Measuring Rights: Counseling, Informed Choice, and Decision Making
The fundamental right of women and girls to decide, freely and for themselves, whether, when, and how many children to have is central to the vision and goals of FP2020.
Four years into the initiative, many efforts are underway to ensure that family planning programs are built on and respect rights principles. Core Indicators 14, 15, and 16 measure facets of empowerment, informed choice, and quality of care, all of which are important aspects of rights-based family planning.
Core Indicator 16 (Estimate Table 16) measures the percentage of women who make family planning decisions either by themselves or jointly with their husbands or partners. Across countries that have had surveys since 2012, the indicator shows a high level of women’s participation in contraceptive decision-making, ranging from 71% in Comoros to 98% in Egypt and Rwanda.
It is important to note that in more than half of these countries (15 of the 29) at least 1 in 10 female users reported that they were not involved in important choices, such as whether and when to use contraceptives and what method to use. These data suggest that in many countries work remains to be done to ensure that all women and girls have the ability to make contraceptive decisions voluntarily and free of discrimination, coercion, or violence.
The results from Indicator 16, however, paint an incomplete picture of empowerment. Given that the indicator scores are fairly high and vary little across country and year, the indicator is likely not capturing many of the challenges related to decision making that contraceptive users face. Furthermore, Indicator 16 only measures the decision-making power of women who are currently using a method and gives no insight into the experiences of women who are not using a method or how that decision was made. Other studies indicate some of the barriers that these women face, and a 2016 Guttmacher study on non-use indicates that opposition by partners or others is a challenge for married women with an unmet need for family planning.23 On average, 9% of women in countries with available data cited opposition by partners or others as a reason for their contraceptive non-use, with the proportion as high as 27% in Timor-Leste and as low as 2% in Cambodia and Peru.
The quality of family planning counseling and services available to women is also an underlying factor affecting contraceptive use. Proper counseling provides women and girls with medically accurate information about their bodies and contraceptive options, and enables them to explore and choose among a range of methods as their sexual and reproductive health needs evolve over time. Counseling also helps contraceptive users understand potential side effects and find their preferred method.
Core Indicator 14 (Estimate Table 14), the Method Information Index (MII), serves as a proxy for quality of counseling and reflects the extent to which women are informed about side effects and alternate methods. The MII is a summary measure constructed from three questions asked of current contraceptive users about the occasion when they obtained their current method:
- 1. Were you informed about other methods?
- 2. Were you informed about side effects?
- 3. Were you told what to do if you experienced side effects?
The MII value is the percentage of respondents answering “yes” to all three questions. For countries with sufficient data since 2012, we report the overall MII value, the MII value by method, and the percentage of women who positively answered each question.
In 2016, MII values range from 13.5% in Pakistan24 to 71.8% in Zambia. Users of implants and IUDs tend to receive more information regarding their methods, and on the whole, women tend to be told of other methods more often than they are informed of side effects or how to handle them. A closer look into countries and methods with low MII values is needed to understand why providers are not sharing the information that is critical to informed consent.
Results from the 2016 Guttmacher study suggest that women are not being provided with the information they need to make informed choices about using contraceptives. It found that many women who do not use contraceptives because of infrequent sex or amenorrhea/breastfeeding—two of the most commonly cited reasons—may be underestimating their risk of becoming pregnant. For example, significant proportions of women who cited infrequent sex as a reason for non-use were sexually active in the last month. Similarly, the majority of women who cited postpartum amenorrhea and/or breastfeeding had given birth more than six months ago.
The Guttmacher study also found that a large proportion of women not using contraceptives are concerned about side effects or health risks. In 21 of the 52 countries included in the study, fear of side effects was the most common factor driving nonuse. In most countries, it accounted for between 20 and 33 percent of women who wanted to avoid pregnancy but were not using contraceptives. These women are significantly more likely to have already used a modern method than women who cite other reasons for nonuse, suggesting that these fears come from women’s actual experience with methods and service providers. Whether these fears stem from misinformation or real health risks associated with a given method, their pervasiveness highlights the importance of family planning counseling to address women’s concerns and to assist them in selecting the method they feel is right for them.