Hopkins Report: New Informed Choice Strategy for Developing Countries

The proposal, addressed to
policy-makers and health care providers working in and for developing
countries, appears in the latest issue
(http://www.jhuccp.org/pr/j50edsum.stm) of Population Reports published by
the Johns Hopkins Population Information Program.

The new strategy broadens efforts to assure people's informed choice in
family planning. "Informed choice" means that individuals and couples can
make their own free decisions about using family planning based on accurate
information and access to services and supplies to carry out their
decisions. This principle has long been fundamental to family planning
programs around the world.

"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," writes author Ushma D. Upadhyay in calling for the new strategy.
For example, in all 50 developing countries surveyed at least 80% of women
who planned to start using family planning in the next year already had a
specific method in mind. In 26 of those countries the percentage was over
90%.

"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 and services," writes Upadhyay.

Good communication between clients and providers during counseling remains
essential, the report notes. Many people want help thinking through the
decision-making process and learning how to use a method correctly.
Providers also can help clients assess whether they are at risk of HIV/AIDS
and other STIs. In view of the AIDS epidemic, "it is more important than
ever for people...to consider dual protection" against unintended pregnancy
and STIs, according to the report. "Making a family planning choice without
considering STI risk and protection is not a fully informed choice."

Whether people can make their own choices is key to their satisfaction with
family planning. An Indonesian study, for example, found that 91% of women
who received the family planning method they wanted were still using that
method a year later. By comparison, only 28% of those who did not get their
preferred method were using the method they received after a year.

The proposed comprehensive strategy includes:

· Setting supportive policies. Endorsement at the top sets the tone for the
entire health care system. National policies in Malaysia, Mexico, Peru, and
Zambia intend to protect people's rights and ability to making informed
choices. For example, 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."
· Widespread communication programs. Information campaigns in the mass media
and in the community can inform people of their right to make their own
decisions, explain their options, and direct them to health care providers
who can help. For example, Bolivia's "Las Manitos" ("Little Hands")
campaign advised people that their reproductive health was in their own
hands and that there is a range of contraceptive methods to choose from,
including condoms which protect against HIV/AIDS.
· Improving access. A range of contraceptive methods and outlets helps
people carry out their choices. In nine countries surveyed, from 11% of
women in Mauritius to 48% in Costa Rica said they would rather use a
different family planning method. Most often, their preferred method was too
expensive, too difficult to obtain, or not available at all. Falling funding
levels make better access increasingly difficult, however. Donor governments
and international organizations are contributing less toward the cost of
contraceptives. In 1999, the last year for which data are available, donor
support for contraceptives totaled US$130.8 million, down 9% from the
previous year. This continues a trend of falling funds that began in 1996.
· Stronger management and leadership. Program management that improves
quality of care enhances clients' choices. In Kenya, after new service
delivery guidelines were instituted, the percentage of clients unnecessarily
denied family planning services because they were not menstruating declined
from 47% to 29%.
· Improving counseling. Counseling can be crucial to helping some people
think through their decisions. It is a partnership of not one, but two
experts--the provider as the medical expert and the client as the expert on
her or his own situation and needs. The "Smart Patient" program in
Indonesia, a pilot project carried out by the Johns Hopkins Center for
Communication Programs, helped clients prepare their questions for
counselors. These clients asked an average of 5.5 questions per session,
compared with 3.5 among clients who were not coached.

Ushma Upadhyay prepared the report, Informed Choice in Family Planning:
Helping People Decide. Population Reports is an international review journal
of important issues in population, family planning, and related matters. It
is published four times a year in four languages by the Population
Information Program at the Johns Hopkins Center for Communication Programs
for more than 170,000 family planning and other health professionals
worldwide, with support from the US Agency for International Development
(USAID). USAID administers the US foreign assistance program, providing
economic and humanitarian assistance in more than 80 countries worldwide.

For more information contact: Kim Martin at Johns Hopkins Center for
Communication Programs, 111 Market Place, Suite 310, Baltimore, Maryland
21202, USA. Tel: 410 659-6140; Fax: 410 659-6266; e-mail: [email protected]
or [email protected]. WEB SITE: http://www.jhuccp.org/.