Counselling & interactions

1. The doctor-patient script

This script, which was the most common across the data, because it reflects familiar roles that have traditionally characterised healthcare interactions. These roles are based on hierarchical relationships, with health providers or clinicians as the sole authority at the top of the hierarchy. Doctors especially are allocated the role of the expert who makes decisions in the patient’s interests. It is the patient’s responsibility to follow the doctor’s directions; she has little input aside from specific requests for information (e.g., medical history, past experiences, preferences). The doctor-patient script does not necessarily arise intentionally or due to the caregiver’s ill intentions. Rather, this is an established script that becomes an entrenched way that medical consultations happen, including with contraceptive care. In addition, time pressures or other constraints around consultation can reinforce this script.

A problem with this script, evident in most participants’ accounts, is that the power imbalance may be intimidating for a patient, who then feels that she cannot ask questions or provide important information or input since she is not ‘the expert’. As Jolene (34, Māori, IUD user) said, “I find most often that because they're the professional I just go "Oh, yeah, okay" and accept the recommendation”. Kiara’s account also shows how her experience was shaped by a hierarchical power dynamic. When asked if she had been informed about the full range of contraceptive options available to her, she replied:

I wasn't willing for the jab at that point. They weren't overly interested in giving it to me, either. There was a very brief, 'OK, well there's the jab, but we think you should go on this.' And it was kind of like 'OK, well, you're medical professionals, I'll go with it’. […] And when a doctor says, ‘we don’t think that’s a good option’, you kind of just nod and agree. (Kiara, 22, Pākeha, implant user)

These power dynamics may result in doctor-centred decision-making that could be especially problematic in combination with other power imbalances related to socially marginalised positions (e.g., gender, ethnicity, education levels). The patient-doctor script might, therefore, be especially problematic for wāhine Māori as reflected in Terina’s comments at the end of her interview:

When I've worked with a lot of our whānau in the community it's just about us not being ashamed or whakamā to stop and re-ask the question if you don't understand and stop nodding because most times our whānau, especially Māori, are quite common to nod. And when we don't even understand and then things happen to us and then we're like, "Oh yeah that's what I meant to do." But, really just re-ask it and then asks them to simplify the question to say we can get a better understanding of what they're doing to you, because it's your health, it's your wellbeing, it's your body, and you need to own it as well as them support you in your journey. (Terina, 28, Māori, implant user)

Terina’s comment illustrates how Māori might be disadvantaged by existing power hierarchies that silence them: so that Māori patients feel compelled to be agreeable and not to speak up in patient-doctor interactions. Added to this might be shame or whakamā, prompted by an awareness of the longstanding deficit view of Māori, rooted in colonialism, which might result in caregivers responding with unfounded racialised assumptions, e.g., ‘uneducated’, ‘ignorant’, ‘hypersexualised’, or ‘irresponsible’. Here, not speaking up in patient-doctor interactions may represent a self-protective strategy, but may also align with some interpretations of tikanga Māori ("the Māori way of doing things") informed by Western taboos of discussions about sexual matters. The presence of shame or embarrassment in the patient-doctor interaction was raised by all Māori participants as a barrier to learning about and accessing contraceptives. Importantly, note that Terina refers not only to responsibility of the patient to speak up, but also the need to be supported. This is consistent with research that situates Māori reproductive responsibility as a collective investment.¹⁷

Another drawback of the doctor-patient script is that the patient’s knowledge about her bodily experiences and personal situation can be overlooked, minimised, or even dismissed. This was evident as several participants described feeling that such knowledge was disregarded or dismissed. Jolene, for example, told about her experience of wanting to have her contraception reversed and feeling dismissed when her doctor said, "Oh well, you know, that's not what usually happens, just wait it out it will settle down". She described feeling unheard as she kept being told to wait longer, waiting a year before her request was met.

Jolene: It's a little bit undermining because by the time I get an in there I'm like I'm done and had enough. […]

Tracy: Does it feel a bit like they're not really listening to you?

Jolene: It did at times feel like I was just wasting my time saying it. That they didn't believe how bad it actually was for me. […] So yeah it is frustrating 'ey. As is you know a patient when you say this, it's, "I'm not happy and I want to change it". And you just sort of get met with "Just a little bit longer, we'll just see if it settles down. You know, it's only been six months it's probably going to settle down now or". Things like that is really frustrating, because you do feel like, well, I just felt like they just didn't really believe me. (Jolene, 34, Māori, IUD user)

Jolene’s story shows how her experience was minimised to the point that she felt that she was not believed. Participants’ perceptions of being dismissed or unheard do not promote trust in the patient-doctor relationship, which has been shown to be essential to meeting women’s contraceptive needs.¹⁸ For participants, this sometimes led to frustration and a combative stance, as some described having to “fight” to be heard or have their experience acknowledged. For example, Melissa (23, Māori, Implant user), recounted how she had been to her GP repeatedly due to heavy bleeding and complications she believed were related to her contraceptive. She described the GP as dismissive and recounted how a confrontation eventually arose: “So, then, I went in there the next week and I took my partner with me and he had a go at her. So, she was forced to do a physical examination”.

2. the health consumer script

This script lies on the other side of the continuum to the traditional doctor-patient script. This script follows similar lines of thinking as the purchase of any other goods or services in contemporary society. In this script it is the woman’s preferences and agenda that drives the process and the ultimate decision rests with her. As a service user, she has the right to good services and the responsibility to make informed choices. As a service provider, the medical practitioner is responsible for providing good services, providing expertise when it is sought and responding to the consumer’s needs and preferences. This corresponds with a common approach to contraceptive counselling in which “providers only give information about contraceptive options and do not assist with decision making”.¹⁵

Healthcare providers may support such patient-driven decision-making in order to respect their patient’s autonomy,¹⁵ but the limitation is that it can also reduce information sharing in consultations. Indeed, a common theme in relation to this script was that of reduced guidance or direction from healthcare providers. For instance, Marie (35, Pākeha, partner sterilised) said, “I didn't feel like they had any sort of preference to which way I went. It was entirely up to me to make the decision, and they'd go with whatever I thought”. Following the consumer script, many participants reported that they did independent research before the consultation and came with a choice already made, discussion then centred on this choice. As a result, several participants did not fully explore their options in some instances and frequently said that if they had they would in hindsight have made a different choice. They reported feeling in retrospect that they had lacked the information needed for decision-making; “you don’t know what you don’t know”.

The consumer script may also place undue responsibility on the patient to be a “savvy customer” and for any consequences of her final choice. For instance, when relating her disappointment in the contraceptive care she had received and the ultimate outcome, Sinead blamed herself for the outcome because she had not been an “informed consumer”:

But yeah, the comparison in care, then, that you hear about other people having received online, is quite different […] to the experience that I had. […] I was a bit disappointed with, um, first of all maybe just myself, for being uninformed. I felt like I could have been a more informed consumer. […] So, I was a bit annoyed at myself, then, for not having done that in advance and then being financially motivated, rather than being a responsible medical patient, consumer person (Sinead, Pākeha, 27, IUD).

As the extract from Sinead’s account shows, when this script was used, participants described needing to make sure that they were informed by researching options before a consultation and asking questions. As a result, when things went wrong, as in Sinead’s case, participants potentially blamed themselves for not being informed, failing to ask the correct questions, or not advocating for themselves. Again, although less adversarial than in the doctor-patient script, this implies that patients cannot fully trust practitioners to act in their interests or honour their requests.

Again, this script is not necessarily the result of a lack of care on the part of ‘service providers’ but could actually be the opposite. The consumer script has emerged as a way of trying to increase patient satisfaction by allowing patients more autonomy.¹⁵ Unfortunately, structuring care around ‘market-place’ thinking, potentially makes interactions transactional, rather than collaborative.

3. The partnership script

The final script, the partnership script, was relatively rare in terms of women’s actual experiences. This can be explained by the fact that it reflects newer ideals around healthcare interactions, sometimes called patient-centred¹⁷ or person-centred^19,20 contraceptive care. Rather, the script most often appeared when participants were describing their ideal scenario for contraceptive care. As mentioned above, most women expressed a preference for a collaborative approach to contraceptive care and decision-making. For example, in the following extracts where participants respond to questions about their overall experiences and preferences for contraceptive care.

Tracy: If you think about, as a woman who's been through the system, how should it ideally be? What could they do differently, to just make it better?

Lisa: More time, and a more personal approach. Yeah. That collaboration between (.) you come in as a partnership, rather than the Doctor, who, sometimes it is that the doctor knows more, so there's always that kind of, like, a slightly more hierarchical [relationship], in a way. Whereas, if you come down to a person's level, discuss all the options, give them time to decide. Say, 'Do your own research' and then talk about it. (Lisa, 26, Pākeha, no contraceptive)

A collaborative sort of process would be best. In my experience, particularly just with the copper [IUD]—even though it wasn't, it was like a sort of time pressured situation and it's a decision that had to be made—there was that little bit of collaboration, or a recommendation based on my medical needs. So, that absolutely made a difference. I remember saying to someone just afterwards, I was like ‘Oh they actually listened to what I was saying and didn't just recommend a standard sort of contraceptive!’ Which is (.) I appreciate that. But generally speaking, yeah, it hasn't always been that way. But I do think that sort of collaborative approach would be ideal. (Jolene, 34, Māori, no contraceptive)

The responses above illustrate how the partnership script is seen as ideal and is focused around collaborative decision-making and shared power in this process. It therefore represents a middle ground between the other two scripts. One of the features that distinguishes this script is that it promotes information sharing between patients and healthcare providers. In Jolene’s account we see her describe how healthcare providers gave expert advice tailored to her specific needs and “actually listened” to her. It was evident that, on one hand, being heard was important to participants, as well as, on other hand, also receiving professional guidance and expertise that is not generic but speaks to their preferences and needs.

One of the most common trends, across the board, was the tendency for people to associate collaborative, patient-centred care with specialised sexual and reproductive health services, rather than GPs. Emma’s comment below illustrates this view.

I do know that GP's are not specialists in their field. […] that's what I like about Family Planning I feel like it's specialised, especially in sexual health and with young people. So, it feels like they're talking to you, not at you. So, it's not as if you go there and you're going on contraception, ‘cause it's such an awkward thing to talk about, ‘cause then everyone knows you're having sex or you're going to have sex. Sex is a REALLY awkward thing to talk about with people you don't know. They're not like "you're a slut" or anything. And they're like "Yeah, cool, what do you want? Are you sure that's the best thing for you and you look at other options; I just want to make sure that you're fully informed with everything" and stuff like that. The whole experience feels a lot more comfortable. (Emma, 28, Māori, condoms)

What is striking in this quote is the description of doctors “talking at” patients, emphasising the feeling of one-sided, top-down communication that aligns with the doctor-patient script. Instead, patients are asked about their desires, preferences, and needs. Like Emma, most participants said that they felt more secure and comfortable in specialised sexual and reproductive health services. They generally described interactions in these spaces as caring and non-judgemental, with personalised guidance provided. It is perhaps not a coincidence that Emma raises the issue of potential embarrassment of talking about sexual matters with strangers, as Māori she could encounter entrenched negative framing of Māori sexuality which makes it difficult to speak without fear of judgement. Talk about shame, secrecy, and embarrassment was clearly noticeable in Māori accounts.

This leads on to the point that patient-centred care can also be important for cultural responsiveness, as indicated in Terina’s description of the contraceptive care received at her GP practice.

And then, with our GPs, they were culturally sensitive. They made sure I understood before I got use the product. They explained other contraceptives as well and how it worked. […] that was the only reason I went for this type of method [the implant]. But they made me understand that culturally they involve my family so they could have attended as well, the appointment as well. I could bring someone with me for support or my sister could come, but yeah just even though they really, really open to having whānau involved with the whole process. (Terina, 28, Māori, implant)

Here Terina raises an aspect of the partnership script that others also touched on: the possibility of involving whānau in contraceptive decision-making. Terina also spoke about this process as a “whānau decision” and others described the various ways that members of their whānau could be supportively involved in contraceptive care and decision-making, under certain conditions.