Contents
Chapters
- Why Informed Choice Matters
- Making Family Planing Decisions
- Policies for Informed Choice
- Communication for Choice
- Improving Access
- Managing for Informed Choice
- Client-Provider Communication
Highlights
- 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
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.
Volume XXIX, Number 1
Spring 2001
Series J, Number 50
Family Planning Programs
Helping Clients Make Informed Choices
Any staff member can learn to counsel clients for informed choice. Everyone on the family planning staff can be oriented to effective client-provider communication and to the principle of informed choice (21, 403).
Providers can help achieve informed choice best through client-centered counseling, in which clients' concerns, desires, and comfort are most important, and clients lead the exchange (244). Client-centered counseling leads to better family planning decisions (114, 295, 432). In Egypt, for example, contraceptive continuation rates seven months after counseling were higher and client satisfaction was three times higher when counseling sessions were client-centered than when sessions were provider-centered (4).
The Maximizing Access and Quality (MAQ) Initiative has developed six principles in client-provider interaction for use in family planning services that can foster informed choice (298). These principles focus on treating each client well, providing the client's preferred method, and offering relevant information and guidance. Similarly, the six-step GATHER process helps counselors and clients through a decision-making process that informs clients' choices (see Population Reports, GATHER Guide to Counseling, Series J, No. 48, Dec. 1998).
Method preferences. As a first step, providers can ask, “What can we do for you today?” and then ask new clients if they have a particular family planning method in mind. Usually the methods that clients prefer are the best methods for them. Providers can discuss the preferred method, asking clients to explain in their own words what they have heard about the method, without challenging or insulting them (100, 348). Providers also can name other contraceptive methods that are available and ask whether clients would like to hear more about any or all of them (298). Even if clients do not want to hear about them, they will at least know there are other methods if their needs change.
Before clients decide on a method, however, providers should be sure to tell them that condoms are the only contraceptive method that protects against STIs (see Choosing Dual Protection). Family planning programs can integrate STI/HIV counseling into their programs by helping all clients understand their own risk of infection and, where appropriate, offering testing. Providers can help HIV-positive women to understand the risk of transmitting HIV to the child if they become pregnant and to weigh the decision whether or not to have children (9).
Some providers are so resolved to avoid making choices for clients that they discuss all methods equally rather than focus on the methods that interest the client (244). It is not necessary—as was once argued—to tell each client individually everything about every contraceptive method (see How Much Information? How Much Guidance?).
Many providers do not ask clients if they prefer a particular contraceptive method. The percentage varies widely from country to country. According to Situation Analyses in 12 sub-Saharan African countries between 1992 and 1997, at the low end of the range was Burkina Faso, where providers asked 48% of new family planning clients what method they preferred. At the high end was Senegal, at 82% (289).
 JHU/CCP Active clients can make better health decisions. In Indonesia the "Smart Patient" project worked with over 500 family planning clients individually to help them become more active in counseling sessions. Training gave clients confidence to speak up during counseling, to ask questions, and to voice concerns. |
Sometimes, clients' initial preferences are based on inaccurate information. To ensure that these choices are informed, providers can ask, without conveying disapproval or approval, that clients explain their choice (244, 348). Research found that providers in Ecuador asked 99% of new clients their reasons for choosing their method, in Zimbabwe, 87% of clients, and in Uganda, 73% (407) (see Figure 4).
For new clients who do not already have a contraceptive method in mind, learning their specific interests—for example, spacing or limiting births, emergency contraception, or protection from STIs—helps focus discussion on the methods of most interest (139). Providers can ask clients what they would like to know about family planning (100, 348), tailor information based on what the client wants to know, and help clients consider what attributes they want in a method (31, 299).
The percentage of providers who discuss contraceptive methods in detail with their clients varies. According to research among more than 15,000 clients in eight Latin American countries, 83% of clients said the time spent in consultation was enough to address their needs, 88% said they had the opportunity to ask questions and clarify doubts, and 90% said use of the method was explained clearly (459). Research in Kenya found that providers explained how the method works in 56% of consultations (300). In Uganda providers told 94% of clients how to use the selected method compared with 83% in Ecuador and 85% in Zimbabwe (407) (see Figure 4).
The contraceptive information that providers give or fail to give in counseling sessions can be crucial to effective contraceptive use. In a clinic in Kenya, for example, women experiencing contraceptive failures were over three times more likely to report receiving inadequate information about their method than other women using the same method (307). As a South African woman explained, “I had been on the pill and I came off it and I was given one of these gel things to use and I didn't really know how it worked and I fell pregnant. After that I've learned a lot more about it” (167).
Counseling about side effects before clients begin use of a method is particularly important in helping clients make informed choices, so that they can choose another method if they prefer. For example, in China continuation rates for injectables were higher when providers told women in advance about possible changes in menstrual bleeding patterns than when they did not tell clients, partly because women who would find such changes intolerable chose a different method instead (267).
Counseling about side effects is also important for contraceptive continuation (92, 141, 191, 193, 458). In Niger, for example, only 19% of women who said they received adequate information about side effects discontinued contraceptive use within six to eight months compared with 37% of women who said they received inadequate information. In The Gambia the difference was even greater—14% compared with about 50% (89).
Nevertheless, not all providers counsel clients about contraceptive side effects. In Uganda 85% of clients were told about side effects, 70% in Zimbabwe, and 70% in Ecuador (407). In Kenya client exit interviews found that service providers told the client what to do if there were side effects in 76% of consultations, described possible side effects in 60% of consultations, and asked if the client had any questions in 60% of consultations (300).
Screening for medical eligibility. The final step in helping a person choose a contraceptive method is screening for medical reasons that prevent its safe use. Once a client has a clear preference for a method, the provider can ask about specific medical conditions that would prevent safe use. A provider can help the client weigh and compare the risks and benefits of both pregnancy and use of that particular family planning method (258). Where use of a method is clearly ruled out for medical reasons and the client is unable to obtain her preferred method, the provider can explain why and help her choose another.
Continuing clients. The decision to continue using a contraceptive method should be as well informed as an initial choice. Asking continuing clients whether they have any problems with their current method invites clients to think about possible doubts that might lead to discontinuation. An essential component of informed choice and client satisfaction is telling clients they have the option to switch methods whenever and as often as needed (59).
Still, many providers do not offer this information during counseling. For example, in Kenya in 1995, of 224 new clients surveyed, 41% had been told they had the option to switch if they became dissatisfied with their method (303). In Zimbabwe a similar study in 1996 found that, of 168 new clients surveyed, just 13% were told they had the option to switch (112).
High method continuation rates sometimes indicate that people do not know they can switch or that they have a limited choice of methods (10). For instance, research in Indonesia found that continuation rates among implant users were four times higher than among IUD users, in part because implant users did not know that removal before five years was possible, while IUD users knew the IUD could be removed at any time (419).
When people stop using a certain contraceptive, it may not be because they are dissatisfied with their method, however. People who stop a method after long-term use usually do so because their reproductive needs or intentions have changed (10, 138, 291). Such change is to be expected and does not necessarily imply problems with the original choice of method. Rather, people are making a choice that better reflects their needs (110, 139).
Whether considering starting family planning, choosing among methods, or continuing use, people can make healthier decisions if they make informed choices—that is, choices they make for themselves, based on accurate information and a range of contraceptive options. Family planning programs and providers, along with governments and donor agencies, can do much to help people make informed family planning choices.
 For the latest, peer-reviewed research on International Family Planning Perspectives is available free to individuals living in or doing work involving reproductive health in the developing world. Paid subscriptions are also available: US$46 for institutions within the US; US$36 for individuals within the US, and US$56 for mailing outside the US. Order at www.agi-usa.org or call 212-248-1111, ext. 2204. |
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Most photos in this report were selected from the Johns Hopkins Population Information Program's Photoshare database of photos for nonprofit educational use, available at www.jhuccp.org/mmc/index.stm. |
