Many providers are using the PATH questions to explore reproductive desires with patients. What are the questions?

Patty Cason explains that. PATH questions are designed to guide providers through a person-centered, non-judgmental counseling approach—building rapport, reducing bias, and clarifying patient needs.

PATH is an acronym for remembering three key questions:

The (PA) stands for: Parenting/Pregnancy Attitudes.

Do you think you might like to have (more) children at some point?

The (T) stands for Timing:

When do you think that might be?

The (H) stands for How important:

How important is it to you to prevent pregnancy (until then)?

PATH Questions in Detail

Parenting/Pregnancy Attitudes

“Do you think you might like to have (more) children at some point?”

This first question intentionally addresses attitudes about parenting, not pregnancy. It invites patients to share their thoughts and feelings about having (or not having) children. This allows you to ask all of your patients the question — regardless of gender, sexual orientation, or ability to carry a pregnancy.

Including the word “might” in this question encourages patients to consider their feelings and attitudes in addition to their thoughts about parenting. This first question does not assume that all people want to be parents. It is important not to skip over this question unless you already know that they want (or don’t want) children in the future.

Relevance to Contraception Counseling

If the patient does not want children (or more children) ever, it may be appropriate to offer information about permanent contraception.

“Since you’ve said you are clear that you don’t want any more children, would you like to discuss permanent contraceptive options for you or your partner?”

Timing

“When do you think that might be?”

If someone doesn’t want any (more) children—skip this question. If someone is open to (more) children at some point, this question explores their thoughts on timing in an open-ended manner.

The question invites individuals to interpret timing in the way that is most meaningful to them: you will find that about one third of respondents answer with an age or number of years, one third answer with a life event, and others reply with a combination of time and life events.

The words “think” and “might” allow for the possibility that the person has not given the matter a lot of thought and that no response is more correct than any other.

There is no need to press the patient for an exact answer about length of time. The essential information is whether they are open to parenting now, sometime soon, or no time soon.

Relevance to Contraception Counseling

The “Timing” question allows the provider to personalize the conversation, but it is not intended to determine contraceptive choice, because:

• Other than depot medroxyprogesterone acetate (DMPA, sold as DepoProvera), all methods have rapid return to fertility.
• Regardless of when they would like to get pregnant in the future, a patient may or may not value “potential” length of use in a method.
• There is no need to match the potential length of use of a particular method with a patient’s reproductive desires. For example, if someone wants to have a child in 3 years, it is not necessary to find a method that will last exactly that long. Methods with a longer “potential” length of use can just be used for 3 years and methods that are shorter acting can be used continually for 3 years.

How Important

“How important is it to you to prevent pregnancy (until then)?”

Before asking about the importance of pregnancy prevention, you must know if pregnancy prevention is relevant. If you do not know the anatomy of the patient’s partner(s) or the patient’s sexual practices, include a statement such as:

“I don’t want to make any assumptions, but if you ever have sex with someone with whom pregnancy could occur, how important is it to you to prevent pregnancy (until then)?” This provides an opportunity for the patient to share if pregnancy prevention is not a current concern.

When you ask “how important,” you provide your patient the space to consider the acceptability of potential pregnancy.

The (until then) is a placeholder. When the patient has told you about the timing or circumstances of their parenting desires, personalize the question. For example:

“How important is it to you to prevent pregnancy for the next 10 years?”

“How important is it to you to prevent pregnancy until you finish your program?”

“How important is it to you to prevent pregnancy until you find the right partner?”

If you don’t know any personal details, you can just say,

“How important is it to you to prevent pregnancy until then?”

If the patient has said they do not want children in the future, just leave off “until then” but be sure not to leave out the question altogether!

“How important is it to you to prevent pregnancy?”

Relevance to Contraception Counseling

This question can inform whether contraceptive effectiveness is a priority for the patient. Research shows that most people seek effectiveness in their contraception but some do not prioritize effectiveness, or it may be one of several things that are a priority for them.

Examples

“I’ve heard you say it’s very important to you to avoid pregnancy until you finish school. Am I correct, then, that one of things you’re looking for in your birth control is that it does a good job at preventing pregnancy until you’re ready?”

“I’m hearing you say that you are sure that you don’t want any more kids and it’s really important to not have any surprises. Would you like to discuss permanent contraception as well as other highly effective options?”

Source:

Cason P, Pritzker J. Person-centered reproductive Health conversations and contraceptive counseling. In: Cason P, Cwiak C, Edelman A, Kowal D, Marrazzo JM, Nelson AL, Policar MS, Hatcher RA. Contraceptive Technology, 22 nd edition. Burlington, MA:Jones-Bartlett Learning, 2023.