• 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.

People differ widely in their reproductive intentions, awareness of reproductive rights, perceived risk of becoming pregnant, attitudes about contraception, ability to make decisions, and other factors that affect family planning decisions (106, 153, 169, 187, 304, 311, 359). People also differ in their cultural and religious beliefs, and some do not use family planning at all or avoid certain methods because of their values or beliefs (100).

People's family planning preferences typically change over the course of their reproductive years, reflecting sexual experience, childbearing, contraceptive experience, as well as family structure and household economic situation (187, 241). The nature of a person's sexual relationship—whether in a long-term monogamous marriage or occasional sexual contacts, for instance,also influences the choice of contraception (160). Unmarried people who have sex infrequently or have sex with more than one partner often prefer condoms because the condom is the only method that protects against HIV/AIDS and other sexually transmitted infections (STIs), as well as against pregnancy (see Choosing Dual Protection).

People who know they have HIV may make different decisions about childbearing and family planning. A 1998 study in Côte d'Ivoire found that, among 21 women who attended an antenatal clinic and knew they were HIV positive, all said they wanted to have another child (9). A study in the US found, however, that women with HIV are less likely than uninfected women to become pregnant, more likely to get sterilized, and more likely to have an abortion (35).

Contraceptive method attributes. Most people value such method attributes as effectiveness, safety, and absence of side effects (59,172, 322). A focus-group study with women in seven countries found a strong interest everywhere in method effectiveness, protection from pregnancy for three to five years, and minimal changes in menstrual bleeding (392). Similarly, a review of research on method attributes found that women select and continue to use methods that are highly effective and have minimal side effects (190).

Still, individual preferences about contraceptive methods vary greatly. No general assumptions can be made about what attributes a particular person favors in a family planning method (90, 187, 328).

Women consider many family planning method attributes when choosing a method. They consider attributes such as whether it is permanent or reversible, whether it can be used while breastfeeding, whether it is provider- or client-controlled, how easy it is to use, whether it is male- or female-controlled, whether it must be used at each act of intercourse, whether it has added health benefits, and also what it looks, feels, or even sounds like (31, 187, 298, 322, 455).

Many people choose a particular method not because of its desirable attributes but rather to avoid the negative attributes of other methods. The choice of a particular contraceptive method may not indicate that a person likes the method but only that it seems better than other methods that the person dislikes even more (380). Because people tend to focus on possible negative consequences of specific contraceptives, it may be more important for providers to help clients to understand the drawbacks of a method than to explain its advantages (380, 393, 455). Many people tolerate undesired side effects and other negative attributes of contraception because they have a strong motivation to avoid unintended pregnancies (393, 455). Many women use a particular method for many years even though they are dissatisfied with it (362, 392). As one woman interviewed in Karachi, Pakistan, put it, “There is pain in these methods but at least there is no danger that the woman will conceive” (392).

The way that specific method attributes accord with individual values and health beliefs affects choices (187, 356, 361, 379). Some people choose condoms or fertility awareness-based methods because they believe that using hormonal methods will disrupt natural body rhythms that they want to maintain, while these methods will not (164). In Togo a 1998 study found that, when family planning users experienced menstrual disturbances, they interpreted them as signs that the contraceptives did not suit their bodies and thus would cause infertility. These health beliefs led many to discontinue use (188).

Some methods have attributes that make them easier for women to use clandestinely. Many women visit family planning clinics and use contraception without their husbands' knowledge (32, 257), sometimes fearing violence if their husbands find out (46, 186). Where privacy is lacking at home, the major considerations in choosing a method for clandestine use often include how easily the method can be concealed, how to account for travel time to obtain the method, and how to hide any abnormalities in bleeding caused by contraceptive use (392).

JHU/CCP Some women say that family planning decisions should involve their spouses and others in the household. Others prefer to make fmaily planning decisions by themselves. People consider a wide range of factors in choosing family planning.

Informed Choice Strategy

Programs can best help ensure that people can make informed family planning choices by adopting a strategy that focuses on the range of factors that influence how people make family planning decisions. A complete informed choice strategy covers five areas:

1. Government policies. When governments establish policies that empower people to make choices for themselves and provide the services that people want, the principle of informed choice can become a reality (see Chapter 3, Policies for Informed Choice).
2. Communication. Communication programs provide information crucial to family planning decision-making and encourage popular support for informed choice (see Chapter 4, Communication for Choice).
3. Access. Offering a range of contraceptive methods through a variety of easily accessible service locations provides more family planning choices (see Chapter 5, Improving Access).
4. Leadership and management. Program leadership and effective management help ensure services that support informed choice (see Chapter 6, Managing for Informed Choice).
5. Client-provider communication. Counseling for informed choice is a partnership of two experts—the service provider as the family planning expert and the client as the expert on her or his own situation and needs (see Chapter 7, Client-Provider Communication).