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The term “informed choice” refers to a decision that people can make for themselves. Nevertheless, family planning program managers and service providers, as well as policy-makers, family planning donors, and the mass media, have important roles to play in encouraging informed choice. |
Policy-makers can:
- Ensure that regulations do not restrict contraceptive options.
- Eliminate all demographic targets, incentives, and disincentives regarding family planning in national policy.
- Eliminate restrictions on mass-media advertising of contraceptive methods and family planning service locations.
- Develop national guidelines that reduce medical barriers to family planning use, and update them regularly.
- Ensure access to good-quality education for all children, so they can learn to read, write, and exercise critical thinking for informed decision-making—not just in family planning but in all aspects of life.
Family planning donors can:
- Support principles of informed choice in recipient programs.
- Assist in assuring a reliable supply of contraceptive commodities.
- Help develop indicators to measure achievement of informed choice.
Communication media can:
- Inform the public of their right to make informed choices about family planning.
- Portray providers who respect people's family planning choices.
- Present detailed, accurate, and balanced information on a variety of family planning methods, their sources, cost, effectiveness, safety, reversibility, and correct use.
- Provide technical assistance and donate air time and editorial space to mass-media campaigns about family planning choices.
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Program managers can:
- Set organizational policies explicitly stating that all clients should receive the family planning method they want provided they understand the method and there are no medical reasons that rule it out.
- Ensure access to a range of family planning methods for all clients.
- Regularly evaluate service delivery procedures to ensure that clients are satisfied and able to make informed choices.
- Develop referral systems by creating links with other agencies to meet the range of clients' family planning needs.
- Ensure that printed information on correct use and the availability of other methods is provided along with contraceptives that are distributed through community-based distribution (CBD), social marketing, or other family planning sources outside clinics.
Service providers can:
- Give clients their desired family planning method unless it is medically inappropriate.
- Provide clear, unbiased information on the advantages and disadvantages of the various contraceptive methods and explain correct use of the chosen method.
- Tailor counseling and advice to each client's expressed needs and personal situation.
- Explore topics and issues that the client raises.
- Refrain from judging the client and from holding preconceived perceptions about what is best for the client.
- Respect the client's decision even if she or he chooses a less effective method than you would advise.
- Respect the client's decision to switch from one method to another, even if the client switches frequently.
- Respect the client's decision to refuse any or all services.
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Help yourself, too. People considering family planning for themselves can do much to ensure that they make informed choices. They can actively seek information about their health and about family planning from the mass media and community sources. They can discuss family planning with their sex partners, family members, and friends.
If they visit a family planning provider, they can prepare questions, ask these questions, and expect to receive answers. As more and more people expect to make family planning decisions for themselves, all people will be better able to make informed family planning choices.
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Chapter 1
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In view of the global HIV/AIDS epidemic, it is more important than ever for people everywhere to consider dual protection—preventing both unintended pregnancies and sexually transmitted infections (STIs). Family planning providers have a responsibility to help people understand STIs, assess their own risk, and make healthy choices (414).
Assuring dual protection involves both choosing a family planning method and making decisions about one's sexual behavior at the same time. To make these decisions, a person must know whether he or she personally is at risk for STIs and also how to protect against STIs.
Assessing Risk
The provider can help clients assess their own risk for STIs by urging them to ask themselves the following questions before they choose a family planning method:
- Are you having sex with more than one person?
- Does your sex partner have sex with others or share injection needles with others?
People who answer yes to either question are at risk for STIs.
Some clients want to talk about risk and sexual behavior. Others do not. Providers need to be ready to talk comfortably and honestly about sex and risky behavior. They also need to be ready to help the client silently assess her or his own risk and make decisions without explaining. Therefore, before a client makes a final decision about a family planning method, providers should point out that any person at risk of STIs should use condoms, alone or with another contraceptive method.
Choosing Protection
As clients consider any family planning method, providers should tell them
whether that method will protect them against STIs (298). Many
family planning providers, however, do not. For example, in Uganda
providers explained to 39% of clients whether their method protects
against STIs, and in Zimbabwe 10% did (407) (see Figure
4). In fact, presenting condoms as
the family planning choice that also prevents STIs can make condoms
more appealing to many people, particularly those who think their
chances of getting pregnant are greater than those of getting
an STI (66, 277). Indeed, some condom promotion campaigns now
advertise condoms for “protection” without specifying protection
from STIs or pregnancy (155, 441).
There are five ways that people can practice dual protection. Not all of them include condom use. Thus even some people who do not want to use condoms can find a way to protect themselves from STIs. People can:
- Use a male or female condom alone;
- Use a male or female condom along with another family planning method;
- Use a method other than condoms along with mutual monogamy;
- Practice only nonpenetrative sex; or
- Practice abstinence (203, 277, 298).
Family planning providers and communication campaigns can make people aware of all of these options.
Behavior Changing
Surveys in Africa and Latin America show that people have been changing their sexual behavior to avoid HIV/AIDS. Among never-married men and women (whether sexually active or not) who have heard of AIDS, the most commonly reported change in behavior to avoid AIDS was to stop having sex or, if not yet sexually experienced, to delay sexual initiation. Beginning to use condoms was the second most common behavior change. Among married people in every country surveyed, the most common reported change in sexual behavior was to restrict sex to the person's spouse (155).
Some family planning providers worry that advising a client who is at risk for STIs to practice dual protection may interfere with the client's ability to make an informed choice of a family planning method. In fact, however, making a family planning choice without considering STI risk and protection is not a fully informed choice. Providers, therefore, need to incorporate a discussion of sexual behavior into each client's family planning decision-making process.
With accurate information, people at risk for STIs, including HIV/AIDS, usually choose to protect themselves. For example, in a Mexican family planning clinic, among women who had information about the intrauterine device (IUD) and STIs, those at risk for STIs could rule out use of the IUD better than providers could through routine screening. After providers gave clients information on risk, the odds that a woman at risk for STIs would choose condoms almost doubled (83, 266).
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Chapter 2.3 | Return to
Chapter 7.3
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EVALUATION QUESTIONS CAN HELP MEASURE WHETHER FAMILY PLANNING
CLIENTS ARE ABLE TO MAKE INFORMED CHOICES: |
To evaluate
any family planning program:
- Does government policy specifically mention the right to a free and informed choice to plan one's family?
- Does government policy avoid setting numerical targets and avoid offering incentives or disincentives that impede informed choice?
- Does the family planning agency specify that informed choice is a key goal?
- Has the family planning agency eliminated all unnecessary medical barriers and arbitrary restrictions on who can be served?
- Are program procedures for ensuring in-formed choice the same for men and women?
- Is informed choice covered in training?
- How many contraceptive methods are approved for distribution?
- How many methods are available at the service site?
- For how many methods are clients referred to other programs?
- Do clients receive their method of choice?
- Are clients satisfied with the method they received?
Adapted from: CEDPA 1996 (72) and Hardon 1997 (179) |
To evaluate
client-provider communication:
- Does the client participate actively in the discussion and selection of the method?
- Does the provider encourage the client to ask questions?
- Does the client ask questions and receive courteous and complete answers?
- Does the client receive his/her method of choice?
- Can the client explain why he or she chose the method?
- Does the provider ask about the client's reproductive intentions?
- Is the provider responsive to the client's questions?
- Does the provider ask the client which method she or he would prefer?
- Does the provider give accurate, detailed information on the method chosen?
- Does the provider tell the client whether the chosen method protects against STIs including HIV/AIDS?
- Does the provider tailor key information to the particular needs of the specific client?
- Does the provider give instructions on when to return?
- Are all methods that the program provides available at the time of the client's visit?
Adapted from: MEASURE Evaluation 1999 (286) |
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IN ADDITION TO THE QUESTIONS ABOVE,
THE FOLLOWING QUESTIONS CAN BE ANSWERED: |
To evaluate
community-based distribution (CBD):
- How many nonclinical methods are available from CBD workers?
- Do CBD workers refer clients for methods that are not available in the CBD program?
- Do CBD workers put any restrictions on methods beyond those stipulated by program policy?
Adapted from: The EVALUATION Project 1993 (122) |
To evaluate
communication programs:
- Do people know they have the right to make informed choices for themselves?
- Do people know about family planning methods?
- How many methods do people know about?
- Which methods do people know about?
- Do people accurately understand these methods, including how to use them?
- Do people know where to get these methods?
- Do people know where to get family planning information?
- Are people planning to consult a family planning provider for more information or guidance?
- Do people speak to family or community members about family planning?
Adapted from: Bertrand and Kincaid 1996 (40) |
To evaluate
retail outlets such as pharmacies:
- How many contraceptive methods are available?
- Does the owner/employee refer customers for methods that are available only elsewhere?
- Does the customer receive adequate information about how to use the product?
- Does the retailer think that the information he or she has about the product is adequate?
Adapted from: The EVALUATION Project 1993 (122) |
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Return to
Chapter 4.1 | Return to
Chapter 6.3
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Postpartum and postabortion women deserve extra care to ensure that they can make and carry out informed family planning choices.
Postpartum Family Planning
A woman's presence in a medical setting during pregnancy presents an opportunity for health care providers to inform her about the range of family planning options. Many women have difficulty making major decisions during labor or immediately postpartum because of the pressure of time and the pain and stress of childbirth (49, 50). Therefore, prenatal counseling for postpartum contraception is needed, especially when women consider permanent or provider-dependent methods (235). Particularly if a woman considers sterilization, she should make her decision before giving birth, since the chances that a woman will regret her decision are higher among women who decide at delivery than among women who have made the decision earlier (129, 468).
Providers should never ask women to make contraceptive choices while they are in labor or sedated. Stress, pain, and sedatives may hamper their ability to make decisions. Nor should a husband's consent serve as a substitute for the woman's while she is sedated. Women are more likely to regret a decision made by the husband alone than when the decision is made by the wife alone or by the couple (414). |
Contrary to the principle of informed choice some providers equate postpartum contraception with IUD insertion or sterilization only (349). Thus they do not offer other methods. Some providers feel obliged to convince postpartum women who already have many children to have a sterilization procedure or IUD insertion (212). For their part, women who have already consented to sterilization may be under the impression that, because they have delivered, they must now go through with postpartum sterilization. For this reason, after the delivery it is wise to review the client's decision with her to find out if she has changed her mind (184).
Postabortion Family Planning
Many women have induced abortions because they were unable to make informed choices about family planning. If a woman does not have the opportunity to make an informed choice after an induced abortion, then the health care system has neglected her twice (269). |
Susheela Engelbrecht, JHPIEGO
A Ghanaian health provider gives prenatal care to a pregnant client. Offering women contraceptive counseling before they go into labor helps foster informed decisions about postpartum family planning. |
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Women receiving postabortion care should be informed that another pregnancy can occur almost immediately. They need to consider if they want contraception. They should be able to choose from a range of methods. Provided the woman has no other medical condition that rules out a particular method, all contraceptive methods can be used safely after abortion, and most methods can be started immediately after treatment for complications (182) (see Family Planning Following Postabortion Treatment, supplement to Population Reports, Series L, No. 10, Sept. 1997). Protection is needed immediately because fertility returns soon after abortion. Often, referral systems are needed to make it easy for postabortion women to get the contraception they want (305, 469).
Providers who work with postabortion clients can help women best if they avoid expressing disapproval or taking actions that limit a woman's contraceptive choices (365). Similarly, provision of care should not be contingent on a woman accepting contraception in general or using a particular contraceptive method (469).
Clients may say after an abortion that they will never have sex again, and they may refuse contraceptives (305). Nevertheless, providers can give information on a variety of methods and how to obtain them. They also can give these women supplies of condoms, pills, or oral emergency contraception, which the women can take home and use if needed (269).
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to Chapter 6.4
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How much information and how much guidance do family planning clients need? These are two important practical questions facing those concerned with client-provider communication for informed choice. Research on people's medical decision-making finds great variation in how much information and how much guidance people want (116, 118). Some clients want to make family planning decisions completely on their own. Others want substantial help from a provider (285). The challenge for family planning providers is ascertaining and meeting those individual needs while meeting the ethical obligation to try to help every client make informed choices.
To help clients make informed choices about contraceptive use, family planning programs once thought providers should give clients a lot of information about all methods equally. This approach, however, overloaded clients with technical information and did little to help them apply information to their own lives (403).
People can generally assimilate two or three important pieces of information in a brief time. Receiving too much information is stressful (244). Particularly when they are passive listeners, clients forget or distort much of what providers tell them (100). If a client experiences fear, stress, or anxiety, information takes longer to assimilate. If clients become confused by an overload of information, they often do not use family planning well and are more likely to discontinue contraception than when clients receive clear, concise counseling (193).
Shared Decision-Making and Informed Choice
Some studies have found that patients do not want to make their own health decisions?particularly when these decisions could have serious consequences (57, 118). Instead they prefer to leave these decisions to others, including physicians and family members (37, 156, 336, 420). Most studies of medical decision-making, however, favor shared decision-making over a model in which the provider makes the decision alone (73). In shared decision-making the provider involves the patient in the decision-making process, recognizing the need to weigh patients' personal information in treatment decisions (74, 99, 171).
The informed choice model goes a step further than shared decision-making: clients make family planning decisions for themselves. The provider still has an important role, however. The provider's role is to help the client think through the decision-making process, focus on key issues, and evaluate options (31, 74, 100). Also, the provider makes sure clients' decisions are well informed. In these important ways, family planning decisions differ from other, more complex reproductive health matters such as STI and AIDS treatment, complications of pregnancy, and postabortion care, as well as such medical decisions as major surgery and cancer treatment, where leaving decisions entirely to the patient often increases their anxiety and creates feelings of abandonment (37, 156, 336, 420). |
Studies show that, when family planning clients have good information, they are often as capable as providers of correctly assessing their own health risks and avoiding inappropriate contraceptive choices (113, 475). For example, in rural Mexico both pill users and nonusers were as likely to know whether they had high blood pressure or heart disease as providers were to diagnose these conditions (474).
What Providers Can Do |
JHU/CCP
In this Bangladesh community a health worker meets with a couple to counsel them on family planning choices. People often differ widely in how much information they want. |
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Because clients differ substantially in the amount of information and guidance they want in making family planning decisions, the provider needs to find out efficiently and ethically what the client already knows and has decided and also how much more information and guidance the client wants. Today programs increasingly advocate that providers tailor and personalize information to help individual clients think through their choices (98, 100, 118, 149, 272).
Providers can ask clients how much they want to know and then provide the information that is relevant and that the client can consider (299). Using common language that clients understand, while avoiding technical terms, helps clients understand and remember information. Providers can repeat the most important information and give clients time to review the information, if they need more time for consideration (100). Providers also can give clients permission to make their decisions at their own pace, even if that means putting off an immediate decision in order to consult a spouse or family member.
If clients say that they want the provider to decide for them, providers should respect this desire. Providers can describe the concept of informed choice, explain how the client will benefit from taking a part in decision-making (358), and try to involve the client in the process to some degree (99, 146, 171, 358). Respect for clients' autonomy is a principle of informed choice and a component of many health care professions' codes of ethics (198, 470).
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to Chapter 1.3 | Return
to Chapter 7.3
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