• Editors' Summary
• Credits

1. Why Informed Choice Matters
2. Making Family Planing Decisions
• The Individual in the Community
• Household Influences
• Individual Values and Personal Characteristics
• Informed Choice Strategy
3. Policies for Informed Choice
4. Communication for Choice
5. Improving Access
6. Managing for Informed Choice
7. Client-Provider Communication

• Figures
• Table
• Side-bars
• Bibliography

• What can be done?
• Women know what they want
• Why communities matter
• Eliminating targets
• More methods, more choices
• "Your health is in your hands"
• Do clients have choices?
• Please Ask!
• How much guidance?
• Active clients, better choices
• Counseling continuing clients

• POPLINE
• Media/Materials Clearinghouse
• Other Reports
• To Order
• CCP Home Page

Published by the Population Information Porgram, Center for Communication Programs, The Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202, USA.

Social and cultural norms, gender roles, social networks, religion, and local beliefs influence people's choices (53). To a large extent, these community norms determine individual childbearing preferences and sexual and reproductive behavior. Community and culture affect a person's attitudes towards family planning, desired sex of children, preferences about family size, family pressures to have children, and whether family planning accords with customs and religious beliefs (106, 170, 448). Community norms also prescribe how much autonomy individuals have in making family planning decisions. The larger the differences in reproductive intentions within a community, the more likely that community norms support individual choices (53, 107).

Household and community influences can be so powerful that they can obscure the line between individual desires and community norms. For instance, in some cultures, many women reject contraception because bearing and raising children is the path to respect and dignity in the society (33, 75, 262). In other countries most women use contraception because having small families is the norm (275, 292). People are often unaware that such norms influence their choices.

In other cases they are particularly aware. For example, young people often decide not to seek family planning because they do not want their parents or other adults to know that they are sexually active. Many fear ridicule, disapproval, and hostile attitudes from service providers and others (219).

A person's social environment usually has more influence on family planning decisions than do the attributes of specific contraceptives. In Kenya, for example, when new clients were asked to give a single reason for their choice of a specific family planning method, most cited the attitudes of their spouse or their peers, or their religion or values (244).

In many countries family planning programs are part of national economic and social development efforts. Efforts to foster equity in decision-making and raise awareness about reproductive rights in the family, community, and society also promote informed choice of family planning (209). As women gain more autonomy, they are better able to claim their rights as individuals, including the right to act to protect their own reproductive health (186).

The influence of social networks. Everybody belongs to informal social networks that influence their behavior to some degree (293, 313, 354, 437). Social networks include the extended family, friends, neighbors, political groups, church groups, youth groups, and other formal and informal associations. During the course of the day, women often speak to other women about family planning and experience with contraceptive use. For many women informal communication is a primary source of family planning information (360).

The influence of social networks is crucial to informed choice. Most people seek the approval of others and modify their own behavior to please others or to meet others' expectations (52, 401, 442). Individual health behavior is influenced by how a person thinks that others view their behavior (360). In Nepal, for example, some women said that it was difficult for them to use family planning because their relatives or friends were not using it. These women were reluctant to be the first in their social group to use family planning (401).

People choose contraceptive methods that are commonly used in their community because they know that it is socially acceptable to do so, and they tend to know more about these methods (355, 442). Many women use the same family planning method that others in their social networks use (163). A 1984 study in rural Thailand found that the more widely used a method was, the more attractive it became to others in the village (121). Entire communities may encourage one type of contraceptive based on the choices of early contraceptive users, rather than individual needs (330). Even when people are aware of the side effects or failures experienced by other users of a method, sometimes they still prefer it because it is familiar (121).

While social networks exert a strong influence on most people's reproductive attitudes and behavior, family planning programs themselves influence social norms through the diffusion of new ideas about contraceptive use (81). Based on a review of studies over the previous two decades, research in 1996 found that programs have helped convert people's interest in having fewer children into a definite demand for contraception. They have done so largely by making contraceptive use more accessible, common, and acceptable in many communities (143). Family planning programs are often the deciding factor for people who want to avoid pregnancy but who feel uncertain about using family planning (215, 276).

The role of social networks in the diffusion of new ideas about family planning has been recognized for several decades (345). As more and more people decide to use family planning, it has become increasingly acceptable for others to choose to do so as well (82).

A person's marital status, the stability of the marriage, communication with the person's partner, and status within the family influence family planning decisions (232). Some women say that contraceptive use is not an individual decision but one made by the couple or the family (107). In the Philippines 88% of women surveyed in 1994–1995 said that family planning is often a family decision (6). Many women, however, say that contraceptive use is an individual decision and that they do not involve partners and family members (100, 283, 296).

Sometimes, decisions reflect women's misperceptions of their husbands' preferences (265, 366). In Uganda, for example, 55% of wives incorrectly perceived their husbands' attitudes towards family planning, and in the Dominican Republic, 41%, according to DHS data.

For some, decisions about family planning may reflect pressures from family members—to use a particular method, for example, or not to use any method. Where women have little autonomy, their husbands, mothers-in-law, or other family members often make family planning decisions for them (384).

When partners disagree about family planning, sometimes the man's preference dominates and sometimes the woman's does (26, 33, 64, 271, 401). A study of DHS data in 18 countries found no significant patterns as to whose preference dominates when couples disagree about whether to have more children (29).