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2 Informed Choice in Family Planning: Legacies and Challenges o 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 clients perspective. Adapted from AVSC International 1998

3 Examples: r Campaigns to sterilize persons with mental disabilities, mental illnesses, or hereditary diseases r Assigned quotas r Policies officially enforced through rewards and incentives Abusive Policies and Practices in Family Planning

4 Y Rare for governments to explicitly sanction coercive practices Y Most nominally require informed consent Y Imposed by funding institutions Y Response to ethical or legal requirements Y The activist demands of womens and rights groups

5 J An international consensus against coercion emerged during the 1970s and 1980s J Policy consensus gained in 1994 POA of ICPD

6 ò Policy consensus has not solved the problem ò Problems are complex, subtle, hard to document, and more difficult to change

7 u Counseling approaches that do not respect and reinforce principles of client choice u Failure to afford access to a reasonable range of contraceptive choices u Failure to train staff adequately or monitor compliance with policy mandates regarding informed choice u Provider biases toward preferred methods of contraception that have the effect of unnecessarily restricting client choice.

8 u Institutional environments that silently endorse targets or quotas for the use of particular family planning methods u Failure to address differences in values and experiences between health care providers and individual clients seeking family planning services

9 u The continuing need for solutions at the service-delivery level u Policies are necessary but insufficient for ensuring informed choice u New approaches to the factors that jeopardize choice are necessary

10 _ The essential purpose of the informed choice process is to enable the client to make her/his own decision. This principle addresses the providers 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 k Clients are individuals with different needs and circumstances. The providers principal role in communication is to listen to the client so as to learn about and address the special needs of each client.

12 p 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 P 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 Beyond Family Planning The 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 p The Cairo consensus initiated and reinforced a more holistic approach and a broadening mandate p 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 Does the Family Planning Model Apply? X Family planning and reproductive health services share certain attributes X Individual autonomy, dignity, and privacy are central to decisions about whether and when to bear a child X Decisions related to family planning and reproductive health are intimate, deeply personal and life-affecting. X Often made on the basis of religion, social values, individual identity, and the shared goals of couples or families.

17 X 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 X Called the shared decision-making model X A shared decision should reflect the contribution,s values and perspectives of both the provider and client X the balance of provider input and client autonomy will differ from one situation to the next

18 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? u 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 B 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 Potential Health Impact of the Decision What is the relative severity of the potential health impact related to the decision?

21 q Complexity of the Information What is the relative complexity of the information relevant to the decision?

22 A Number of Treatment Options or Method Alternatives Are there multiple treatment options or method alternatives with the same or comparable medical results?

23 z Implications for the Health of Others Are there broader public health implications?

24 O 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 Q Biases or Attitudes of Providers and Clients What is the likelihood that provider or client values or assumptions will adversely influence communication and decision making?

26 p Informed choice is a process of decision making. Informed consent is one of several possible results of that process.

27 Client Centered SharedProvider-Centered

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

29 ò The balance of provider input and client autonomy that is right for any given health care decision is a challenging process ò ample time, a service delivery context that supports this process

30 ò a provider who is willing to listen, sensitive and responsive to individual needs and able to respect and support a client decision ò 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 ò A focus on the development of skills needed ò Programmatic initiatives that promote provider education regarding informed choice and shared decision making ò initiatives that promote client empowerment

32 Decision Making Process Client Provider Implications for the Health of Others Biases Or Attitudes External Pressures Number of Alternatives Complexity of Information Potential Health Impact Nature of the Information Time Available for Decision Making AVSC International 1998

33 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