articles only. Using these terms and limiters, 20 articles were located. Additionally, four white papers and two conference proceedings were included in the analysis. We also selectively included five recent partner violence-related studies in the analysis. We believe that this body of literature is critical to the discussion of women’s reproductive control in the context of reproductive life planning. Walker and Avant’s (2011) eight-step method (Figure 1) of analysis was used to examine the concept of the reproductive life planning. A summary of the attributes, antecedents, and consequences of the concept of reproductive life planning is presented in Figure 2. Uses of the Concept
1. Select a concept 2. Determine the aims or purpose of the analysis 3. Identify all of the possible uses of the concept 4. Determine the defining attributes 5. Identify model cases 6. Identify borderline, related, contrary, invented, and illegitimate cases 7. Identify antecedents and consequences 8. Define empirical referents
The concept of reproductive life planning is found in literature in which the primary focus is preconception care, and the two terms are often used synonymously. As a part of a list of recommendations intended to improve preconception health, the CDC introduced the concept of reproductive life planning and recommended that all women, men, and couples of sexual maturity create a reproductive life plan (Johnson et al., 2006). After the introduction of the term, the concept received attention in the literature. Wade, Herrman,
Figure 2. Attributes, Antecedents, and Consequences of Reproductive Life Planning
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Reproductive Life Planning
F. Liu et al. and McBeth-Snyder (2012) included reproductive life planning as a component of preconception care; however, they did not present a theoretical understanding of reproductive life planning. With regard to its clinical usage, the literature has adopted the concept and used it in the context of a reproductive life planning tool (Moos et al., 2008; Wade et al., 2012). The concept of reproductive life planning is instrumental to nurses when developing guidelines to assist individuals in planning for reproductive health and responsibility (Files et al., 2011). Mittal, Dandekar, and Hessler (2014) found that reproductive life planning is effective in assisting women with chronic disease in making constructive and informed decisions in regard to contraception and pregnancy planning. Reproductive life planning is also considered an intervention for improving birth outcomes (Malnory & Johnson, 2011). Sanders (2009) discusses the introduction of reproductive life planning to a primarily female population. Further, its significance at different stages of the reproductive life cycle has been addressed, with particular attention to women in adolescence or middle age, along with the associated risks and potential outcomes of unintended pregnancy at those respective phases of life (Barry, 2011; Coffey & Shorten, 2014; Sanders, 2009). Attributes Multiple attributes are associated with reproductive life planning. The first attribute, as recommended by the CDC, is that reproductive life planning is inclusive of both sexes (Frey, Navarro, Kotelchuck, & Lu, 2008; Johnson et al., 2006; Posner, Johnson, Parker, Atrash, & Biermann, 2006). However, a stringent interpretation of this attribute may pose concerns among women who report pregnancy coercion and birth control sabotage by their partners, known as reproductive coercion (Barry, 2011; Miller et al., 2010, 2014). As would be expected, women are placed at the center of the proposed conceptual model of preconception care (Posner et al., 2006). Nevertheless, in reproductive life planning, the role of the male and the female should be addressed separately, with each as an individual and as part of a couple (Barry, 2011; Frey et al., 2008; Posner et al., 2006). The second attribute, also recommended by the CDC, is responsibility (Johnson et al., 2006). A reproductive life plan consists of an individual’s intent and plans in regard to the number and timing of pregnancies (Files et al., 2011; Johnson et al.,
2006), and is an individual’s responsibility across his or her life span (Johnson et al., 2006). Thus, the third attribute is that it is a lifelong plan. It is appropriate to initiate reproductive life planning at the beginning of an individual’s reproductive years and to continue until reproduction is no longer possible. In this way, reproductive life planning spans decades and various reproductive stages, including preconception, pregnancy, and interconception (Malnory & Johnson, 2011). Preconception health is a larger framework in which reproductive life planning functions as a tool for life planning (Johnson et al., 2006). Specifically, reproductive life planning can be used to initiate discussion and education about reproductive health (Sanders, 2009). Hence, the fourth attribute is communication. Nurses and healthcare providers frequently have the opportunity to introduce reproductive life planning with simple questions about desires and plans in regard to the number of children, spacing of children, and life and family goals. Lu (2007) recommends that a discussion of reproductive life planning be included in every routine office visit, with the aim of developing a reproductive time line. A reproductive life plan is not static but can and should change as the individual’s goals and experiences change (American College of Nurse-Midwives, 2011; Files et al., 2011). This fifth attribute, flexibility, allows individuals to take life circumstances into consideration. Medical and social services are needed to help clarify the reproductive life goals of an individual, especially in cases in which the individual is high risk for poor pregnancy outcomes (Lind, Godfrey, Rankin, & Handler, 2014). An individual’s life circumstances are unique, and as such the reproductive life plan is personalized for each individual or couple. Thus, the sixth attribute of reproductive life planning is personalization. Accordingly, reproductive life planning is patient-centered (Bello, Adkins, Stulberg, & Rao, 2013).
Presentation of Cases Model Case A model case provides an example of the concept and demonstrates all defining attributes of the concept, that is, serves as a pure exemplar (Walker & Avant, 2011). For a model case, consider the following constructed example. 57
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Reproductive Life Planning A teenager is beginning to date and determines that she wants to delay sexual activity. She discusses her plans with her boyfriend and determines that she intends to remain abstinent but will use contraceptive protection when she chooses to become sexually active. She plans to complete college and to establish a career and marriage before starting a family. She wants to decide on the number of children she will have, taking into consideration her future husband’s wishes and input. During a routine wellness exam, she shares her decisions with her healthcare provider, who counsels her to maintain a healthy lifestyle to promote health and wellness, and discusses which form of contraception is most appropriate for her lifestyle and goals when she decides that the time is right to have sexual relations. After the visit, she accesses the reproductive life planning tool found on the CDC web site and formally writes her intentions. This model case exemplifies reproductive life planning with inclusion of all attributes in each situation. Borderline A borderline case is an example of a case in which some, but not all, defining attributes of the concept are demonstrated (Walker & Avant, 2011). Borderline cases are inconsistent in some way with one or more of the defining attributes of the concept. For a borderline case, consider the following constructed example. An 18-year-old male is headed off to college. He decides that he will probably not “settle down” for a long time because he wants to date extensively while attaining his education. He wants to eventually marry and to have four children by the time he and his wife are 40. He is sexually active. He receives advice on methods of conception from his primary care provider during a routine office visit. However, he expresses his intention to request that his sexual partner take responsibility for contraception, and thus to rely on her for protection. This case is considered borderline because it does not contain all of the attributes of reproductive life planning. Specifically, the attribute of responsibility for contraception is missing. Contrary A contrary case is one in which none of the defining attributes are met, or is a case that is “not the concept” (Walker & Avant, 2011). For a contrary case, consider the following constructed example. 58 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
F. Liu et al. A 16-year-old female high school student from a rural community has dated a classmate for a year. She begins sexual relations with her boyfriend without any discussion or decision in regard to contraception. She believes that she cannot get pregnant due to her age and irregular menses. Although she goes to a family healthcare provider regularly, she avoids answering any sexual- or family planning-related questions asked by the provider. She has verbalized no plans beyond high school graduation; she assumes that she will work locally until she gets married. This case is considered contrary because it contains none of the defining attributes of reproductive life planning. Antecedents Antecedents are those circumstances that occur before the introduction and use of the reproductive life plan. Antecedents for reproductive life planning include having reproductive potential, a perception of need, and the ability to understand and execute a reproductive life plan. These antecedents are relevant to reproductive life planning, regardless of lifestyle or sexual orientation (Files et al., 2011; Lu, 2007). Any man or woman, in achieving sexual maturity, is an appropriate candidate for a reproductive life plan. Having reproductive potential is an important antecedent because it means that the desire to have children has the potential to be actualized during the reproductive life span. There are times, however, when the discussion of having a reproductive life plan may not be as pertinent, such as when an individual has been diagnosed with infertility. Nonetheless, reproductive life planning may still be applicable to a couple for whom one partner has a confirmed diagnosis of infertility. Whether the focus is on individuals or couples, perception of need is another reason for developing a reproductive plan. Such a need is closely linked to one’s awareness of the risks of unintended pregnancies and undesired pregnancy outcomes. Healthcare providers are well positioned to increase awareness of the need for reproductive planning (Atrash et al., 2008). For example, an individual may not have considered reproductive planning or considered the possibility of an unintended pregnancy, and thus is an appropriate candidate with whom to initiate the reproductive life plan (Bello et al., 2013). Healthcare providers must recognize the lack of reproductive planning to initiate a conversation or intervention (Chuang et al., 2012). Often, the intervention
Reproductive Life Planning
F. Liu et al. involves the provider’s reframing his or her thinking while providing counseling and reproductive-related education to the patient (Atrash et al., 2008). To understand and execute a reproductive life plan, the individual must have the ability to understand the information and options for making informed decisions (Malnory & Johnson, 2011). Thus, health literacy is an important antecedent of reproductive life planning. The healthcare provider needs to assess what the individual knows about reproductive health, appraise the patient’s health literacy, and make alterations to educational interventions at a level appropriate for the individual (Sanders, 2009). Consequences Reproductive life planning is a precursor to family planning, which includes inquiry into appropriate and effective contraceptive methods (Files et al., 2011). In setting a time line for reproduction, the individual or couple provides critical information to the healthcare provider that guides the choice for suitable contraception based on the reproductive life plan. Individuals may not have access to appropriate contraception, however, for financial or social reasons. Regardless of the life situation of a woman, the provision of reproductive life planning-based information can increase knowledge of a woman’s choices and how to achieve them (Noyes & Savin, 2012a, 2012b; Stern, Larsson, Kristiansson, & Tyden, 2013). As such, reproductive life planning is a precursor to preconception care, a framework in which risks and behaviors that are potentially harmful to the mother or infant are addressed, which guides the individual to optimal pregnancy outcomes (Biermann, Dunlop, Brady, Dubin, & Brann, 2006; Files et al., 2011; Witt & Kelly, 2014). Finally, for both men and women, reproductive life planning can lead to a sense of empowerment and control of the future (Malnory & Johnson, 2011; Stern et al., 2013).
question: “Do you plan to have any (more) children at any time in your future?” Then, there is a series of questions that follow, based on whether the patient responds “yes” or “no.” This tool is available on the CDC web site (CDC, 2014a). Additionally, the CDC (2014b) provides a publicly available reproductive life plan worksheet. The Women’s Health Branch of the Colorado Department of Public Health and Environment developed, piloted, and evaluated a reproductive life plan booklet (Thomson & Archer, 2012). The objective for developing the tool was to provide women of reproductive age with educational materials that present preconception health concepts as easy-to-understand steps for healthy behavior, including pregnancy planning. The booklet is available on their web site (Thomson & Archer, 2012). Another publicly available booklet created by a state agency is Plan Your Health, Life Your Life, published by the Utah state government (Utah Department of Health, 2009). Further, based on the work done by the Preconception Health Council of California, Mittal et al. (2014) developed a modified version of a reproductive life plan to include additional sections specific to counseling patients with diabetes, obesity, and/or hypertension. The revised reproductive life plan is retrievable via a web link provided in the article. Although various reproductive life planning tools are available, none has explicitly addressed the needs of women who are affected by intimate partner violence. Clark, Allen, Goyal, Raker, and Gottlieb (2014) reported that male behavior to control the fertility of female partners in an abusive relationship is common. Further, fear of violent consequences can become a barrier to women practicing contraception themselves (Williams, Larsen, & McCloskey, 2008) and to negotiating condom use with their partner (Mittal, Senn, & Carey, 2013). The control and climate of fear seen in abusive relationships warrant further refinement of the existing reproductive life planning tools to address the issue of fertility control and safety concerns.
Empirical Referents
Implications for Nursing Practice
The CDC Preconception Care Workgroup and the Select Panel on Preconception Care suggest developing, evaluating, and disseminating reproductive life planning tools for women and men that are ageappropriate, culturally relevant, and cover both general health topics and specific risk behaviors. The CDC RLP Tool for Health Professionals begins with the
Many women have the potential to make uninformed decisions on contraception, which can lead to unplanned pregnancy. Notably, nurses are in a pivotal position to introduce women to the idea of reproductive life planning and to facilitate the development of such a plan. Nurses are advised to modify a reproductive life plan to fit the unique needs of an individual 59
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Reproductive Life Planning (Coffey & Shorten, 2014). To this end, they must assess the individual’s ability to understand and execute reproductive life planning (Sanders, 2009), as well as her access to reliable birth control methods. For example, Dunlop, Logue, Miranda, and Narayan (2010) found that almost half of their study sample, who reported never wanting a child or not wanting a child for at least 1 year, were at risk for unintended pregnancy, based on their reported contraceptive practices. In cases in which reproductive coercion occurs with partner violence, the nurse should work with the prescriber to select contraceptive methods that cannot be tampered with or sabotaged, such as subdermal implants (American College of Obstetricians and Gynecologists, 2013; Secura, Allsworth, Madden, Mullersman, & Peipert, 2010). Nurses should also take an active role in statewide initiatives related to preconception care and reproductive life planning (Noyes & Savin, 2012a, 2012b). Finally, nurse leaders, educators, and researchers can promote the use of reproductive life planning as a necessary and integral component of the individual’s health continuum (Steiner, Finocchario-Kessler, & Dariotis, 2013; Witt & Kelly, 2014).
Conclusion This concept analysis was undertaken to present a theoretical understanding of reproductive life planning. Based on a small body of available literature, we conducted the analysis and proposed a set of antecedents, attributes, and consequences associated with reproductive life planning. However, as new evidence adds to the topic, this set of antecedents, attributes, and consequences should be expanded. A limitation of this analysis is that we referenced heavily the landmark report by Johnson et al. (2006) when considering the attributes of the concept. Thus, once the available literature grows, the concept of reproductive life planning should be revisited. Despite this limitation, this concept analysis has yielded important implications. Nurses should incorporate reproductive life planning across the healthcare spectrum, for both men and women of reproduction age, regardless of life situation or sexual orientation. Notably, a reproductive life plan can serve as a framework for promoting better pregnancy outcomes. Nevertheless, refinement of existing reproductive life planning tools is needed to address the unique challenges of an abusive relationship. 60 © 2015 Wiley Periodicals, Inc. Nursing Forum Volume 51, No. 1, January-March 2016
F. Liu et al. Acknowledgment. We would like to thank Dr. Donna Scott Tilley at Texas Woman’s University College of Nursing for providing feedback on the manuscript. References American College of Nurse-Midwives. (2011). Planning your family: Developing a reproductive life plan. Journal of Midwifery & Women’s Health, 56(5), 535–536. doi:10.1111/j.1542-2011.2011.00057.x American College of Obstetricians and Gynecologists. (2013). ACOG Committee opinion no. 554: Reproductive and sexual coercion. Obstetrics & Gynecology, 121(2, Pt. 1), 411–415. Atrash, H., Jack, B. W., Johnson, K., Coonrod, D. V., Moos, M. K., Stubblefield, P. G., . . . Reddy, U. M. (2008). Where is the “W”oman in MCH? American Journal of Obstetrics and Gynecology, 199(6), 259–265. Barry, M. (2011). Preconception care at the edges of the reproductive lifespan. Nursing for Women’s Health, 15(1), 68–74. doi:10.1111/j.1751-486X.2011.01613.x Bello, J. K., Adkins, K., Stulberg, D. B., & Rao, G. (2013). Perceptions of a reproductive health self-assessment tool (RH-SAT) in an urban community health center. Patient Education & Counseling, 93(3), 655–663. doi:10.1016/ j.pec.2013.09.004 Biermann, J., Dunlop, A. L., Brady, C., Dubin, C., & Brann, A., Jr. (2006). Promising practices in preconception care for women at risk for poor health and pregnancy outcomes. Maternal & Child Health Journal, 10(5), S21– S28. Centers for Disease Control and Prevention. (2014a). Preconception health and health care reproductive life plan tool for health professionals. Retrieved from http://www.cdc.gov/ preconception/documents/rlphealthproviders.pdf Centers for Disease Control and Prevention. (2014b). Preconception health and health care: My reproductive life plan. Retrieved from http://www.cdc.gov/preconception/ documents/reproductivelifeplan-worksheet.pdf Chuang, C. H., Hwang, S. W., McCall-Hosenfeld, J., Rosenwasser, L., Hillemeier, M. M., & Weisman, C. S. (2012). Primary care physicians’ perceptions of barriers to preventive reproductive health care in rural communities. Perspectives on Sexual & Reproductive Health, 44(2), 78–83. doi:10.1363/4407812 Clark, L., Allen, R., Goyal, V., Raker, C., & Gottlieb, A. (2014). Reproductive coercion and co-occurring intimate partner violence in obstetrics and gynecology patients. American Journal of Obstetrics & Gynecology, 210(1), 42.e1– 42.a8. doi:10.1016/j.ajog.2013.09.019 Coffey, K., & Shorten, A. (2014). The challenge of preconception counseling: Using reproductive life planning in primary care. Journal of American Association of Nurse Practitioners, 26(5), 255–262. doi:10.1002/23276924.12054 Dunlop, A. L., Logue, K. M., Miranda, M. C., & Narayan, D. A. (2010). Integrating reproductive planning with primary health care: An exploration among low-income,
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