• Helping women learn to make informed choices in new areas of their lives,
• Supporting women's choices,
• Encouraging women to recognize their strengths and to build on them,
• Improving women's skills at communicating with their husbands and with people outside their families, and
• Creating new images and models of competent women and caring men.

Self-awareness can be the first step. Whether services meet women's needs can depend on providers' most basic assumptions about women and men (see Table 4). For example, if providers assume that women are solely responsible for contraceptive use, they may design services that make it difficult for men to obtain information and services. If, instead, providers assume that both men and women need services, they are more likely to design services that both men and women can use easily.

Making informed choices. Women make many decisions throughout their lives, but they may need to gain confidence in making new kinds of decisions, such as decisions to control their fertility or to seek new social roles. In a Mexican study young women with unplanned pregnancies seemed to be women with little awareness that they could make decisions for themselves. They were less likely than nonpregnant young women to know about contraceptives, to have discussed sex with their girlfriends, and to have aspirations and plans for the future (249). Women surveyed in parts of such countries as Bangladesh, Ghana, Jordan, Mali, Nigeria, Pakistan, and Tanzania say that they do not participate in decisions about having children. Many say that they obey their husbands' wishes or the will of God (88, 184, 205, 231, 242, 317, 384) (see side-bar, Who Makes Reproductive Decisions?).

Reproductive health programs can help women make wider choices. By discussing reproductive needs and goals with clients, providers can give women practice in assessing a situation and making thoughtful decisions. Since making fertility decisions may be unfamiliar to some clients, the process requires skill and patience on the part of the provider. Ideally, the provider imparts information, listens attentively, encourages discussion, helps clients recognize their own needs, and answers clients' questions. The clients themselves make the decisions about whether and when to have children and how to carry out their plans (186).

Supporting women's choices. Respecting clients' wishes builds women's confidence in their own decision-making and their right to make decisions. For example, many women already know what contraceptive methods they want before they come to a family planning provider (68, 82). Honoring a woman's preference is important to her satisfaction with family planning (32). In Indonesia, for example, 91% of women who were given the method that they chose were still using that contraceptive method after one year compared with only 28% of women who were given a method that was not their first choice (244). A 6-country IPPF study also found that women were more likely to continue contraceptive use when they received the method that they wanted (142).

Women's choices reflect their own needs. Providers cannot assume what women need or want. For example, in Peru some women in focus groups said that they preferred the rhythm method because it gave them the right to make choices about when to have sex. Also, its use implied the intelligence to take charge of one's life. Women chose this method because it requires cooperation between sexual partners, and that cooperation enhanced the relationship (247).

Therefore, to create the best services, managers can ask clients what they want and design programs and train staff accordingly. Even better, they can directly involve female clients and community members and groups in planning and monitoring services (see Chapter 7.3 Involving Clients in Program Design). Such a client-oriented approach is rare. Indeed, providers' biases often block access to contraception and to a choice of methods (299). Often because of misinformation about methods, providers may favor one method over all others or shun certain methods. Because of negative assumptions about clients, particularly about women, providers may deny clients a choice of methods or discourage use of methods that require clients to act—for example, using barrier methods at each act of coitus or taking an oral contraceptive tablet daily.

Recognizing women's strengths. Successful counseling helps women identify their strengths and build upon them in planning their lives. In India group leaders from the Institute of Health Management ask groups of women who is the most important person in their homes. At first, the women never mention themselves. Then the group leaders recite a list of household chores and ask the women who does each chore in their homes. The women repeatedly answer that they do the chores. When the leaders ask again who is the most important person in their house, the women laughingly answer that they are most important (386). Good counseling can help women recognize that they already plan their time, save money or grain, and care for their families and homes. Building on these skills, women may learn to plan other aspects of their lives, including their reproductive lives, in which they may have depended previously on others. Recognizing their own managerial role in the home, women can have more confidence applying these skills elsewhere. A manual prepared by the United Nations Educational, Scientific, and Cultural Organization (UNESCO) suggests an exercise to help women build their self-esteem: Women list their skills, such as planning their time and organizing their families. Then they say how those skills would help them in a business situation (336).

Improving communication skills. Family planning programs can help women speak up on matters that concern them. In particular, programs can encourage and enable women, and men, to talk about contraceptive use and reproductive health. Women's discussion groups have been the approach most widely used to help women bring up and discuss these issues.

To help women learn to talk about family planning, a program in rural Bangladesh designed with assistance from JHU/PCS organizes volunteer discussion groups. The program was set up to reach more people than family planning field workers could reach in home visits and because women were isolated and unaccustomed to discussing family planning with each other or with their husbands. The discussion groups, called Jiggasha ("to enquire" in Bangla), are formed for men and women separately. Leaders and meeting places are chosen to take advantage of the existing networks of communication in the community (see side-bar, Family Planning Field Worker Helps Create New Rules for Women).

The Jiggasha meetings have encouraged women to discuss and use family planning. About 65% of participants report that, after attending several meetings, they have discussed family planning with their husbands or with other women in the group, and about 50% report talking to people outside the group or to a family planning field worker. Some 30% of the women began to use a modern contraceptive method, and 20% visited a health clinic (169).

In Bolivia in the early 1990s client-provider materials produced to improve the quality of reproductive health services and counseling contributed to communication between spouses. Before-and-after surveys found that significantly more clients had talked with their spouses about family planning after seeing and receiving the materials--95% compared with 84% before they had seen the materials in clinics. By comparison, the increase among those who had not seen the materials—from 83% to 88%—was not statistically significant (343). Later a video drama entitled Hablemos en Pareja (Let's Talk Together) was produced and shown in clinic waiting areas to help clients overcome barriers to communication between spouses.

Couples may find talking about family planning and reproductive health easier if they have discussed the subject first with someone of their own sex. Programs such as Jiggasha can help. For example, women in a rural area of northern India could not talk to their husbands about sexually transmitted diseases, even though they feared that their husbands might infect them. Health advisors organized the women into groups that discussed the problem and decided how to approach their husbands. After practicing the conversation in groups, the women were better able to talk with their husbands (332).

Family planning providers can help couples communicate better if they are aware of social conventions. For example, in Mexico a survey revealed that couples thought it immodest for the wife to start a discussion of family planning. These couples said that husbands should start such discussions and decide whether the couple uses a family planning method. In response, family planning providers designed counseling services for men and women advocating that women start discussion and that the couple make a decision together (256).

Strengthening communication skills is important to women and men who want their partners' support and cooperation in planning their families and protecting their reproductive health. For some, discussion may be a necessary step to taking an action they desire. For example, according to DHS data from six African countries, women who approved of family planning were more likely to use a modern contraceptive method if they had discussed family planning with their husbands in the year before the interview than were women who approved of family planning but had not discussed it (see Table 6). Studies in Java and South Korea have found that the more often couples discuss family planning, the more likely they are to use a contraceptive method (168, 359). Discussion between partners may make continued contraceptive use easier, too. In the IPPF 6-country study, women who thought that their partners agreed with their use of a family planning method were significantly more likely to continue using that method than women who did not know that their partners approved (142). Although studies link spousal communication with contraceptive use, the nature of the link is not obvious. It is not always clear whether more communication leads to more contraceptive use or, instead, couples talk more about contraception because they already use or plan to use a method. Also, some couples may not have an immediate reason to discuss family planning—for example, the woman is pregnant, the couple wants a child, or they have no access to contraceptives.

New images of women and men. It will be easier for women to take new opportunities when society respects them as strong and competent. Men will find it easier to help women when they see positive images of men who support those qualities in women. Family planning communication can provide these images by portraying competent women and caring men in radio drama, videos, films, advertisements, and users' testimonials.