INDICATORS 14-16 : MEASURING RIGHTS: COUNSELING, INFORMED CHOICE AND DECISION MAKING
MEASURING RIGHTS: COUNSELING, INFORMED CHOICE AND DECISION MAKING
Rights-based family planning is an approach to developing and implementing programs that aims to fulfill the rights of all individuals to choose whether, when, and how many children to have; to act on those choices through high-quality sexual and reproductive health services, information, and education; and to access those services free from discrimination, coercion, and violence. FP2020 partners are working across countries to translate rights principles into practical programs and measurable indicators. The data collection for these efforts includes facility audits, provider interviews, client observation, and client exit interviews. The knowledge gained will inform future measurement and monitoring of rights and quality at the facility, provider, and client-level.
FP2020 relies on household survey data for Core Indicators 14, 15, and 16, which measure informed choice, quality of care, and empowerment, all of which are important aspects of rights-based family planning. Measurement limitations are primarily due to what data are available from household surveys and comparable across countries.
Core Indicator 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:
- Were you informed about other methods?
- Were you informed about side effects?
- Were you told what to do if you experienced side effects?
The MII total is the percentage of respondents answering “yes” to all three questions. For countries with sufficient data since 2012, we report the MII total, the MII value by method, and the percentage of women who positively answered each question.
Research has shown that improved quality of care, one aspect of rights-based family planning, results in declines in contraceptive discontinuation and increases in contraceptive use. Proper counseling provides women and girls with medically accurate information about their bodies and contraceptive options, enables them to explore and choose among a range of methods as their sexual and reproductive health needs evolve over time, and helps them understand potential side effects.
MII values in 2017 span a wide range, from 13% of contraceptive users in Pakistan to 71% of contraceptive users in Zambia responding “yes” to all three questions. Looking at the individual components (Figure 15 ), a greater percentage of women report receiving information on other methods (average across countries of 63%) than report being informed about side effects (52%) or how to handle them (52%). Users of implants and IUDs tend to receive more information regarding their methods. Long term trends available from the DHS show that most countries with multiple surveys show an improvement over time in counseling. Comparing the two most recent surveys, however, reveals that very few countries have made recent progress in the MII measures of providing counseling and information to women adopting a contraceptive method.14 These findings show that there is room for improvement in counseling across the 69 FP2020 focus countries.
Core Indicator 14 measures the information and counseling received by women who have adopted a method. Core Indicator 15 measures the proportion of women who received any kind of family planning information in the last 12 months, either from a health worker in a facility or in the field (among both those using and not using contraception). The percentages vary across countries with available data, from 6% in Guinea to 52% in Liberia. These numbers must be interpreted in context, as not all women want or need family planning information, and information may be provided by other channels, including media, schools, and social networks. But in half of the countries with data for this indicator (16 out of 32), at least 75% of women reported not receiving information on family planning in the last year in their contact with health providers. This indicator signals that many countries will need to expand family planning information, education, and communications efforts if they hope to enable more women and girls to make informed contraceptive choices by 2020.
Core Indicator 16 measures the percentage of women using family planning who made 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 15 of 35 countries with data, at least 1 in 10 female users reported that they were not involved in such important choices 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 can make contraceptive decisions voluntarily and free from discrimination,coercion, or violence.
The results from Indicator 16, however, paint an incomplete picture of empowerment. Given that the indicator scores are high and vary little across countries and years, the indicator is likely not capturing many of the challenges that women face in deciding to use contraceptives. 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. Research on reasons for non-use of family planning among women with unmet need indicates that opposition by partners or others is a challenge for women, along with more commonly cited reasons: fear of side effects, infrequent sex, and amenorrhea or breastfeeding.15 Survey changes in the next DHS questionnaire mean that in the future this question will be asked of women not using contraceptives, as is already done by PMA2020. These data will likely serve the longer-term SDG measurement effort as well, as SDG indicator 5.6.1 is “the proportion of women aged 15–49 years who make their own informed decisions regarding sexual relations, contraceptive use and reproductive health care.”
While Core Indicators 14, 15, and 16 are limited in what they each reveal, they can paint a fuller picture when examined alongside each other. In Chad, for example, one of FP2020’s newest commitment makers, where contraceptive prevalence is very low, substantial efforts are needed to integrate rights and quality of care into family planning. Only 14% of women have received information on family planning in their recent contact with health providers, and among the small percentage of women using family planning, only 38% reported that they had been informed about side effects and alternatives to their current method. A relatively large percentage of contraceptive users also reported that they had not made the decision to use contraceptives alone or with their partners (18%). In its new FP2020 commitment and in response to data from the recently completed DHS, Chad has identified actions the country needs to take to improve rights within its family planning program. As FP2020 partners and focus countries learn from efforts to operationalize and measure rights and empowerment principles at the service delivery point, these lessons will need to be shared widely in the public and private sector. These efforts are critical to sustaining and expanding contraceptive use while respecting, protecting, and fulfilling the rights of all contraceptive users.