Contraceptive counseling and choices in pregnancies with maternal cardiac disease

Abstract Objective Unplanned pregnancies in women with maternal cardiac disease (MCD) are associated with increased morbidity and mortality, but the majority of these individuals do not use highly reliable contraception on postpartum hospital discharge. Contraceptive counseling in this population outside of pregnancy is incomplete and counseling during pregnancy remains poorly characterized. Our objective was to evaluate the provision and quality of contraceptive counseling for individuals with MCD during pregnancy. Methods All individuals with MCD who delivered between 2008 and 2021 at a tertiary care institution with a multidisciplinary cardio-obstetrics team were sent a 27-question survey. A subset of questions were derived from the validated Interpersonal Quality in Family Planning (IQFP) survey, which emphasizes interpersonal connection, adequate information, and decision support for the individual. Each participant received a $15 gift card for survey completion. We performed chart review for clinical and demographic details, including cardiac risk score. Results Of 522 individuals to whom the survey was sent, 133 responded and met inclusion criteria. Overall, 67% discussed contraception with their general obstetrician, 36% with their maternal-fetal medicine (MFM) specialist, and 24% with their cardiologist. Compared to individuals with low cardiac risk scores, those with high cardiac risk scores had a nonsignificant trend toward being more likely to discuss contraception with a MFM provider (52% vs 33%, p = .08). 65% reported that their provider was ‘excellent’ or ‘good’ in all IQFP domains. Respondents valued providers who respected their autonomy and offered thorough counseling. Respondents disliked feeling pressured or uninformed about the safety of contraceptive options. Conclusion Most individuals with MCD reported excellent contraceptive counseling during pregnancy. Additional work is needed to understand barriers to and enablers for effective, patient-centered contraceptive counseling and use in this population.


Background
Cardiovascular disease (CVD) is the leading cause of pregnancy-related mortality, associated with over one third of maternal deaths and increased maternal morbidity through cardiovascular events such as arrhythmia and heart failure [1]. Specific risk, frequency of follow-up, and level of recommended specialist care for pregnant individuals with maternal cardiac disease (MCD) varies with the severity of cardiac lesion. Using the modified World Health Organization (mWHO) classification system, patients in the lowest risk class (mWHO class I) experience a risk comparable to that of the general population, while patients with higher risk cardiac lesions (mWHO class III or IV) experience a high risk of severe morbidity and require management at an expert center for pregnancy and cardiac disease [2]. Optimization of MCD before pregnancy is essential, given the long-term health effects of CVD and the significant economic costs of increased maternal morbidity [1,[3][4][5][6].
Even with this increased risk of maternal morbidity and mortality, individuals with MCD across all risk categories have a high rate of unplanned pregnancies [7][8][9][10]. Despite the availability of safe contraceptive methods and the advantages of planning pregnancy CONTACT  to optimize maternal health prior to conception, only a minority of these individuals with cardiac disease utilize highly reliable contraception, and previous studies from tertiary care institutions demonstrate that the majority of the MCD population does not select highly reliable contraception at postpartum hospital discharge [9][10][11][12][13][14][15][16][17][18]. This may be related to inadequate contraceptive counseling in this population [8,10,17,[19][20][21][22][23][24].
Pregnancy is a crucial time for contraceptive education for individuals with MCD. Contraceptive counseling for individuals with MCD is poorly characterized and whether specific cardiac subgroups have increased access to counseling is generally unknown. We designed this survey study to explore patient perspectives regarding the provision and quality of contraceptive counseling during pregnancy for the MCD population.

Instrument development
We designed a 27-question electronic survey that included multiple-choice questions and free text options. The first section of the survey asked the participant to recall with whom and when they discussed birth control during their pregnancy. The second asked participants to rate the provider with whom a birth control plan was made according to 10 questions from Dehlendorf's Interpersonal Quality in Family Planning (IQFP) survey, a validated tool developed to evaluate communication specific to contraceptive counseling using a Likert scale ranging from poor (1) to excellent (5) [25,26]. The survey emphasizes interpersonal connection, adequate information, and decision support for the individual through prompts such as 'respecting [the respondent] as a person,' 'taking [their] preferences about birth control seriously,' and 'giving [the respondent] enough information to make the best decision about birth control method' [25,26]. The third section included an optional free text response question for any additional information the respondent wanted to share. The survey was developed and reviewed by two MFM specialists (AGC and NCS) based on clinical experience with the workflow of our cardio-obstetrics team, with the multiple-choice format of the first two sections intended to facilitate survey participation and the elective free response section intended to invite qualitative insight at the respondent's discretion.

Data collection
This was a cross-sectional study of all individuals with MCD with at least one live delivery at a tertiary care institution between August 2008 and June 2021. At this institution, the multidisciplinary Pregnancy and Cardiac Treatment (PACT) team, made up of specialists in maternal-fetal medicine (MFM), cardiology, anesthesiology, and nursing, is responsible for managing the care of all pregnant women with MCD. This population includes individuals with congenital heart disease (CHD), arrhythmias, acquired valvular disease, cardiomyopathies, pulmonary hypertension, and other cardiac diagnoses. We sent all patients in the PACT database a survey invitation via automated REDCap email and offered a gift card worth $15 for survey completion. Non-responders received three additional reminders via email invitations. We attempted two phone calls to reach those who did not respond to the email invitations. Spanish-speaking individuals received documents and telephone calls in Spanish. Informed consent preceded survey administration in all cases. The Institutional Review Board approved this study.

Analysis
After return of survey responses, our team reviewed medical records to confirm a diagnosis of significant MCD, and we excluded participants with the following diagnoses: asymptomatic patent foramen ovale, tachycardia with negative cardiac workup, muscular dystrophy without cardiac manifestations, uncomplicated syncope, and postural orthostatic tachycardia syndrome. From the medical record, we abstracted demographic and obstetric details for participants with completed surveys. We selected the mWHO classification system to assess cardiac risk, as this system integrates both congenital and acquired maternal cardiac disease, and assigned all respondents a mWHO class based on the 2018 European Society of Cardiology (ESC) guidelines [27]. For the purposes of analysis, we dichotomized mWHO scores into low risk (mWHO < III, including class II-III) and high risk (mWHO III or IV), with the latter group recommended for care at an expert center per ESC guidelines. An Adult Congenital Cardiologist (AA) and an MFM specialist (NCS) reviewed participants who could not be directly assigned into one of the mWHO classes and categorized them as high-or low-risk based on their clinical details.
Descriptive data for the entire cohort are provided as median, interquartile range (IQR), and n (%).
For comparative analysis, the high-risk mWHO group was compared to the low-risk mWHO group using Fisher's exact and Kruskall-Wallis tests for categorical and continuous variables, respectively. All statistical analyses were performed using STATA version 17.0.
Most respondents (67%) recalled discussing their contraceptive plan with a general obstetrician, with small proportions reporting a contraceptive discussion with their specialty care providers (36% with MFM and 24% with Cardiology). Overall, 8% of respondents could not remember with whom they discussed contraception (Table 1). Compared to the low-risk group, the high-risk group was more likely to discuss contraception with their MFM (52% vs 33%; p ¼ .08). In terms of contraceptive discussion timing, 43% of respondents remembered discussing contraception during pregnancy, 39% in the hospital after delivery, and 58% in the outpatient setting after delivery (Table 1). There were no differences in the timing of contraceptive discussion between the high-and lowrisk mWHO groups.
The average IQFP score was above 4 (between 'very good' and 'excellent') in all ten domains of contraceptive counseling, and 65% of respondents reported that their provider was 'excellent' or 'very good' in all ten IQFP domains (Table 2). There were no differences in average IQFP scores in any domain between the highand low-risk mWHO groups.
In the optional free response section of the survey, participants commented on the quality of their contraceptive counseling during pregnancy and the rationale for their postpartum contraceptive choices. Reports on the provision and quality of contraceptive counseling were heterogeneous.
Several participants reported positive experiences. One described being in an 'open dialogue' with her providers about birth control options, and another stated her providers were respectful of her desired method and offered information on alternative options. Others described the counseling they received as 'the right advice,' 'appreciated,' and even 'perfect.' Multiple respondents reported feeling their provider was considerate about their health and feelings, that they did not feel forced, and that their decisions had been respected. Several reported they were counseled thoroughly about birth control options.
Others reported negative experiences. One respondent reported that multiple providers wanted to discuss birth control methods with her, which gave her a sense of 'overbearing,' 'interrogat[ion],' 'guilt,' and 'pressure.' She reported feeling that the counseling was ill-timed, as her main interest was getting through her current pregnancy rather than future planning. Two stated they had not been thoroughly informed about breastfeeding as a contraindication to their selected contraceptive plans, with one expressly noting that the disagreement between her providers regarding the safety of her desired contraception was confusing and led to a delay in her contraceptive method selection. Four respondents explicitly noted the absence of any contraceptive counseling, and five noted that their counseling was brief and/or rushed.
Several respondents reported being uninterested in birth control due to desired fertility, with varying responses from the care team. One low-risk respondent stated she was "never advised of risks with birth control and [her] heart condition," and another stated her providers did not discuss contraception because she was uninterested. One high-risk respondent with cardiomyopathy emphasized her desire for her additional children despite her care team's prohibitive warnings.

Main findings
In this survey study of contraceptive counseling during pregnancy in women with MCD at single tertiary care center, we found that almost all respondents discussed contraception with at least one provider and the majority reported very good or excellent quality of contraceptive counseling. In general, respondents appreciated providers who respected their decisions and offered thorough explanations about their contraception choices and had negative experiences when they felt pressured.

Comparison with existing literature
Previous studies have demonstrated that women in higher mWHO risk classes were more likely to receive heart-specific contraceptive counseling, and that women with CHD were likely to look to their cardiologist as a primary source of reproductive counseling [16,28]. In our population, individuals with high cardiac risk were more likely than low-risk individuals to have contraception discussions with their MFM. This also applied to discussions with a cardiologist, though to a lesser degree. This is a promising indication that higher risk patients trended toward receiving more specialized care, particularly in a setting where care is provided by a multidisciplinary cardio-obstetric team.
Multidisciplinary programs for MCD patients have been consistently associated with improved outcomes and may have contributed to higher patient satisfaction in our study [12,29,30].
Individuals with MCD in previous studies have voiced concerns about contraception method-specific safety issues and expressed desire for specific health counseling [28,31]. These sentiments were echoed by our respondents. Different cardiac lesions bear varied degrees of risk for contraception safety and even some providers are misinformed, uncertain, or feel unqualified to speak about contraception appropriateness and safety in gravidas with cardiac conditions [21,31,32]. Two of our survey respondents also described instances in which providers had a nonunified understanding of contraceptive safety during breastfeeding, which impeded contraceptive selection and usage, even at an institution that regularly treats individuals with MCD.

Clinical implications
The importance of strategic contraceptive use should not be underestimated, given that interpregnancy interval length is a modifiable risk factor for severe maternal morbidity [33]. This is especially important for individuals at higher risk due to maternal cardiac disease. While most respondents report satisfaction and patient-centeredness in their experiences of contraceptive counseling, the range of positive and negative experiences in the free response section suggests the experience in this population is heterogeneous. The general quality of counseling may require refinement and standardization with the cardio-obstetrics team.
The success of a multidisciplinary cardio-obstetrics team draws on the variant expertise of its members, including the cardiologist, with expertise in the hemodynamic effects of pregnancy and cardiac pathophysiology; the MFM specialist, with expertise in high-risk To report average score, data are presented as mean (SD). To report 'Very Good' or 'Excellent' responses, data are presented as n (%).
obstetrics and safe antepartum/intrapartum management; the obstetrician, with expertise in delivery and general pregnancy management; and the nurse, with expertise in the daily coordination of outpatient and inpatient care and monitoring [34]. Each of these various experts may provide contraceptive advice to patients with MCD. In our study, the minority of respondents discussed contraception with a cardiologist, MFM specialist, or nurse, and a third did not specifically remember discussing contraception with a general OB/GYN. This mixed, non-uniform source of contraception advice suggests that counseling is not standardized and may account for some of the variety in experiences reported. It is possible that some providers refrained from discussing contraception due to limited expertise with the pathophysiology or pharmacotherapeutics of complicated cardiac patients. It is also possible that specialists focus more on the medical complexity of cardio-obstetric risks rather than providing thorough reproductive counseling, leading to a perception that counseling is brief or not patient centered. Based on the findings from our survey, we propose a few specific measures to improve counseling.
Previous studies in the general population demonstrate that patients who receive both antenatal and postnatal counseling have higher odds of using contraception than those who are counseled during only one time period [35]. Since fewer than 50% of survey respondents recalled discussing birth control with their healthcare team during pregnancy and in the hospital after birth, one area for improvement is for providers to initiate more systematized conversations on contraception during the pregnancy and postpartum periods. At our institution, the standard of care is to ensure that a contraceptive plan is discussed in the hospital postpartum and to include this plan in the discharge summary. Additional management offered by the cardio-obstetrics team for patients with MCD provides further opportunities to confirm that contraceptive counseling occurs at multiple time points.
Incorporating MCD-specific contraceptive checklists into routine prenatal care for these patients may be another method to improve counseling in this population. Templates can be built within the electronic medical record that remind all providers to engage in contraceptive counseling in the second and third trimester and to document patient response to contraceptive planning. Such a template could also provide general guidelines for contraceptive counseling, such as soliciting barriers to contraceptive use, addressing perceptions of low susceptibility to pregnancy, and offering evidence-based counseling about side effects as applicable [36]. To address uncertainty or discrepancies in knowledge of contraceptive safety specifically for the MCD population, these templates can also incorporate a section for specialists to note the presence or absence of contraceptive contraindications for the patient's particular cardiac condition. Importantly, given that not all contraceptive options are safe for certain cardiac lesions, this section should have abundant flexibility to accommodate heterogeneity in recommendations [37,38]. For each patient, the priority should be the identification of a safe contraceptive method that is acceptable to the individual patient, tolerated without side effects, and decreases the risks of an unintended pregnancy. This type of clear and templated documentation within the electronic medical record could have the additional benefit of preventing providers from repeating information in a manner the patient finds overbearing or unwelcome. Finally, improving communication at time of delivery discharge is another area for improvement, as previous studies have suggested that poor communication at discharge decreases patient adherence to treatment [39,40]. Templates describing the necessity of followup for contraceptive decision-making for individuals with MCD could be created and incorporated into discharge paperwork.

Limitations and strengths
Our study's small sample size limits its power of to detect significant differences in contraceptive counseling by cardiac risk. As we invited individuals from over a span of 13 years to participate in our study, we are unable to fully characterize our limited response rate. For all participants, responses were subject to recall bias and could not be objectively validated via the electronic medical record. We were also unable to quantify the exact amount of counseling received. Our respondents represent a highly educated, majority White population with a range of individuals with MCD from a single major tertiary center with a multidisciplinary cardio-obstetric program, which limits the generalizability of our findings. We invited patients to share additional information through one freeresponse question but did not perform extended interviews, which limits us from making detailed qualitative conclusions. Respondents rated only the provider with whom a contraception decision was made, and it is possible that their experiences with the rest of their multidisciplinary team were different. Some providers, cognizant of their role in a multi-disciplinary clinic, may have deferred contraceptive counseling to other specialists or limited their own conversations, with patients less likely to recall these shorter discussions. In these cases, a lower percentage of reported conversations with these provider types would not necessarily represent a failure to provide counseling. Finally, several respondents noted desired fertility as a determinant of their family planning, regardless of counseling quality. This indicates that counseling does not necessarily lead to contraception and the individual, not provider team, makes the ultimate decision regarding contraceptive plan. Conclusions about contraception use in such a population solely based on patient awareness of contraceptive counseling may be misleading.
Despite these limitations, this study captures an MCD population at a major tertiary care center, eliciting a variety of responses regarding both positive and negative experiences with contraceptive counseling. Our results reveal potential avenues for promoting patient-centered care. Future in-depth qualitative studies in a larger study population could provide additional insight.

Conclusion
At a multidisciplinary tertiary center offering comprehensive cardio-obstetric care, high quality contraceptive counseling is frequently provided for individuals with MCD. Our study provides insight into how contraceptive counseling could be further improved for these individuals. Future qualitative and mixed methods research would allow additional insight into enhancing patient experiences and overcoming barriers to contraceptive counseling and use in women with MCD.

Acknowledgements
Preliminary results from this study were presented in virtual poster format at the Seventh International Congress on Cardiac Problems in Pregnancy (CPP) in Porto, Portugal from October 19-22, 2022. We thank the Volunteer Health Interpreters Organization at UC Berkeley for translating our documents into Spanish.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
No external funding was utilized for this work.

Data availability statement
The data that support the findings of this study are available on request from the corresponding author, SJS. The data are not publicly available to preserve the anonymity of survey respondents.