JHU/CCP Contents Editors' Summary Credits 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 Bibliography Highlights What can be done? Women know what they want Why communities matter Eliminating tarkets 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 Credits This report was prepared by Ushma D. Upadhyay, M.P.H. Research assistance provided by Vidya Setty. Bryant Robey, Editor. Stephen M. Goldstein, Managing Editor. Design by Linda D. Sadler. Production by John R. Fiege, Merridy Gottlieb, Peter Hammerer, Mónica Jiménez, and Deborah Maenner. The assistance of the following reviewers is appreciated: Jane Bertrand, Barbara Crane, Margarita Diaz, Alison Ellis, Bernard Guyer, Jill Tabbutt-Henry, Michele Heerey, Ronald Hess, Sallie Craig Huber, Monica Jasis, Young Mi Kim, Jan Kumar, Alice Payne Merritt, Suellen Miller, Rosalind Petchesky, Phyllis Tilson Piotrow, Malcolm Potts, Sharon Rudy, Avantika Singh, J. Joseph Spiedel, Patricia Stephenson, Marcel Vekemans, Judith Winkler, and Nancy Yinger. Suggested citation: Upadhyay, U.D. Informed Choice in Family Planning: Helping People Decide. Population Reports, Series J, No. 50. Baltimore, Johns Hopkins University Bloomberg School of Public Health, Population Information Program, Spring 2001. Population Information Program Center for Communication Programs The Johns Hopkins University Bloomberg School of Public Health Phyllis Tilson Piotrow, Ph.D., Director, Center for Communication Programs, and Principal Investigator, Population Information Program (PIP) Ward Rinehart, Project Director, PIP Anne W. Compton, Deputy Director, PIP, and Chief, POPLINE Digital Services Hugh M. Rigby, Associate Director, PIP, and Chief, Media/Materials Clearinghouse Jose G. Rimon II, Deputy Director, Center for Communication Programs; Project Director, Population Communication Services developing family planning communication strategies, projects, training, and materials. Population Reports (USPS 063–150) is published four times a year (Spring, Summer, Fall, and Winter) at 111 Market Place, Suite 310, Baltimore, Maryland 21202–4012, USA, by the Population Information Program of the Johns Hopkins University Bloomberg School of Public Health. Periodicals postage paid at Baltimore, Maryland and other locations. Postmaster to send address changes to Population Reports, Population Information Program, Johns Hopkins University Bloomberg School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202–4012, USA. Population Reports is designed to provide an accurate and authoritative overview of developments in the population field. Published with support from the United States Agency for International Development, Global, G/PHN/POP/CMT, under the terms of Grant No. HRN-A-00-97-00009-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the US Agency for International Development or Johns Hopkins University.

Informed Choice in Family Planning Helping People Decide The best decisions about family planning are those that people make for themselves, based on accurate information and a range of contraceptive options. People who make informed choices are better able to use family planning safely and effectively. Providers and programs have a responsibility to help people make informed family planning choices. Decisions about childbearing and contraceptive use are most likely to meet a person's needs when they reflect individual desires and values, are based on accurate, relevant information, and are medically appropriate?that is, when they are informed choices. To make informed choices, people need to know about family planning, to have access to a range of methods, and to have support for individual choice from social policies and community norms. Informed choice offers many benefits. People use family planning longer if they choose methods for themselves. Also, access to a range of methods makes it easier for people to choose a method they like and to switch methods when they want. People's ability to make informed choices invites a trusting partnership between clients and providers and encourages people to take more responsibility for their own health. Enabling clients to make informed choices is a key to good-quality family planning services. An Informed Choice Strategy The principle of informed choice refers to decisions that people can make for themselves—not to a process that family planning programs and providers carry out. Nevertheless, programs, providers, and policy-makers can do much to support people's ability to make informed family planning choices. Programs can do so best by adopting a strategy that covers five areas—government policies, communication programs, access to family planning, leadership and management, and client-provider communication. Supportive policies. To support people's ability to make informed family planning choices, national governments and family planning programs can set standards and guidelines for service delivery; eliminate unnecessary medical barriers and all demographic targets, incentives, and disincentives; and ensure that people can have access to the methods they prefer. National social and economic policies, too, can improve people's ability to make informed choices for themselves, as when they improve women's education and social status. Communication programs. Communication programs can reach and inform the public about their family planning choices. In the mass media and through community social networks, communication can convey that people have a right to information about their own health and that they can make good family planning decisions for themselves, based on their own needs and desires. Messages can emphasize contraceptive methods that are available and tell where and how to find information and services. Communication programs also can encourage people to visit family planning providers for answers to their questions and concerns. More access. The more family planning methods that are available, the more people can choose a suitable method and the better they can switch methods as their needs change. Offering a variety of methods through as many service delivery outlets as possible helps to ensure choices for everyone, including people living in rural areas, those with low incomes, those who cannot easily leave home, and those who do not want to visit clinics. Leadership and management. Strong leadership can establish the principle of informed choice as a program goal and a measure of success. Program managers can make informed choice the organizational norm by analyzing and improving performance, providing effective supervision, training staff members, and evaluating results. Managing for informed choice requires particular attention to decisions about permanent and long-term methods—sterilization, IUDs, and implants—because these decisions are not easily reversed once they have been made. Client-provider communication. People can make informed choices without ever seeing a family planning provider. When people visit providers, however, there is much that providers can do to ensure informed choice. Providers can ask new clients what method they prefer and usually can give them that method. They can ask continuing clients whether they would like to switch methods. They can avoid making decisions for clients or interfering with their ability to make choices. In effective counseling for informed choice, clients play an active role, asking questions, expressing concerns, and participating equally with providers. Ensuring Informed Choice Decisions about reproductive health and contraceptive use are among the most crucial that people of childbearing age make. With widespread endorsement of informed choice in family planning, people around the world can have better information, a wider range of choices, and more support for making appropriate decisions themselves. Ensuring informed choice in family planning should be the goal of donor agencies, governments, family planning programs, and providers everywhere. Why Informed Choice Matters Choices about childbearing and contraceptive use are among the most important health decisions that many people make (162). They are most likely to meet a person's needs when they reflect individual desires and values, are based on accurate, relevant information, and are medically appropriate—that is, when they are informed choices (22). “The process by which an individual arrives at a decision about health care” is an informed choice when it is “based upon access to, and full understanding of, all necessary information from the client's perspective,” according to one definition by EngenderHealth, formerly AVSC International. “The process should result in a free and informed decision by the individual about whether or not she or he desires to obtain health services and, if so, what method or procedure she or he will choose and consent to receive” (22). The concept of informed choice can be applied to a wide range of sexual and reproductive health decisions. This issue of Population Reports focuses on informed choice in family planning—including whether to seek to avoid pregnancy, whether to space and time one's childbearing, whether to use contraception, what family planning method to use, and whether and when to continue or switch methods. The term “informed choice” refers to a decision that a person can make for herself or himself—not to a process that a family planning provider carries out. Nonetheless, policy-makers, program managers, and service providers have important roles to play (see box, Encouraging Informed Choice—What Can Be Done?). Family planning programs can help people make informed choices best by adopting a strategy that covers five areas: policy, communication programs, access, leadership and management, and client-provider communication (see Chapter 2.4, Informed Choice Strategy). Understanding Informed Choice In the term “informed choice,” each of the two words refers to an essential aspect of family planning decision-making (182). Being informed is necessary to making a well-considered decision. But being informed is not sufficient; a person also needs choices—including access to a range of contraceptive methods, convenient sources of supply, good-quality services, and the ability to continue or discontinue using the method as desired (103). People can make informed choices only when prevailing social policies and community and gender norms support personal decision-making regarding family planning. Such support helps people have the confidence and opportunity to make their own family planning decisions, rather than have these decisions imposed on them, whether by medical personnel, family members, community pressures, or others. Of course, people have varying levels of access to information and to choices. Educational attainment, family background, social class, and providers' attitudes are among the factors that can either aid or hinder a person's ability to make informed family planning choices.

Encouraging Informed Choice— What Can Be Done? 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. 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. 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. JHU/CCP Danielle Baron, JHU/CCP Mrudula Amin, JHU/CCP In Egypt (left), Senegal (middle), and India (right), people obtain information about family planning from family, friends, and community workers as well as from service providers. Many people make their decisions long before they seek contraception itself. Benefits of Informed Choice Informed choice has many benefits. The ability to make informed family planning choices increases people's control over their own lives, encourages people to take more responsibility for their own health, and invites a trusting partnership between clients and providers (306). Continued contraceptive use. Having an informed choice encourages continued contraceptive use. People use a family planning method longer if they have chosen it for themselves (316, 318). A six-country study—in Guatemala, Hong Kong, Jordan, Kenya, Nepal, and Trinidad and Tobago—conducted between 1984 and 1987 among over 11,500 women found that continued use of a contraceptive method was strongly associated with obtaining the method that the client had in mind, as well as with a client's motivation to avoid pregnancy and the knowledge that her partner would agree with her choice of method (193). Similarly, a 1988 study in Indonesia found that 91% of women who obtained their preferred method were still using that method after one year compared with 28% of other women (317). A number of studies in the US have found that people who make their own health decisions are more likely to carry out those decisions (105, 110, 137, 168). Offering many method choices encourages use of contraception, making it easier for people to choose a method they like and to switch methods (170). For each additional contraceptive method that is widely available in a country, the percentage of married women using contraception increases by an average of 3.3 percentage points, according to analysis of Demographic and Health Surveys (DHS) data from 44 countries (45, 351). Many people switch contraceptive methods at least once during their reproductive years, and some use many different methods over a lifetime (165, 174, 281). When the family planning project in Matlab, Bangladesh, began to offer a full range of family planning methods, 80% of women were still using a family planning method after one year compared with 40% when only condoms and pills were offered (466). Good-quality care. Informed choice is a key aspect of good-quality family planning. In the quality-of-care framework developed by Judith Bruce in 1990, two of the six elements that characterize good quality—choice of methods and information given to clients—are central to making informed choices (59). For family planning programs, attention to providing good care attracts clients and increases client satisfaction by offering services, supplies, information, and emotional support that clients need to meet their reproductive goals (256, 445). (See Population Reports, Family Planning Programs: Improving Quality, Series J, No. 47, Nov. 1998.) Evolution of Informed Choice The concept of informed choice can be traced to the late 1700s, when several prominent physicians in the US advocated demystifying medicine by giving people more access to medical information and educating patients about their conditions. The rationale, however, was that informed patients would better comply with physicians' recommendations, not that patients would be able to make informed decisions for themselves (125). Since the advent of the family planning movement early in the 20th century, many advocates for good reproductive health have sought to expand people's access to medical information and widen their family planning choices (84). In the late 1960s the first US legislation providing government financial support for family planning programs in developing countries, through the United States Agency for International Development (USAID), strongly endorsed the voluntary practice of family planning in all such programs (433, 435). The term informed choice itself first appeared in the family planning literature in the early 1970s (210, 233, 457), applied mainly to increasing access to family planning. In 1982 the concept of informed choice came to the forefront of international family planning policy when USAID stated that its “support for fam-ily planning service programs is based on two fundamental principles: voluntarism and informed choice” (434). One of the first international symposiums for family planning leaders on voluntarism and choice took place in 1984, sponsored by the World Federation of Health Agencies for the Advancement of Voluntary Surgical Contraception. The focus was on the importance of voluntary choice in decisions about sterilization (24, 409). In 1987 the Task Force on Informed Choice convened with a focus on informed choice for all family planning methods. Sponsored by USAID, the task force had representation from 17 organizations, including the United Nations Population Fund (UNFPA), the International Planned Parenthood Federation (IPPF), the World Bank, and Cooperating Agencies of USAID (411). Later, at the 1994 International Conference on Population and Development in Cairo, 179 countries agreed that informed choice in family planning is based on human rights (426). Today, most family planning programs around the world subscribe to the principle of informed choice. Centro de Orientación Familiar (COF) This Bolivian poster says, "Family planning is the right of everyone." For decades, programs, governments, and donors have been expanding access for all who want it. Informed choice and informed consent. The concepts of informed choice and informed consent are related but quite different in their intent. Informed consent means that a client understands the medical procedure proposed and the other options and has agreed to receive the proposed care. Informed consent alone does not constitute informed choice, however. The purpose of informed choice is to ensure that all clients decide for themselves on health care that best meets their needs. In contrast to the evolution of informed choice, informed consent largely reflects legal opinions, beginning in 1767 in England, when a court ruled against a pair of physicians who used an experimental device on a patient without the patient's knowledge or consent (125). The term “informed consent” itself first appeared in US case law in 1957, and the medical community gradually became aware of the legal requirement to obtain the informed consent of patients to their medical treatment (231). Today, one purpose of obtaining informed consent is often to protect the health care provider from false accusations of wrongdoing, including lawsuits alleging malpractice. In the US the concept of informed consent as it relates to family planning evolved in the late 1960s in response to policies and practices involving sterilization without consent (23). Today, in family planning programs informed consent usually is required only for sterilization, because it is a permanent method. Informed consent often involves a written statement that the client signs to verify understanding of the method, medical procedure, and risks. Practical questions. Informed choice has become a goal in many family planning programs. Practical questions persist, however, about how best to make informed choice a reality for everyone. For example, how much does a person need to know to make an informed choice? How much can this knowledge vary from one person to the next? How much should a person know about other contraceptive methods before deciding to choose a particular method? (see How Much Information? How Much Guidance?) Questions remain for providers, too. How can providers best guide clients to make informed choices without interjecting their own preferences and values? Does the provider have responsibility for judging whether the client has made an informed choice? What is the best way for a provider respectfully to confirm that the client's understanding is accurate? These and other practical questions concern programs trying to make informed choice a reality for clients. Making Family Planning Decisions The principle of informed choice focuses on the individual. Yet most people's family planning decisions also reflect a range of outside influences. These include household influences and community norms, government laws and policies, information available, and access to family planning methods and services. People often are unaware of the factors that affect their ability to make informed choices, because these factors are indirect. Governments influence people's family planning decisions both indirectly, as when laws affect women's ability to make independent decisions, and directly, as when policies regulate access to contraceptive information, supplies, and services (67). The information and values communicated in the mass media and from person to person affect how much people know about family planning and how interested they are in it (81, 345). Access to contraception—the number of methods that are available and how easy they are to obtain—affects people's ability to use the methods they prefer (143) (see Figure 1). While counseling has long been considered a key to ensuring informed choice, what happens before people visit a service provider may be even more important. In general, people make their family planning decisions incrementally over the course of their reproductive lives, rather than as a single choice (438). A person's biggest family planning decisions—whether to control one's fertility and whether to use a family planning method—usually are made before the person ever seeks contraception or meets with a service provider. By the time people become family planning clients, they usually also have a particular contraceptive method in mind and already have some information—or misinformation—about it (244). For example, in each of 50 countries with DHS data, among currently married women who planned to start using family planning in the next 12 months, at least 80% said that they had a preferred method in mind. In 26 countries the percentage was over 90% (see Table 1).   Region, Country, and Year % of Women Intending To Use Family Planning Who Know What Method They Want Table 1 Women Know What Method They Want Percentage of Married Women Not Currently Using Contraception but Intending to in the Next 12 Months Who Know What Method They Want, 1990–1999 DHS questions include: "Do you intend to use a method within the next 12 months?" and "When you use a method, which method would you prefer to use?" Source: Demographic and Health Surveys SUB-SAHARAN AFRICA Benin 1996 86
Burkina Faso 1999	95
Cameroon 1998	84
Central African Rep. 1994	88
Chad 1997	90
Comoros 1996	96
Côte d'Ivoire 1994	93
Ghana 1998	87
Guinea 1999	99
Kenya 1998	88
Madagascar 1997	85
Malawi 1992	96
Mali 1996	86
Mozambique 1997	89
Namibia 1992	95
Niger 1998	91
Nigeria 1990	84
Rwanda 1992	98
Senegal 1997	80
Tanzania 1996	91
Togo 1998	84
Uganda 1995	82
Zambia 1996	89
Zimbabwe 1994	99
ASIA & PACIFIC
Bangladesh 1997	87
India 1999	93
Indonesia 1997	91
Nepal 1996	89
Pakistan 1991	82
Philippines 1998	96
Vietnam 1997	98
CENTRAL ASIA
Kazakhstan 1995	86
Kyrgyz Rep. 1997	98
Uzbekistan 1996	98
LATIN AMERICA & CARIBBEAN
Bolivia 1997	83
Brazil 1996	92
Colombia 1995	88
Dominican Rep. 1996	92
Guatemala 1999	91
Haiti 1994	96
Nicaragua 1997	95
Paraquay 1990	83
Peru 1996	82
NEAR EAST & NORTH AFRICA
Egypt 1995	89
Eritrea 1995	97
Jordan 1997	94
Morocco 1992	100
Sudan 1990	94
Turkey 1998	85
Yemen 1997	87

In the six-country study previously mentioned (see Continued contraceptive use in chapter 1.2), 75% to 100% of women had a specific method in mind when they arrived at the family planning clinic (193). Also, in Ecuador, Uganda, and Zimbabwe, over 94% of clients had a preference for a specific method before they received counseling from a provider (407). In Kenya at least 46% of new clients arrived at the clinic with a strong preference for a specific method (244). In a Nigerian clinic 55% of new clients asked for a specific method (7).

The more that policy-makers, program managers, and service providers know about how people make family planning decisions and the factors, both direct and indirect, that influence people's family planning decisions, the better they can help people make informed choices.

Danielle Baron, JHU/CCP

In Senegal women come together at a community meeting to discuss their health. Community values and norms shape people's attitudes. They determine whether it is socially acceptable to use contraception and whether people can make family planning decisions for themselves.

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).

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).

Choosing Dual Protection 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).

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).

Policies for Informed Choice

Public polices can support informed choice of family planning. The principle of informed choice is recognized internationally and is based on human rights (426). National governments have responsibility for ensuring that the principle becomes a reality.

Two fundamental human rights underlie informed choice: (1) the right to decide freely how many children to have and when to have them and (2) the right of access to family planning information and services. These rights have long had their basis in international consensus statements, including the Proclamation of Teheran, issued at the 1986 International Conference on Human Rights (425).

The 1994 International Conference on Population and Development (ICPD) Program of Action states that “the aim of family planning programs must be to enable couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so and to ensure informed choice and make available a full range of safe and effective methods” (426).

Governments that sign international documents of principle make a commitment to act on these principles (202). The extent of government attention to such commitments and the amount of money allocated to implementing them, however, vary considerably around the world. Informed choice advocates have urged that governments be held to their commitments, that people be encouraged to exercise their rights, and that providers respect these rights (204, 315, 320).

IPPF The IPPF Charter recognizes the principle of informed choice. Official policies can advocate choice in family planning.

Zambia Ministry of Health As in Zambia, countries can update their guidelines to enable more people to get their planning method of choice.

National Support for Informed Choice

National governments can help insure the right to informed choice by putting the principle into law. For example, as amended in 1974, Article 4 of Mexico's constitution states that every individual has the right to decide in a free, responsible, and informed manner the number and spacing of his or her children (376). Reflecting this principle, in the same year Mexico established the National Population Council (CONAPO), made up of eight Ministers of State, to ensure that people in every social group and in every region have access to family planning and other reproductive health services (428).

In several other countries, including Malaysia, Peru, and Zambia, laws explicitly protect informed choice (71, 131, 344). Similarly, a city law in Buenos Aires, Argentina, passed in 2000 recognizes “sexual and reproductive rights free of violence and coercion as basic human rights” and guarantees women's and men's access to contraceptive information, methods, and services (473). When governments incorporate informed choice standards into their laws, the courts can enforce them (87).

National laws and other policies for informed choice work best when they have the support of top government officials. During his career in public service, for example, former Philippine Secretary of Health Juan Flavier was an ardent supporter of people's right to make their own family planning decisions—for example, launching a national communication campaign to tell people about their family planning choices (18, 377). Under his leadership between 1992 and 1994, family planning funding quintupled, programs offered a wider variety of contraceptive methods, and the number of people using family planning increased substantially (347).

National governments play the major role in developing and enforcing standards for health services in both the public and private sectors, including guidelines for service delivery (67, 426). National family planning guidelines are most accurate when they are based on international consensus documents such as the medical eligibility criteria developed under the auspices of WHO (467). As of 1998, 54 countries were in the process of updating or disseminating new service delivery guidelines, in part to eliminate barriers that unnecessarily prevent or restrict access to services (280). Many of these new guidelines state that all people, including adolescents regardless of their marital status, shall have the right and access to family planning information and services (177, 396, 412, 432).

Government policies often determine which contraceptive methods are available in a country and how they should be made available. Such policies include approval and registration of contraceptive products; prescription requirements; inclusion on the essential drugs list; regulations on sales, distribution, or delivery of services; restrictions on private medical practice; and policies on advertising (93, 205, 224).

Government limitations on service delivery can make it difficult for people to obtain family planning,for example, if the pill is available only by prescription, or if condoms can be sold only through pharmacies (236). Tax and import policies that increase commodity costs—for example, import tariffs, quotas, and exchange controls—often limit choice and access by deterring private and nonprofit sectors from providing contraceptives (94, 132, 133). Policies supporting decentralization or local decision-making, however, can increase access to family planning by responding better to needs specific to the community (185).

Government restrictions on advertising and promotion of prescription drugs or of family planning methods or brands usually mean that people have less family planning information (5, 236). When governments deregulate contraceptive advertising and increase broadcast airtime, people can obtain more information that helps them make family planning decisions for themselves (72).

Policies that prohibit certain methods entirely restrict choices. Japan banned oral contraceptives for family planning until 1999, when advocates for women's rights won a repeal of the ban on the basis that women needed more contraceptive choices. Some legislators argued that permitting the pill would decrease condom use and thus increase STIs including HIV/AIDS. Now, providers in Japan who prescribe the pill are required to advise women that the pill does not protect against STIs and to counsel pill users to use condoms for dual protection if they are not monogamous (302, 430).

Some countries—China and India, in particular—in effect have limited contraceptive choice through policies that promote long-term and permanent contraception over temporary methods (78, 463). Although the government of India now advocates a wider contraceptive method mix, some family planning providers still are ill equipped to offer the pill and other temporary methods (153, 199).

Policies that establish demographic targets, incentives, and disincentives in family planning policies and programs are undesirable because they focus on achieving numerical goals instead of meeting people's health needs. Explicit policies that constrain people's family planning choices are less common now than in the past. They continue to arise occasionally, however, and remain a concern (324, 443).

Targets. Such statistics as the number of clients served, couple-years of protection, continuation rates, and fertility rates can be valuable for management, planning, and projecting program needs (350). If they serve as programmatic or performance targets or goals, however, they jeopardize the principle of informed choice and threaten the rights of clients (1, 70, 255, 446, 449, 450).

Programmatic targets originated in the 1960s and 1970s, when some countries started national family planning programs out of concern that rapid population growth threatened national well-being and that people immediately needed to start having fewer children. Today most countries have abandoned such policies in response to objections from advocates for good-quality care and women's rights, and from others (207, 331).

Governments increasingly recognize that concerns about rapid population growth can be met best not by establishing demographic targets but rather by investing in better quality family planning programs that help people meet their own reproductive goals (388). For example, in March 1998 Peru reformed its family planning policies to remove programmatic targets that in 1997 had set the goal of performing 130,000 sterilization procedures for the year (71). This target had put pressure on local health centers to perform sterilizations even among women who did not consent. China's national family planning program, which pursued a “one-child” policy until the mid-1990s, has begun to offer more client-oriented services, and government regulations now prohibit family planning workers from imposing contraception on clients. Nevertheless, the central government has yet to fully implement the new policies, and many local practices have changed little (67, 333, 385).

Incentives and disincentives. Offering clients incentives and creating disincentives to influence people's choice of family planning methods can interfere with informed choice (207, 364), as can paying self-employed agents for recruiting clients (81). Most countries have never offered incentives or disincentives, while others have discarded them. Some programs, however, still reward clients who accept a contraceptive method (36, 261, 385). Family planning programs have offered clients money, goods, clothes, increased food rations, preference in housing, and similar inducements (261, 456, 476).

By far the most extreme population policy was in India between 1975 and 1977, when the government called a state of emergency, suspending civil rights (398). The government initiated a mass sterilization program, offering incentives such as road paving jobs for men and in some areas coerced thousands to undergo sterilization (456). These policies created a public backlash and led to a national fear of family planning. They also contributed to electoral defeat for the party in power in 1977 (207, 398).

There is debate about what constitutes an actual incentive. Some have said that payments to clients are justified when they help overcome fear and inertia to try reversible contraceptive methods (81, 406). Others have argued that payments are acceptable when they reimburse clients for their out-of-pocket costs of obtaining contraception, including travel or meals, because such payments are considered too small to influence the client's family planning behavior (338, 404). In Bangladesh, where family planning programs provide clean garments, subsidized food at the hospital, and the equivalent of US$3 to people who choose sterilization (226), the payment is intended to cover costs and compensate for lost work time. Whether these payments influence people's family planning decisions is unknown (225).

Disincentives usually have been designed to take effect after a couple has a specified number of children. Disincentives may include loss of maternity leave, restrictions on access to public housing, limits on schooling choices, and increased taxes (142, 340, 385). Iran's national assembly approved a law that went into effect in 1994 banning public benefits—such as paid maternity leave and social welfare subsidies to low- income women—for the birth of any child after the third (8).

Since disincentives in effect reduce a family's income, the poor feel their impact most (456). Some disincentives even focus on the “excess” children, penalizing children for the behavior of their parents (207). For example, the Indian state of Maharastra withholds subsidized food grains for the third child in an otherwise eligible family (381).

In Europe, where in a number of countries fertility has fallen below the replacement level of about two children per woman, governments have tried to encourage people to have more children by offering various incentives and disincentives (142, 251, 264, 452). In Romania from 1966 to 1989 the government imposed a tax on childless couples and limited access to contraception as pronatalist measures (97). Over the long term, however, policies that promote childbearing have had little effect (96, 314, 472).

Government policies for social and economic development can improve people's ability to make informed family planning choices, particularly women's. Policies that improve women's status help them to make decisions for themselves, no matter what their age, class, race, or educational level (107).

Laws governing women's autonomy can foster informed choice by allowing women to make decisions for themselves, including decisions about family planning. In some countries, however, legal codes, based on strict interpretations of customary law, require that wives always obey their husbands, fathers, or sons (86).

Education and literacy policies and programs are crucial to foster reading, writing, and problem-solving skills. Particularly when girls receive more education, these policies and programs impart new attitudes and skills that enhance informed choices in many aspects of people's lives, including family planning. Women with more education typically have more autonomy and are better able to make decisions for themselves (27, 218, 297). Also, people who can read have more access to printed information about family planning and contraceptives (128).

Policies that encourage economic opportunities for women also encourage informed family planning choices. In 1995 research in Bangladesh found that participants in a microcredit program for women were more likely to communicate with their husbands and to have more autonomy and more decision-making authority than other women. This result held true even after researchers took into account differences between the characteristics of women who joined microcredit programs and those who did not (12).

Luthern World Relief In Ecuador young people study in a rural classroom. When policies promote education and literacy, particularly among girls, they help build reading, writing, and problem-solving skills needed to make informed choices, including those about family planning.

Donor Agencies

Most major family planning donors have official policies on informed choice that programs they fund must follow. Donor agencies with such policies include the United Nations Population Fund (UNFPA), the British Department for International Development, the United States Agency for International Development (USAID), the German Ministry of Cooperation and Development, and the European Commission (79, 95, 101, 161, 363, 433).

In October 1998 the US Congress passed an amendment, proposed by Congressman Todd Tiahrt, writing into national legislation many of the informed choice provisions that were already USAID policy. The legislation now requires that USAID formally include the policy in all agreements with organizations that assist family planning service delivery projects (433).

Donor agencies, like governments, need to ensure that their program priorities do not send mixed messages about informed choice (175). Some donors prescribe that programs simultaneously address such contradictory objectives as couple-years of contraceptive protection and informed choice (16, 260). The tension between different program objectives can mean that family planning programs must decide which objective takes precedence.

Family planning donors have long played an essential role in encouraging choice by ensuring that family planning programs have adequate supplies of contraceptive methods. Funding for donated contraceptive commodities is falling, however. In 1999 total donor support for commodities amounted to US$130.8 million, a decrease of US$12.4 million, or about 9%, from the previous year (431). Governments, donors, and programs that are committed to meeting the needs of the people will give high priority to informed choice principles and to providing the means for people to realize their choices (22).

Communication for Informed Choice

Communication plays a vital role in assuring informed choice of family planning. Effective communication empowers people to seek what is best for their own health and to exercise their right to good-quality health care (346). As noted, people make many of their biggest family planning decisions ,including whether to control their fertility and whether to use a family planning method,before ever seeking contraception (see Chapter 2). In order to make informed choices, therefore, most people need to know a lot about family planning long before they decide to visit a health care provider.

Around the world, millions of people get their family planning information from the mass media. Sometimes it is their main source of information. In Kenya, for example, of 1,518 people surveyed in 1992, 42% said their main source of information was radio or television (252). In 49 countries with DHS data, the percentage of married women who heard or saw family planning messages on radio, television, or both in the six months before the survey ranged from 12% in Côte d'Ivoire to 92% in Jordan. Among married men surveyed in 26 countries, the percentage ranged from 24% in Mozambique to 84% in Peru.

For people who decide to become family planning clients, communication programs supplement information that family planning counselors provide. Family planning clients want information but sometimes worry that providers do not tell them all of the facts (188). While counseling is valuable, a single counseling session with a family planning provider usually cannot cover all of the information that a person needs to make an informed choice. Nor should counselors and other front-line health care providers have to bear all responsibility for seeing that clients are well informed.

Ghana Ministry of Health

As this poster from Ghana shows, communication materials can encourage people to seek information from a service provider and discuss their concerns.

Using a variety of communication channels increases the number of people and the range of audiences who can receive family planning information. Increasingly, the mass media provide reproductive health messages in entertaining and memorable ways. Communication programs also build on mass media messages and extend them through community social networks and organizations.

Mass-media approaches. Many communication programs use multimedia approaches—radio, television, print, street theater, community fairs, and even the Internet—to inform people and to influence their health behavior in positive ways. Communication programs worldwide have combined radio, television, and other mass media, as well as community-based traditional media, in the Enter-Educate approach to health communication—using such popular entertainment as music and drama to convey family planning and other reproductive health messages.

Print materials provide information to help people make informed choices before, during, and after they see a health care provider. Family planning programs often distribute print materials to clients in waiting rooms or through social service organizations. Illustrations of healthy behavior can be particularly helpful to clients who have little education or cannot read (134).

Many communication campaigns have encouraged people to make decisions for themselves and have informed them of the range of available methods. Still, few have explicitly aimed to improve informed choice. Even fewer have sought to document changes in informed choice as a result of their efforts. Most communication campaigns measure such results as the increase in clinic attendance or family planning use. They do not measure whether more people are able to make their own decisions in an informed way. To evaluate how communication campaigns contribute to promoting informed choice, informed choice should be a stated goal and be measured. Also, communication programs can monitor indicators specific to informed choice (see Evaluating Informed Choice).

Community information networks. Communication programs can build on the way information flows from person to person in social networks and other community channels. For example, research in Nepal between 1997 and 1999 found that women with positive attitudes about family planning but little knowledge of it tended to seek out discussions with others they considered “local experts”—that is, long-term users of contraception in the community (55). Communication programs are a useful source of information for such opinion leaders since people who learn about family planning from the mass media often discuss it with others, who discuss it with still others in turn (56, 158, 263, 309, 471) (see Chapter 2.1).

Sara A. Holtz, Peace Corps

In Togo a health volunteer shows women a poster of contraceptive methods available at the local clinic. Because of such information, many people have a method in mind by the time they see a service provider.

Building coalitions of organizations can help opinion leaders and other influential people in the community know more about family planning and encourage them to help spread this information. In Uganda a project has brought together a wide range of experts representing public and private institutions in reproductive health, human rights, youth issues, journalism, law, and research to established the Coalition in Health on Informed Choice Enhancement (CHOICE) (120). The coalition works at three levels: at the community level with leaders to promote better understanding about health needs and rights; at the policy level with government ministries to focus on policies that affect access to contraceptive choices; and at the clinic and hospital levels to make administrators and health care providers more aware of informed choice.

Another program designed to help people in communities participate actively in their own family planning decisions is the Reproductive Health Awareness (RHA) approach. Developed by the Institute for Reproductive Health at Georgetown University, it emphasizes client empowerment. Through training and community education sessions, people learn to be advocates for themselves, to seek medical attention when needed, and to communicate with health care providers (62, 196, 279, 312, 460).

Family planning providers and others with experience in family planning, including clients, women's advocates, researchers, and teachers, also can reach people who want information about family planning by speaking at social group meetings and schools (103). Community groups, service organizations, nongovernmental organizations (NGOs), employers, schools, and religious groups all can be important venues for sharing family planning information (278).

To help people make informed choices, communication can stress people's right to information about personal health and their ability to make family planning decisions for themselves. Messages can point to the range of contraceptive methods available, describe the characteristics of specific methods, and tell where and how to find family planning information and services. Communication can help people get the most out of family planning counseling by discussing the need and responsibility to ask questions and obtain answers from family planning providers.

The right to information about health. Communication helps make people more aware of protecting their own reproductive health—that is, increasing health literacy (387). Health literacy refers to people's ability to obtain, interpret, and understand information needed to make appropriate and informed health decisions (341). Communication about health is more effective when it advises people of their choices and gives them something to think about than when it tells people what to do or what to think (341).

Communication programs that promote health literacy empower people to use health services effectively and sustain healthy behavior because such behavior is based on the desires of each individual. They encourage people to take active responsibility for their own health decisions, as in the Bolivian campaign “Las Manitos” (see Las Manitos, Promoting Informed Choice Through Communication).

In South Africa in 1995 a national campaign, “Health Rights Are Human Rights,” informed citizens about their health rights and responsibilities, including access to care, confidentiality, treatment, choice, and information. The campaign used comic strips and commercial and community radio to promote these concepts. A resource manual provided health workers, policy analysts and health planners the information they needed to integrate the respect for these rights into their everyday practice (145).

The ability to make decisions. Informed choice is a concept that is still unknown or unapplied in many places (368). Many health care providers expect to choose the appropriate treatment for their patients, and many family planning providers believe that choosing a client's contraceptive method is the provider's responsibility, not the client's right. Often family planning clients, too, do not expect to participate in medical decisions (178).

Communication programs can build people's ability and confidence in their own health care decision-making (59, 346). They can raise people's expectations of providers and encourage them to demand more from family planning services. Messages in the mass media can help create a positive image of service providers—those who care that clients' decisions are informed ones (325, 374). Such family planning communication campaign slogans as “It's your right” (Kenya, 1993), “Reproductive health is in your hands” (Bolivia, 1994), and “Ask, Consult” (Egypt, 1994) inspire people to seek information, to expect good services, and to make family planning decisions for themselves (246, 441) (see Promoting Informed Choice Through Communication).

Communication efforts can help speed the diffusion of new ideas through communities (345). They can tell people that they have the right to plan their families and the ability to do so as they choose (367). As more and more people are able to make informed family planning choices for themselves, and as more providers respond to heightened expectations, communication can help make informed choice a social norm.

Contraceptive choices. Communication can make people aware of the range of contraceptive choices, whether they are interested in starting family planning or in switching methods. Widespread communication about contraceptive choices also is helpful because each service delivery outlet usually provides information only on the few methods that it offers, whereas people need to be aware of a range of methods and sources in order to make informed choices. Communication about contraceptive choices also helps to publicize new and lesser-known methods. Where entire communities are using the same methods due to strong social networks, communication efforts can encourage women to consider a variety of contraceptive options, not just those that are familiar (163, 330).

Patricia Poppe, JHU/CCP

In Peru street theater actors perform "Ms. Rumors," a skit develped to correct misinformation about family planning. Providing information about specific methods can lessen people's fears about contraception.

The level of awareness of a range of contraceptive methods provides a rough measure of the availability of family planning information in the country. In countries where people have more exposure to family planning messages on radio and television, people are aware of more methods (91). People's knowledge of a range of contraceptives varies widely among countries according to their mass media exposure. In Colombia, the Dominican Republic, and Jordan, women of reproductive age can name an average of almost nine methods, either spontaneously or with prompting. At the other extreme, in Chad women can name only an average of 1.4 contraceptive methods, according to Population Reports analysis of DHS data (see Figure 2).

People must have accurate knowledge of emergency contraception (EC)—including when to use it and where it can be obtained—since women must know in advance or soon after the fact that they can prevent pregnancy after sexual intercourse (88, 124). A 1997–1998 media campaign in six US cities significantly increased the knowledge, by at least 16 percentage points, that pregnancy is preventable after sex, and it increased knowledge by at least 9 percentage points of the term emergency contraception. In two cities knowledge that women have only 72 hours in which to begin oral EC increased by 8 percentage points (418).

Characteristics of contraceptive methods. Communication programs can provide accurate information about the characteristics of specific contraceptive methods (411). Providing method-specific messages shifts some information- giving responsibility from providers to other information sources—thus saving providers time for what they can do best face-to-face—providing good-quality counseling that helps clients think through their choices in light of their individual circumstances and helping them determine how they will use their chosen method.

Many people hold inaccurate beliefs about the characteristics of family planning methods. These often reflect concerns of people in a community. They often begin with someone's personal experience with contraceptive side effects or other problems.

Communication programs have a responsibility to help replace false beliefs without criticizing or dismissing the community members who believe incorrect information (352). Communication programs can reach service providers, too, who sometimes hold misperceptions about particular methods, often based on outdated information (54).

Between 1992 and 1994 a Peruvian street theater performance, “Ms. Rumors,” portrayed a couple searching for contraception who encounter a woman spreading misinformation about family planning. Don Victor, the local pharmacist, dispels these myths and counters fears with simple explanations. Some 61,000 people saw the play. Correct knowledge about contraception increased significantly among women in the audience (439).

Where and how to find family planning. Communication can publicize family planning service delivery locations. Communication programs can tell people at any stage of the individual decision-making process where they can get information (440). They can direct people to nearby health care services and provide telephone numbers for detailed information about how to reach health care providers, as in the Egyptian campaign “Ask, Consult” (see Ask, Consult, Promoting Informed Choice Through Communication) (240).

Print materials, which pass easily from person to person, can tell people exactly where to go for services. In Sierra Leone, for example, 78% of women who received a booklet on the pill kept the booklet and used it to tell friends and relatives how and where to get more information (59).

Ask questions and get answers. Communication programs can encourage people to ask questions. Many current and potential family planning users have questions and want answers. For instance, in a 1996 Indonesian study over 40% of family planning users wanted more information on side effects, over 26% wanted to know how contraceptives work, over 17% wanted to know how their method was affecting their menstrual cycle, and over 18% wanted to know what to do if problems occurred (206).

Researchers in Nepal found that, when both clients and providers had listened to a distance education radio program about client-provider communication, the number of active client behaviors, such as asking questions in a counseling session, increased significantly, from an average of 2.9 to 3.3, and the average number of facilitative provider behaviors, such as encouraging questions, increased from 7.8 to 8.3 (54, 223). Such communication programs for communities improve both client and provider communication skills, which reinforce each other in the clinic.

Continuing clients, especially, need continued encouragement to seek information that addresses their concerns. In Indonesia a 1996 study found that implant users knew that their implants must be removed in five years, but they did not know why. The concept of a decreasing amount of hormone was unclear to them. Because they lacked accurate information, many thought that the five-year rule might be arbitrary, with little consequence to their health. As a result the belief emerged that the implant rods themselves prevented pregnancy and could be maintained after the five-year limit as long as the woman had no medical symptoms (194). For more effective contraceptive use, communication programs need to encourage clients to seek out accurate information from reliable sources.

Improving Access

Offering widespread access to as many contraceptive methods as possible is key to helping people make informed family planning choices. As more methods become available, and as access to these methods increases, more people can find the methods they want.

Many people are using a family planning method other than the one that they prefer. For example, among nine countries with comparable reproductive health survey data, the percentage of women who said that they would rather be using a different method ranged from 11% in Mauritius to 48% in Costa Rica (see Figure 3). Most often, the reasons were that the preferred method was too expensive, too difficult to obtain, or not available at all. Other reasons included medical ineligibility and family disapproval. Other studies report similar findings (19, 393, 407).

More Methods Mean More Choices

As more contraceptive methods become available, more people can find a method that suits them—initially, and later if they want to switch methods (170). Today, a larger variety of contraceptives exists than ever before. Nonetheless, to ensure more choice for more people, new contraceptive methods are needed (130, 159, 187, 287), and several are in development (48).

The range of contraceptive choices vary widely. Among developing regions, Latin America provides the widest range of methods, and Africa, the narrowest (357). Although virtually every country provides at least a few methods, in many countries people have little or no access to certain methods.

Among 88 developing countries studied in 1999, the average percentage of couples who had convenient access to condoms was 79%, to oral contraceptives 76%, to IUDs 61%, to female sterilization 43%, and to male sterilization 29%. This analysis gives equal weight to each country regardless of population size. The same study found that couples in 50 countries have little or no access to vasectomy; in 29, to female sterilization; in 14, to IUDs; in 5, to oral contraceptives; and in 2, to condoms (357). Reflecting differences in availability of specific contraceptives, countries have widely different contraceptive method mixes (151). At the national level, a country's method mix can sugggest whether people can make informed choices (41).

Rick Maiman, Courtesy of the David and Lucile Packard Foundation

In Mexico youth counselors travel by bzicycle-carts through urban areas, providing contraceptives and information. Offering more sources of family planning can provide people with more choices.

The option to switch methods is central to continued use of family planning (90). Having a range of methods helps people switch methods when their needs change, rather than use one that has become inappropriate or unsatisfactory or else to discontinue use of contraception altogether. Offering a range of methods also helps ensure that at least some methods will always be available, even where shortages occur because the supply chain is erratic (60).

To expand contraceptive choices, family planning programs can offer fertility awareness-based methods along with supply methods (189). Service providers should be able to explain fertility awareness methods to their clients or else know where to refer clients for training in these methods. Studies are underway in five countries to examine access to fertility awareness-based methods (160, 273).

How many methods? Few programs have the resources to offer the entire range of family planning methods. How wide a range of methods must a program offer to ensure choice? WHO guidelines on contraceptive method mix do not mention specific methods that programs should offer. They state that “programs should provide a variety of types of methods to meet the different needs of different individuals and couples” (465). Other experts advise programs to offer:

• Contraception options both for men and for women,
• Temporary methods and permanent methods,
• Hormonal methods and nonhormonal methods,
• Supply methods and fertility awareness-based methods,
• Provider-controlled methods and user-controlled methods,
• Contraceptive options for breastfeeding women, including the Lactational Amenorrhea Method (LAM), and
• Emergency contraception (178).

Because most family planning programs in developing countries depend on donated commodities, they often can offer only the methods that donors provide. Reductions in donor contributions typically reduce people's access to family planning. Increased donor support is crucial to ensuring informed choice (see Chapter 3.6). In addition, changes in donors and the methods that donors supply, as well as supply cycles and poor coordination, often cause temporary outages in contraceptive supplies (429).

Broadening the types of service delivery can provide more choices, especially for people whom conventional programs have difficulty serving (327). These include people with low incomes, those in rural areas, women who cannot leave their homes, and others who want their contraceptive use to remain private (335, 395). In addition, with more service delivery outlets, people who want a particular contraceptive—for example, a specific brand of condom or pill formulation—can more easily find it.

Many people base their choice of family planning on how accessible a method is—particularly if visiting a clinic requires long travel (160). A nearby source can even make the difference between using contraception and not using it at all. In Morocco, for example, a survey of women who in 1992 had not intended to use contraception found that by 1995 those who lived close to a hospital, clinic, doctor, or pharmacy were more likely to be using family planning than those who lived farther away. While such other factors as social and economic differences or changes in reproductive intentions could explain the difference, the researchers concluded that proximity to a source of supply was the most likely reason (276).

Programs can offer methods through community-based distribution, social marketing, and private providers, as well as through family planning clinics and hospitals. In CBD programs fieldworkers visit each household in the community or use community organizations and institutions to offer contraceptives (16, 323).

Although CBD can be expensive to sustain (217), it expands family planning choices by bringing contraceptive methods to people rather than requiring people to visit clinics or pharmacies (197). CBD can be especially helpful if CBD agents are trained to give contraceptive injections safely, thereby increasing the method choices they can offer (337). CBD agents, however, cannot be effective counselors if they prefer to offer only methods that they can provide immediately and so stress supply methods over methods involving referral (244).

Population Services International A pharmacist in Cambodia demonstrates how to use a condom correctly. When pharmacists and other private providers are trained to offer detailed information on correct use of family planning methods, they can help their customers use their chosen method more effectively.

Contraceptive social marketing—the promotion and sale of family planning methods at subsidized prices—can improve access by making contraceptives better known, more affordable, and widely available through shops, pharmacies, and other retail outlets. Social marketing programs typically offer condoms, pills, and spermicides and have proved particularly successful at marketing condoms for STI prevention (108, 135, 375).

For the most part, social marketing programs are designed to promote specific contraceptives, not to ensure information about and access to a range of methods. For this reason some have argued that social marketing programs—no matter how well-intentioned—inevitably bias people's family planning choices (335). Increasingly, social marketing programs are training pharmacists, shopkeepers, community health workers, and others who sell social marketing brands to provide clients with more information about family planning choices (11, 126). Social marketing programs can encourage retailers to discuss the range of methods with customers and to offer information about safety and instructions for proper contraceptive use (17, 148, 334).

Pharmacies, private-practice physicians, and other private-sector providers are a growing source of family planning supplies and services (238, 270). In developing countries the commercial sector serves 20% of women who use modern contraceptive methods (390). In some countries people say that private family planning services offer better quality than public services, and people are increasingly able and willing to pay the full price of services (47, 390, 417).

Managing for Informed Choice

For family planning programs, improving the management of service delivery can improve clients' ability to make informed choices. Managing for informed choice requires commitment by leadership and an environment designed to give clients what they want. Ensuring that clients are able to make informed choices requires attention to such key managerial areas as analyzing and improving performance, providing effective supervision, training staff members, and evaluating results.

Management should take special care that clients who choose permanent or long-term methods—sterilization, IUDs, and implants—are making informed decisions. Also, managing for informed choice is particularly important in low-resource settings, where staff members may be few, contraceptives in short supply, and informational material scarce.

Strong leadership can establish a program environment that facilitates informed choice (386). If top managers set an example of ensuring informed choice, other staff will follow. Mentioning informed choice in the program's mission statement and in official policy guidelines can help staff members and clients become aware that the program is committed to the principle of informed choice and to clients' rights (209, 220).

For example, the International Planned Parenthood Federation (IPPF) policy on informed choice states that all IPPF-affiliated Family Planning Associations (FPAs) shall facilitate access to a broad range of sexual and reproductive health services, including counseling, for all individuals who request them. Also, FPAs are to ensure that services are provided in a noncoercive manner, that the provision of services is not linked to financial incentives, and that no service is conditioned on the acceptance of another service. All FPAs must agree to this policy as a responsibility of membership in IPPF (192).

In programs where the concept of informed choice is new, leadership can make sure that all staff members at all levels of the organization understand it (106). Program leaders can ensure that no program targets, incentives, or disincentives for contraceptive use remain (see Chapter 3.4). Even though targets, incentives, and disincentives are rarely official national policy, and donors generally do not support family planning programs that maintain targets, a target-oriented work culture sometimes remains (253, 398). Programs can establish clients' ability to make informed choices as a major indicator of program success, alongside or even instead of such conventional indicators as growth in the number of new clients (25, 212) (see Chapter 6.3).

Program leadership can support the principle that all clients should receive the contraceptive method they want if it is medically appropriate, in keeping with up-to-date national medical guidelines. Leaders can help remove the barriers that prevent certain groups, such as young people, from using some family planning services or methods (see Chapter 7.1).

When guidelines promoting informed choice are clear and understandable, and they are widely followed, they can increase people's contraceptive options. For example, after Tanzania developed new family planning service delivery guidelines in 1994 and carried out a year-long dissemination process that included training, service providers began to offer injectables to all women. Previously, many providers had seen injectables as a dangerous drug that should be prescribed only by doctors and reserved for women with many children (451).

In Kenya, after a similar process of guidelines dissemination in 2000, the percentage of providers recommending dual protection—using condoms alone or together with another method to protect against STIs as well as against pregnancy—increased from 9% to 23%. The percentage of new clients who were denied family planning services because they were not menstruating declined from 47% to 29% (237).

Management approaches that identify the source of problems with quality of care and develop appropriate solutions can improve clients' ability to make informed choices. One such approach is Performance Improvement (PI)—a process for identifying the most important root cause of gaps between desired performance and actual performance (274). Another is the systems approach, in which family planning managers examine the role of each part of service delivery and how it influences clients' ability to make informed choices (256, 278).

In addition, training providers in interpersonal communication skills is important to informed choice because these trained providers are better able to involve clients in health decision-making (358). In Egypt women who received counseling from providers trained in interpersonal communication knew more about how to use their methods and expressed more satisfaction with services than those seen by other providers (2).

Also, in Ghana a study found that specially trained providers offered a wider choice of contraceptive methods, gave clients more information about side effects, and were more likely to leave the final choice to the client than providers who were not similarly trained (195). In Indonesia providers trained to foster rapport and encourage client participation doubled their facilitative communication in counseling, and clients asked twice as many questions (249).

Continuing support and reinforcement. Trained providers need continuing support and reinforcement from managers and supervisors to keep their skills fresh (222, 249, 250). Recognizing providers who help ensure informed choice—for example, by giving promotions, new titles, and more authority—complements training (220, 386). In addition, programs can maintain provider performance through on-site training, distance education, and self-assessment (58, 343, 412, 462). Management also can make communication job aids such as wall charts, cue cards, flip charts, and checklists accessible for providers to improve their performance and help clients make informed choices (234).

In an Indonesian study self-assessment and peer review helped to maintain providers' performance. Four months after the training, the percentage of providers' remarks that fostered rapport and client participation declined from 29% to 27% among those who did not have any reinforcement. By comparison, among providers who assessed one of their own counseling sessions each week, the percentage of such utterances increased from 28% to 33%. In the group that also participated in weekly peer review meetings to discuss their own performance, such utterances increased from 28% to 37% (249).

This wall chart is available in English, French, and Spanish. Health care providers can request copies on-line at www.jhuccp.org/wallchart/

Monitoring and Evaluation

How well programs help people to make informed choices provides a key measure of program success (286). Managers can gauge a program's ability to ensure informed choice by monitoring a variety of indicators (see Evaluating Informed Choice).

Among the techniques that can apply to evaluating informed choice are using “mystery clients” or other observers in clinics, conducting exit interviews with providers and clients, and analyzing transcripts or videotapes of counseling sessions (256). Evaluation also can examine the number of methods available, the policies governing eligibility for receiving methods, fee structures, use of communication aids such as wall charts, and such service statistics as contraceptive method mix and referrals (286, 319, 407).

Using the HARI Index, developed by the Population Council, also can help programs determine how well they help clients choose a method appropriate to their needs and situation, use it effectively, manage side effects, and switch to another method when desired. HARI, which stands for “Helping Individuals Achieve their Reproductive Intentions,” measures how well a person is able to achieve fertility goals without suffering reproductive health morbidities in the process (211, 214, 239).

Another new evaluation approach for use in service delivery provides a checklist for informed choice and informed choice training modules that were developed by EngenderHealth (259). Also, the MEASURE Evaluation project has developed a tool called the Quick Investigation of Quality, which includes some components for monitoring and evaluation of informed choice (407).

Family planning programs have a particular responsibility to ensure that all clients are making informed decisions when they choose sterilization, which is permanent, or IUDs and implants, which women cannot discontinue using without a provider's assistance. Counseling for informed choice is the role of individual providers, but program management can establish systems that help ensure that these clients are making informed choices for themselves.

Sterilization. Women and men under age 30 and with few children should be carefully counseled when they consider sterilization. People in these groups are most likely to regret their decision (76, 115, 180, 208, 415). Some medical guidelines state that sterilization is rarely appropriate for adolescents and should be considered only in exceptional, medically indicated circumstances (51, 123). Nevertheless, having received information in counseling, a young client has the right to know that there is no medical reason to deny sterilization or any other method based on age alone (136).

Once a client has received sufficient counseling and has made an informed choice of sterilization, it is not necessary to require a waiting period before the procedure. If clients are currently using another form of contraception, however, they should be offered the choice to take time to think about their decision (61, 414, 464, 468). In particular, women may need time to think if they decide they want sterilization at delivery or immediately afterwards (49, 50, 235) (see Helping Women in Special Situations). Clients should understand that they can change their minds at any time before the procedure.

Many programs require that each client sign an informed consent form to document the sterilization decision and to indicate that the client understands the permanence of the procedure (61). Regular audits of informed consent forms help ensure that all clients who received permanent methods consented to them. Satisfying informed consent requirements is not a guarantee that a client is making an inormed choice, however (see Informed choice and informed consent of Chapter 1.3).

In order to make an informed choice about sterilization, a client must understand the following five points before the procedure:

• Temporary contraceptive methods are available;
• Sterilization is a surgical procedure;
• Certain risks are associated with the procedure, as well as benefits, and both should be understood;
• If successful, the procedure is permanent and will prevent the client from ever having any more children; and
• The client can decide against having the procedure without losing the right to medical, health, or other services or benefits (61).

IUDs and implants. When a woman is using an IUD or implants, programs should be prepared to offer advice and care over many years so that she can switch methods or discontinue use entirely whenever she chooses. Managers can establish a system that makes implant and IUD removal services continuously available. They can develop strategies for reminding clients when implants and IUDs should be removed and, if the client wishes, replaced (419). Managers can check client records to make sure they contain the dates that IUDs and implants were provided (194).

Providers should accommodate any client who wants to stop using a method—whatever the client's reasons or ability to pay. Managers can ensure that staff members are trained in IUD and implant removal. Some implant users have reported difficulties getting health care providers to remove implants (372, 477). Some providers tell clients that, because implants are costly, they will not remove them for minor side effects; some providers have refused women who requested implant removal because of amenorrhea (282, 477).

In addition, women sometimes face obstacles when they want their IUDs and implants removed because removal requires time and aseptic conditions. Clinic staff are not always able to remove implants at the time a woman comes in, and some providers do not feel confident of their ability to remove implants (397, 477). Some clients do not want to continue using IUDs and implants but do not know that they can be removed before five years (477), while others think that removal would cost more than they can afford (228).

Any client who reports problems with her IUD or implants should be explicitly offered removal as an option and asked outright if that is what she wants. Providers should heed her wishes (183).

Helping Women in Special Situations 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. 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).

Liz Gilbert, Courtesy of the David and Lucile Packard Foundation In the Philippines a health worker uses pictures to explain to a client how her contraceptive method works. Managers can ensure that all staff have the materials they need to help clients make informed choices for themselves.

Choice in Low-Resource Settings

Managing for informed choice does not need to be costly if it focuses on anticipating problems. In fact, ensuring that clients can make informed family planning choices can conserve resources. For example, studies have shown that informing clients seeking implants about their common bleeding side effects leads some women to choose another method. These clients avoid a method that they would later regret, while the program saves the cost of the implants and the time of inserting and subsequently removing them (80, 140, 310).

To save time, providers can first identify a client's needs and then focus counseling on just those methods that the client wants to know about (103). Longer counseling sessions do not always lead to more information exchange. For example, a 1999 study in Peru found that, although providers covered more information during counseling sessions that lasted at least 9 minutes compared with shorter sessions, the amount of information exchanged improved only slightly more during counseling sessions that lasted longer, from 15 to 45 minutes (268).

In every program, but especially in low-resource settings, effective logistics management can save money, ensure that contraceptive supplies are continuously available, and help deliver services efficiently. Managing the commodity supply chain effectively also helps avoid wasting contraceptives through spoilage (127). When supplies are scarce, programs can find more cost-effective ways to offer them—for example, charging small user fees. Such charges also help ensure informed choice, since most people will agree to pay something for a method they have chosen themselves (103, 417).

Better Client-Provider Communication

Good communication between clients and family planning providers during counseling is key to informed choice. When counseling is a partnership, in which clients and providers communicate openly, share information, express emotion, and ask and answer questions freely, clients are more satisfied, understand and recall information better, use contraception more effectively, and live healthier lives (104, 109, 173).

The process of making informed family planning choices begins long before people visit a provider, of course, and many people make informed choices without face-to-face communication with a provider. When clients do seek services, however, there is substantial evidence on what clients and providers can do together to ensure that family planning decisions are based on the principle of informed choice.

Counseling for informed choice, like good counseling in general, should be thought of as a partnership of two experts—the provider as the medical expert and the client as the expert on her or his own situation and needs (391, 432). Clients can play an active role in the counseling session (248), while providers can understand and address clients' concerns, desires, and needs—engaging in a genuine dialog (299, 436).

JHU/CCP Health workers in Nepal participate in an interactive radio education training program about family planning counseling. Training providers, along with offering continued support, increases their technical knowledge about family planning and improves client-provider communication.

Improving Counseling

Family planning clients and providers both have responsibilities to ensure that the counseling process reflects the principle of informed choice and leads to family planning decisions that clients make for themselves. A number of obstacles often stand in the way of good client-provider communication. These include unnecessary medical barriers and other restrictions that providers place on services, providers' own preferences about contraception and biases toward or against certain methods, both providers' and clients' discomfort with discussing sexuality, the differences in status and knowledge between providers and clients, and gender bias. Finding ways to surmount these obstacles helps foster informed choice.

Avoiding unnecessary medical barriers. Sometimes programs and providers inappropriately prevent clients from receiving the contraceptive method of their choice by adhering to scientifically unjustifiable policies or practices, based at least in part on a medical rationale (39, 382). Outdated contraindications sometimes remain in a program's official guidelines or providers' informal screening routine (39).

These unnecessary medical barriers can inhibit informed choice even where official policies try to ensure that medically eligible clients get the methods they want (383, 467). In a study in five African countries, for example, providers imposed twice as many eligibility criteria as the current national family planning guidelines required (288).

Also, in Kenya a study in 1999 estimated that 78% of nonmenstruating women were sent away without services to wait for their next menses to confirm they were not pregnant—an unnecessary restriction for most hormonal methods (399). Many clients who are turned away never get their contraceptive method of choice or any other method, as they are unable to return to the clinic (396).

Avoiding provider bias. The principle of informed choice means that providers avoid bias and, instead, respect client's preferences over their own—even if a client chooses a less effective method, uses a method only sporadically, switches frequently from one method to another, or refuses any or all services (139). Nevertheless, many providers think that they should make family planning decisions for their clients because they know what is best (102, 119, 244).

Providers sometimes erect barriers based on people's age, marital status, or other inappropriate criteria (178, 289). In particular, many providers deny family planning services to unmarried young people (195, 247). In a 1994 survey in Ghana, for example, 26% of providers said that marriage was a prerequisite to obtain family planning services. Some 76% of providers enforced minimum age requirements for contraception because they thought that access to contraception leads young adults to behave promiscuously (423).

Providers