1. 2 Informed Choice in Family Planning: Legacies and Challenges o Informed Choice refers to the process by which an individual arrives at a decision.

1

prg ilbert / vw -sep98

2

prg ilbert / vw -sep98

Informed Choice in Family Planning: Legacies and Challenges

Informed Choice refers to the

process by which an individual

arrives at a decision about health

care. It must be based upon access

to, and full understanding of, all

necessary information from the

client’s perspective.

Adapted from AVSC International 1998

3

Examples:

Campaigns to sterilize persons with

mental disabilities, mental illnesses,

or hereditary diseases

Assigned quotas

Policies officially enforced through

rewards and incentivesprg / vw -sep98

Abusive Policies and Practices in Family Planning

4

prg / vw -sep98

Rare for governments to explicitly sanction coercive practices

Most nominally require informed consent

Imposed by funding institutions Response to ethical or legal

requirements The activist demands of women’s

and rights groups

5

prg / vw -sep98

An international consensus against coercion emerged during the 1970s and 1980s

Policy consensus gained in 1994 POA of ICPD

6

prg / vw -sep98

Policy consensus has not solved the problem

Problems are complex, subtle, hard to document, and more difficult to change

7

prg / vw -sep98

Counseling approaches that do not

respect and reinforce principles of client

choice

Failure to afford access to a reasonable

range of contraceptive choices

Failure to train staff adequately or

monitor compliance with policy

mandates regarding informed choice

Provider biases toward preferred

methods of contraception that have the

effect of unnecessarily restricting client

choice.

8

prg / vw -sep98

Institutional environments that

silently endorse targets or quotas

for the use of particular family

planning methods

Failure to address differences in

values and experiences between

health care providers and individual

clients seeking family planning

services

9

prg / vw -sep98

The continuing need for solutions

at the service-delivery level

Policies are necessary but

insufficient for ensuring informed

choice

New approaches to the factors that

jeopardize choice are necessary

10

prg / vw -sep98

The essential purpose of the

informed choice process is to

enable the client to make her/his

own decision. This principle

addresses the provider’s role in

empowering the client to make her/his

own choices. In short, the provider is

a facilitator of client choice, not a

decision maker.

11

prg / vw -sep98

Clients are individuals with

different needs and

circumstances. The provider’s

principal role in communication

is to listen to the client so as to

learn about and address the

special needs of each client.

12

prg / vw -sep98

For a client to make an informed

choice, the client will need

certain basic information specific

to the options being offered.

Every client must be given basic

information, including the risks,

benefits, alternatives, consequences,

effectiveness, and nature of the

method or procedure being

considered.

13

prg / vw -sep98

Informed choice requires that all of

the information given be reliable,

timely, and understandable.

Information must be accurate, unbiased,

and provided with sufficient time for

reflection by clients. The provider must

take steps to ensure that the client

understands the information given.

14

prg / vw -sep98

Beyond Family PlanningThe ICPD defined reproductive health as:

[The] state of complete physical, mental and

social well-being and not merely the

absence of disease and infirmity, in all

matters relating to the reproductive system

and its processes. Reproductive health

therefore implies that people are able to

have a satisfying and safe sex life and that

they have the capability to reproduce and

the freedom to decide if, when, and how

often to do so.

15

prg / vw -sep98

The Cairo consensus initiated and

reinforced a more holistic

approach and a broadening

mandate

A broader mandate also creates

the need to determine whether

guidelines developed for family

planning are applicable to other

areas of reproductive health care.

16

prg / vw -sep98

Does the Family Planning Model Apply?

Family planning and reproductive health services share certain attributes

Individual autonomy, dignity, and privacy are central to decisions about whether and when to bear a child

Decisions related to family planning and reproductive health are intimate, deeply personal and life-affecting.

Often made on the basis of religion, social values, individual identity, and the shared goals of couples or families.

17

prg / vw -sep98

The FIGO principle of autonomy lies

somewhere between the provider-

centered and client-centered ends of the

spectrum in models of health care

decision making

Called the “shared decision-making model

A shared decision should reflect the

contribution,s values and perspectives of

both the provider and client

the balance of provider input and client

autonomy will differ from one situation to

the next

18

prg / vw -sep98

Achieving Provider-Client Balance in the Choice Process

A number of factors to achieve the right provider-client balance:

Time Available for Decision Making - Is the health care need urgent?

Nature of the Information to be Evaluated -

Are the determinants and potential

consequences of the decision primarily

medical, or are they primarily related to

individual circumstances, preferences, and

social and economic factors?

19

prg / vw -sep98

Nature of the Information to be Evaluated.

Are the determinants and potential consequences of the decision primarily medical, or are they primarily related to individual circumstances, preferences, and social and economic factors?

20

prg i lbert / vw -sep98

Potential Health Impact of the Decision

What is the relative severity of the potential health impact related to the decision?

21

prg / vw -sep98

Complexity of the Information

What is the relative complexity of the information relevant to the decision?

22

prg / vw -sep98

Number of Treatment Options or Method

Alternatives

Are there multiple treatment options or method alternatives with the same or comparable medical results?

23

prg i lbert / vw -sep98

Implications for the Health of Others

Are there broader public health implications?

24

prg / vw -sep98

External Pressures on Providers and Clients

Are there external pressures, including

government, donor, or other policy objectives, that might influence

medical communication and decision making?

25

prg / vw -sep98

Biases or Attitudes of Providers and Clients

What is the likelihood that provider orclient values or assumptions will

adversely influence communication and decision making?

26

prg / vw -sep98

Informed choice is a process of decision making.

Informed consent is one of several possible results of that process.

27

prg / vw -sep98

Client Centered Shared Provider-Centered

28

prg / vw -sep98

The Provider and client may assess these factors very differently, coming to entirely different conclusions about what their roles and responsibilities should be.

29

prg / vw -sep98

The balance of provider input

and client autonomy that is right

for any given health care

decision is a challenging process

ample time, a service delivery

context that supports this

process

30

prg / vw -sep98

a provider who is willing to listen,

sensitive and responsive to

individual needs and able to respect

and support a client decision

a client who is able to recognize

and respect provider expertise,

trust where trust is warranted and

acquire from the provider necessary

information without losing control

over the final decision

31

prg / vw -sep98

A focus on the development of

skills needed

Programmatic initiatives that

promote provider education

regarding informed choice

and shared decision making

initiatives that promote client

empowerment

32

P rg / vw sep98

Decision MakingProcess

Client

Provider

Implications for the Health of O

thers

Biases Or Attitudes

External Pressures

Number o

f Alte

rnativ

es

Com

plexity of Information

Potential Health Impact

Nature of the Information

Time Availa

ble for D

ecision Making

AVSC International 1998

33

prg / vw -sep98

Key References: Informed Choice

1. AVSC International 1998 Informed Choice in FP: Legacies & Challenges

2. John Hopkins University 1989 Informed Choice Report of the Cooperating Agencies Task Force JHU, Baltimore