When clients have adequate information about contraceptive methods, have several types of methods from which to choose, and make a decision without pressure or coercion, they are more likely to be satisfied and to continue to practice family planning.
However, achieving this level of informed and voluntary method choice can be difficult. Clients, especially women, are not always accustomed to making decisions, deferring instead to spouses and in-laws or following religious, government or provider dictates. Men, who have limited methods from which to choose, may be excluded from family planning programs. And health providers, although trained in the technical skills necessary to provide contraception, may not know how much or what type of information to provide.
Informed choices about reproductive health are more likely when services focus on client needs rather than client numbers. Through counseling, health workers can help clients make choices by offering information about a range of contraceptive methods, then providing details on the method the client requests, including what to do if problems arise. Providers should work to establish a dialogue with clients, so that clients will feel comfortable asking questions or returning for services when their needs change. First-time users of contraception need facts and advice, but so do continuing users who may desire to switch methods.
"Before offering information to the client, the provider should ask what the client wants to discuss and what contraceptives the client had in mind," says Dr. Carlos Huezo, medical director of International Planned Parenthood Federation (IPPF) in London. "Then the provider should tailor the advice to the client's needs. Service providers should react to each client's agenda, not try to impose their own agenda. The first step in informed choice is education and information. Then clients should have access to counseling, then access to methods."
Incomplete information
Informed choice is a continuing process in which women and men make decisions about contraceptive methods and try new methods or abandon methods, depending on their personal preferences. The decision-making process often begins long before clients meet health workers. Women and men gather information from their relatives, neighbors, co-workers and friends. They may learn about family planning from radio or television programs, billboards, newspaper articles or other media.
Counseling from health providers is a key element in helping clients make informed choices about family planning, says Jill Tabbutt-Henry, manager of AVSC International's (AVSC) Advances in Informed Choice program, which educates and trains providers. "There needs to be a partnership. The provider has the background to make medical decisions, but needs to work with the client to figure out which methods work best with the client's lifestyle."
Numerous studies have shown that, while well intentioned, providers often give incomplete information during counseling sessions. A study in Peru by the New York-based Population Council surveyed 112 women who used the three-month injectable, depot-medroxyprogesterone acetate (DMPA), and 38 women who had discontinued the method, to learn why discontinuation rates were high.1 Researchers found that women did not receive sufficient information about how the method works. Also, many women were reluctant to ask questions if they did not understand what providers told them. "I would like to ask questions," said one client, "but the nurses are always hurried, and what is more, there are many people, and it makes me feel ashamed to be asking questions and saying my business out loud."
In addition, amenorrhea, one of the side effects of DMPA, was disconcerting to women. In spite of assurances from providers that amenorrhea was not harmful, women viewed menstruation as beneficial to their health. Some women even skipped injections so their periods would start and they would know they were not pregnant. Many feared amenorrhea was a sign of permanent infertility. As a result of the study, the Peruvian Ministry of Health added training that emphasizes the need to counsel clients about side effects.
In Nigeria, a nationwide study found that in 395 client-provider interactions, nearly all clients said staff were friendly and easy to understand. However, clients did not always receive the information necessary to help them use their method correctly.
Twenty-three percent of new users said they would have preferred another method, fewer than one-third were told what to do if side effects occurred, and 43 percent were not told where to obtain additional contraceptive supplies. Fewer than one-third were asked if they were breastfeeding, but exit interviews revealed that 27 percent of women using combined oral contraceptives (COCs) were breastfeeding. Because they contain estrogen, which can reduce the quantity of breastmilk, COCs are not recommended for women who are breastfeeding.2
In Kenya, researchers monitored 176 counseling sessions with clients. Eighty-two percent of new clients said they had some knowledge of family planning before they came to the clinic, and nearly half (46 percent) had a strong preference for a specific method. Providers respected informed choice and believed that the client should ultimately decide which method to use. Yet, providers did not offer complete information to help clients make decisions. For example, in only half the sessions with new users did providers explain when to begin taking oral contraceptives, and in less than one-third of the sessions did they tell clients what to do if they missed a pill.
In 80 percent of sessions with pill users and 65 percent of sessions with injectable users, providers explained when to return for re-supply, checkups or problems. However, only 20 percent of sessions included information about specific warning signs that could indicate a need to return to the health provider. In two-thirds of sessions, providers collected information on clients' medical history and discussed contra-indications to method use. But providers rarely discussed risks of sexually transmitted diseases (STDs) or reproductive goals.3
An FHI study in Colombia found that new acceptors of COCs did not fully understand instructions for taking pills.4 Of the 572 users, fewer than half knew what to do if they missed taking an active COC -- to take the missed pill as soon as possible, then the next pill at the regular time even if that means taking two pills in one day. Only 15 percent knew that most side effects last less than three months. And the study also found that providers lacked correct information on pill taking. Interviews with 195 rural health promoters found that approximately half knew that side effects lasted less than three months or that women should use a backup contraceptive method if they miss three or more pills.
An FHI study of more than 1,200 pill users in Egypt showed that many women used oral contraceptives incorrectly. Researchers attributed incorrect use to client's lack of information about how pills work and why it is important to take pills daily. For example, about one in five women (22 percent) said they took the pills only "as needed" (when they were sexually active).5Another FHI study, comparing pill compliance in four countries, found many women did not know the correct action to take after missing a pill. For example, only half of the women in Zimbabwe (49 percent) knew the correct response.6
During counseling sessions, providers may be reluctant to discuss side effects, fearing that candid information will discourage clients' contraceptive use. However, several studies show that side effects are a major concern for women. Lack of knowledge about what to expect and how to cope may discourage contraceptive continuation.
An FHI study of 1,076 clients at four clinics in Kenya, for example, found 80 percent of clients discontinued pills after 12 months, as did 39 percent of DMPA users and 20 percent of intrauterine device (IUD) acceptors. Clients said they were satisfied with clinic services but unhappy with side effects.7In FHI's Women's Studies Project, the majority of 490 women interviewed in Indonesia said they received the contraceptive method they wanted when they went to clinics. However, three-quarters of women in Jakarta and Ujung Pandang said they wanted more information about side effects to help them decide.
In Ghana, a study by Johns Hopkins University surveyed 49 new clients and 48 continuing clients and found that the majority of health workers greeted clients, treated them kindly, corrected misconceptions, and explained why a method might be inappropriate. However, workers seldom discussed side effects.8 In Niger and The Gambia, more than 30 percent of 1,200 women interviewed stopped using contraception within a year. Side effects were the most common reason given by women in The Gambia and the second most common reason for discontinuation in Niger.9
Informed voluntary choice about contraception -- including which method to use or whether to use a method at all -- is a cornerstone of high-quality reproductive health services.
People should have access to a variety of contraceptive methods, as well as information about efficacy and side effects of specific methods. Choice is one of the fundamental rights of clients outlined by the International Planned Parenthood Federation, and the World Health Organization has said in its eligibility criteria for contraceptive use that informed choice and counseling are important to high-quality care.1
An international task force of experts from many organizations, sponsored by the U.S. Agency for International Development (USAID), defines informed choice as "effective access to information on reproductive choices and to the necessary counseling, services and supplies to help individuals choose" to use -- or not use -- family planning.2
There are five elements of informed choice, according to the USAID task force:
provision of information, including counseling on pregnancy, breastfeeding, contraceptive use and infertility
appropriate information on the range of family planning methods, their advantages and disadvantages, costs, and the location of services and supplies
comprehensive information on correct use of the client's selected method
counseling to ensure that clients understand what is said to help them make decisions
and efforts to ensure that a range of methods is available either at the clinic site, through community-based distribution, or through referral.
Another USAID study group of international experts recommends that "clients who already have a method preference should be given that method after screening and counseling unless it is inappropriate for medical and personal reasons. However, even clients with a prior preference should be told that other methods are available and asked if they would like to hear more about any or all of these methods."3
-- Barbara Barnett
References
Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Geneva: World Health Organization, 1996; International Planned Parenthood Federation. Rights of the Client, poster. London: International Planned Parenthood Federation, nd.
Cooperating Agencies Task Force on Informed Choice. Informed Choice: Report of the Cooperating Agencies Task Force. Washington: U.S. Agency for International Development, 1989.
Recommendations for Updating Selected Practices in Contraceptive Use, Volume II. Washington: U.S. Agency for International Development, 1997.
What clients need to know
Health workers are often faced with the dilemma of what and how much information to provide, and how to inform thoroughly within the short time allowed with a client.
While health workers may want to begin counseling sessions by telling new clients about contraceptive options, providers should begin instead by asking questions. Providers should inquire about the client's reproductive intentions: whether a couple desires to space pregnancies or end childbearing, whether a woman has had other pregnancies, whether she is currently breastfeeding, both partners' views on contraception, and potential obstacles to effective contraceptive use. In addition, providers should ask about STD risks -- whether the client, or his or her partner, is at risk. Instead of saying, "I want to tell you about family planning," a provider might ask: "What do you know about family planning methods?" or "How do you feel about using these methods?"
"The key is finding out what clients know, what clients understand, and their reasons for making the choices they have," says Tabbutt-Henry of AVSC. "Find out what the clients perceive as their reproductive needs. What do they understand about the method they have chosen? Why have they chosen a specific method? Then information from the provider can be tailored to correct misconceptions or fill in the gaps. Clients have limited time, as do providers. Counseling is the most efficient way to deliver quality services."
Providers should address clients' questions by explaining that there are different types of available contraceptives: reversible and permanent methods, methods that provide long-term pregnancy protection and those that are short-term, and methods that do or do not protect against STDs.
Providers also should explain that some methods may be medically inappropriate for certain clients. For example, the IUD is inappropriate for a woman who currently has an STD, since IUD insertion may increase the risk of pelvic inflammatory disease in these women. For a client who is uncertain as to which method to choose, a provider should make sure the client has all information needed to make an informed choice and help the client decide, without actually making the decision for the client.
After a client has selected a method, the provider should ask what the client knows about the method. If the client has limited correct information, the provider can offer a detailed explanation of how the method works, how to use it, possible side effects and how to cope with them, and problems that could indicate a need to return to the clinic. The provider should ask the client questions to determine if the client understands the information; for example, asking the client to repeat instructions on use or what to do if there is a problem. If the client selects a method that is not available at the clinic, the provider should refer the man or woman to another clinic that does offer the method.
Providers should explain that women and men have the right to change their minds about the method they have chosen. If the client decides not to use the method -- if the client cannot tolerate side effects or simply is dissatisfied with her or his choice -- providers should make another method available.
Providers should ask clients who are returning for services about their experiences with their current method. If there are problems, the provider should explain possible ways to resolve them. The client should decide whether to continue the current method or switch to a new method. Providers should also ask if clients' reproductive goals have changed, if there have been changes in their breastfeeding status, or if their STD risks have changed.
Dr. Huezo of IPPF recommends that providers focus on information that is essential to help the client make a choice and use the method correctly. This means providers must consider the time available to spend with the client in order to cover vital information, and the tailoring of counseling to meet each individual's needs.
In a study of more than 11,000 clients in Guatemala, Trinidad and Tobago, Kenya, Jordan, Nepal and Hong Kong, Dr. Huezo and his colleagues found that counseling can cover too many topics or irrelevant ones. Women who received too much information or confusing information were more likely to discontinue contraception than those who received high-quality counseling and obtained the method they wanted.10
"The emphasis should be on quality of information, not quantity," says Dr. Huezo. "We need to provide in a clear way as much information as is relevant concerning the method the client has decided to use. Information on side effects should be sufficient for the client to make a clear assessment of risks. We need to convey messages clearly, but not rush over issues just because we have a long list to cover."
"Since providers can discuss and clients can absorb only a limited amount of information in a single session, providers must be selective in the information they offer, focusing on the most important issues for the client," writes Young Mi Kim of Johns Hopkins University, who has done extensive research on client-provider interactions. In Kenya, clients said they wanted to say more but were afraid to interrupt the provider. "She looked like she was in a hurry," one client said. Clients were also concerned they might irritate or anger providers.11
Barriers and solutions
Informed choice can be helped or hindered by cultural norms, service delivery systems or health policies.
Cultural norms that encourage large families or discourage women from playing a role outside the home may be a barrier to informed choice. Norms that place the responsibility for contraceptive use solely on women may discourage men from seeking family planning or STD services.
At the policy level, health programs may be dependent on donor support, so supplies are limited to those provided by donors. Or health policy-makers may not yet have adopted standardized national guidelines for provision of health services. Health policies may also emphasize demographic targets or number of contraceptive acceptors.
In family planning programs, informed choice can be limited by insufficient supplies, provider bias, or policies that unnecessarily restrict contraceptives for certain groups. For example, programs may not provide contraception to adolescents or to unmarried women and men, although there are no medical reasons to refuse them. Programs may refuse sterilization to women who do not have sons or to women with fewer than three children. In addition, providers may lack training in communication skills or up-to-date information on contraceptive technology. Individuals may lack access to family planning services because they do not have the money for health care or for the specific method they want.
FHI training sessions for physicians and nurses, recently held in Guatemala and El Salvador, have tried to help counselors see contraceptive choice from the client's perspective. In these sessions, FHI staff asked family planning counselors to name their three favorite contraceptive methods and explain their reasons for choosing these methods, plus their three least favorite methods. Then, to help providers understand that clients often do not make decisions based solely on method efficacy, trainers ask counselors to answer several questions from their own perspectives: Are you currently using a method? If so, what method and why did you choose it? If not, why not? For current users, have you ever used a different method? Why did you stop? For non-users, have you ever used a method? Why did you choose that particular method? What factors or decisions influenced your decisions?
The purpose of the exercise, says Kevin Young, a senior training officer at FHI, is to help providers realize that contraceptive choice is not just a matter of assessing biomedical facts. "Counseling requires focusing on the circumstances, values and needs that affect the client's decision about fertility," says Young. "The factors that affect the method a person uses are more complex than just the various characteristics of that method."
-- Barbara Barnett
References
Gárate MR, de la Peña M, Díaz M. Estudio Cualitativo sobre Inyectable Depo-Provera en dos Regiones del Perú. Lima: Ministry of Health and the Population Council, 1995.
Askew I, Mensch B, Adewuyi A. Indicators for measuring the quality of family planning services. Stud Fam Plann 1994;25(5):268-83.
Kim YM, Kols A, Mucheke S. Informed choice and decision-making in family planning counseling in Kenya. Int Fam Plann Perspect 1998;24(1):4-11, 42.
Hurtado MP, Portilla P, Suárez P, et al. Compliance and Continuation of Oral Contraceptive Acceptors in Magdalena, Colombia, 1986-87, Final Report. Research Triangle Park, NC: Family Health International, 1989.
Trottier DA, Potter LS, Taylor BA, et al. User characteristics and oral contraceptive compliance in Egypt. Stud Fam Plann 1994;25(5): 284-92.
Hubacher D, Potter L. Comparative look at pill compliance in four DHS countries. Proceedings of the Demographic and Health Surveys World Conference. (Columbia, MD: IRD/Macro International, 1991)1395-1409.
Sekadde-Kigondu C, Mwathe EG, Ruminjo JK, et al. Acceptability and discontinuation of Depo-Provera, IUCD and combined pill in Kenya. E Afr Med J 1996;73(12):786-94.
Kim YM, Amissah M, Ofori JK. Measuring the Quality of Family Planning Counseling: Integrating Observation, Interviews and Transcript Analysis in Ghana, Project Report. Baltimore: Johns Hopkins University and Ghanaian Ministry of Health, 1994.
Cotton N, Stanback J, Maidouka H, et al. Early discontinuation of contraceptive use in Niger and The Gambia. Int Fam Plann Perspect 1992;18(4):145-49.
Huezo C, Malhotra U. Choice and Use-continuation of Methods of Contraception: A Multicentre Study. London: International Planned Parenthood Federation, 1993.
Kim YM, Kols A, Thou M, et al. Client-provider Communication in Family Planning: Assessing Audiotaped Consultations from Kenya,Working Paper 5. Baltimore: Johns Hopkins University, 1998.
Informed Consent Needed for Sterilization or Research
Informed choice is a process in which family planning clients base their decisions about contraceptive use on adequate information. Informed consent is a process in which clients give their permission to undergo a procedure, take a medication or participate in a study after being fully informed.
"Informed consent is consent given by a competent individual who has received the necessary information; who has adequately understood the information; and who, after considering the information, has arrived at a decision without having been subjected to coercion, undue influence or inducement or intimidation," according to World Health Organization guidelines. "Informed consent protects the individual's freedom of choice and respects the individual's autonomy."1
Informed consent is important in both family planning programs and reproductive health research.
Informed choice should always be available to clients seeking health services. While written informed consent is not needed for most reproductive health services, it should be obtained from women and men who undergo sterilization, since this involves surgery and is considered permanent. Ideally, couples should be counseled together and informed about available reversible options. However, from a medical perspective, only the person undergoing the procedure needs give his or her informed consent. There is no medical reason to require a spouse's permission.
The U.S. Department of Health and Human Services has listed seven basic elements of informed consent for sterilization. The first letters of key words in the list spell the English word "BRAIDED." Clients should be told about the "benefits" of the method; "risks" of the method, including major and minor risks and possible method failure; and "alternatives" to the method. In addition, they should know that they can make "inquiries" about their rights and responsibility; "decide" not to use the method without penalty; and receive an "explanation" of the method in ways that they understand. Finally, the provider should obtain "documentation" that the client has understood the other points. Usually, providers ask clients to sign a form, and the form is placed with the client's medical records.
Fully informed
Volunteers who participate in contraceptive studies must be fully informed of the risks and benefits of any new drugs or devices they receive. They should understand the potential effects of methods not only on their physical health, but also on other aspects of their lives, including emotional well-being and privacy. Ethical reviews before research begins are essential to ensure protection of study participants.
To ensure that study participants fully understand the purpose of the research and personal consequences of their participation, FHI researchers have used several tools to measure the "readability" of informed consent documents. In the early 1990s, FHI evaluated informed consent documents for nine clinical trial studies using a variety of measurements.2Researchers found that the documents contained many words that, while familiar to researchers, were likely to be unfamiliar to clients. Researchers recommended that complex sentences be replaced by several shorter sentences. In addition, they recommended that medical terms be translated into common, everyday language. For example, a form could say "high blood pressure" instead of "hypertension."
Even with attempts to simplify language, researchers must still work to ensure that clients understand what they have been told. An FHI study of 70 women who participated in four clinical trials for barrier contraceptive methods asked the women to recall information up to 41 weeks after admission to the trials. Almost all participants correctly recalled the number and frequency of follow-up visits, tests and examinations. Few participants, however, correctly recalled the risks of pregnancy associated with contraceptive use.3
-- Barbara Barnett
References
Council for International Organizations of Medical Sciences. International Ethical Guidelines for Biomedical Research and Experimentation Involving Human Subjects. Geneva: World Health Organization, 1993.
Rivera R, Reed JS, Menius D. Evaluating the readability of informed consent forms used in contraceptive clinical trials. Int J Gynecol Obstet 1992;38:227-30.
Fortney JA. A pilot study to assess recall and understanding of informed consent in a contraceptive clinical trial. Unpublished paper. Family Health International, 1998.
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