How to help women to choose a contraceptive method

1. How to help women to choose a contraceptive method Mirella Parachini S.Filippo Neri Hospital Rome,Italy

2. Helping Women Choise The best decisions about contraception are those that women make for themselves, based on accurate information and a range of contraceptive options Women who make informed choices are better able to use a contraceptive method safely and effectively Population Reports Vol. XXIX, 1, Series J, Number 50, 2001

3. “informed choice” The term “informed choice” refers to a decision that a person can make for herself or himself,not to a process that a family planning provider carries out a decision about health care is an informed choice when it is “based upon access to, and full understanding of, all necessary information from the client's perspective” ASSOCIATION FOR VOLUNTARY SURGICAL CONTRACEPTION (AVSC). Informed choice. New York, AVSC International, Folder. 1998.

4. The principle of informed choice is recognized internationally and is based on human rights “the aim of family planning programs must be to enable couples and individuals to decide freely and responsibly the number and spacing of their children and to have the information and means to do so and to ensure informed choice and make available a full range of safe and effective methods” Programme of Action of the International Conference on Population and Development. Cairo, 1994.

5. factors that affect contraceptive decisions Individual values and personal characteristics Household Influences Social networks Government policies Information Access

6. Individual values and personal characteristics Socio-demographic Life-Cycle • Reproductive intentions • Number of sexual partners • Health status • Sexually transmitted infections (STIs) • Frequency of intercourse • Perceived risk of getting pregnant • Personal beliefs • Ability to make decisions • Partner relationship • Age • Sex • Marital status • Age at marriage • Number and ages of children • Personal income • Workload • Media exposure

7. Household Influences Social networks • Attitudes towards contraception • Relationship in family • Marital stability • Status within family • Household income • Cultural norms • Religious beliefs • Local health beliefs • Gender roles

8. Information Government policies • National Family Planning guidelines • Contraceptive supply • Service delivery outlets • Range of methods available • Costs of services and methods • - Interpersonal communication • Mass media • Health literacy

9. Being informed is necessary to making a well-considered decision • Being informed is not sufficient : a person also needs choices including access to • a range of contraceptive methods • convenient sources of supply • good-quality services • the ability to continue or discontinue using the method as desired

10. Government policies • approval and registration of contraceptive products • prescription requirements • inclusion on the essential drugs list • regulations on sales, distribution, or delivery of services • restrictions on private medical practice • policies on advertising

11. Guidelines Reviews Position statements Recommendations Standards How Much Information? How Much Guidance?

12. Australia • Australian Medical Association Reproductive Health And Reproductive Technology [1998] • Canada • Recommended Clinical Practice Guidelines : Contraceptives [2004] • Society of Obstetricians and Gynaecologists of Canada • Canadian contraception consensus. Part 1,2,3 [2004] • France • Haute Autorité de santé • How to choose a method of female contraception [2004] • Netherlands • Health Council of the Netherlands • Contraception for people with mental retardation [2002] • Sweden • Sida : Contraception. Issue Paper [1998]

13. United Kingdom • Department of Health • Contraception [Collection of guidelines] • Contraception and sexual health, 2002 [2003] • Prodigy Knowledge • Contraception [2005] • Royal College of Obstetricians and Gynaecologists - Faculty of Family Planning & Reproductive Health Care • The use of contraception outside the terms of the product licence [2005] • Contraception for women aged over 40 years [2005] • Contraceptive choices for women with inflammatory bowel disease [2003] • UK Selected Practice Recommendations for Contraceptive Use [2002] • Perimenopausal Contraception [2000]

14. United States of America • Alan Guttmacher Institute • Women and Societies Benefit When Childbearing Is Planned [2002] • American Medical Association • Contraception [Collection of guidelines • Food and Drug Administration • Birth Control Guide [2003] • Guidance for Industry - Uniform Contraceptive Labeling [1998] • Information and Knowledge for Optimal Health (INFO) Project, Johns Hopkins University • World Health Organization Updates Guidance on How To Use Contraceptives [2005] • Institute of Medicine • New Frontiers in Contraceptive Research: A Blueprint for Action [2004] • Maximizing Access and Quality • Contraceptive Security: What You Can Do [2004] • Contraception for Women on First-Line Antiretrovirals (ARVs) [2004] • National Guideline Clearinghouse • Contraception and family planning. A guide to counseling and management. Brigham and Women's Hospital [2005] • Population Reference Bureau • Family Planning [Collection of guidelines] • Population Reports • New Contraceptive Choices [2005] • New Survey Findings: The Reproductive Revolution Continues [2003] • Birth Spacing: Three to Five Saves Lives [2002] • ReproLine • Family Planning [Collection of guidelines] • Contraceptive Methods [Collection of guidelines] • Contraception for Special Circumstances [Collection of guidelines]

15. WHO World Health Organization • Family planning - Continuous Identification of Research Evidence (CIRE) System [Collection of guidelines] • Family Planning [Collection of guidelines] • The effects of contraception on obstetric outcomes [2004] • Selected practice recommendations for contraceptive use [2004] • Medical eligibility criteria for contraceptive use - Third edition [2004] • Making decisions about contraceptive introduction: A guide for conducting assessments to broaden contraceptive choice and improve quality of care [2002] • Exploring common grounds: STI and FP activities [2001] • Health benefits of family planning [1995]

16. International • Association of Reproductive Health Professionals • Clinical Proceedings [Collection of guidelines] • Appropriate Contraceptive Choice and Usage [2000] • Cochrane Reviews • Cochrane Fertility Regulation Group [Collection of guidelines] • EngenderHealth • Choices in Family Planning: Informed and Voluntary Decision Making [2003] • Family Health International • Mechanisms of the Contraceptive Action of Hormonal Methods and Intrauterine Devices (IUDs) • International Planned Parenthood Federation • Family Planning, Contraception [Collection of guidelines] • Population Council • Product Development - Contraceptives [Collection of guidelines] • Contraception [Collection of guidelines] • Program for Appropriate Technology in Health (PATH) • Contraceptive Methods And Supplies [Collection of guidelines] • Reproductive Health for Refugees Consortium • Family Planning [Collection of guidelines] • United Nations Children's Fund - UNICEF • Fertility and Contraceptive use • United Nations Population Division • World Fertility Report 2003 [2005] • Partnership and Reproductive Behaviour in Low-Fertility Countries [2003] • Completing the Fertility Transition [2002]

17. To help clients make informed choices about contraceptive use, family planning programs once thought providers should give clients a lot of information about all methods equally This approach overloaded clients with technical information and did little to help them apply information to their own lives People can generally assimilate two or three important pieces of information in a brief time Receiving too much information is stressful ! Family planning counseling:An evolving process. International Family Planning Perspectives 19(2), 1993.

18. Anaes (National Agency for Accreditation and Evaluation in Healthcare) www.anaes.fr, www.sante.fr Clinical practice guidelines How to choose a method of female contraception December 2004

19. 1. Involvement in the choice of method Everyday efficacy of a contraceptive method differs from the optimum efficacy given by clinical trials, for instance because of problems of compliance. For this reason, women and couples should be actively involved in choosing a method that suits them.

20. 2 . Freedom of choice leads to greater satisfaction and more widespread use. Published articles emphasise the need to focus on the couple and to take the partner's view intoaccount. Disagreement or reticence of a partner can adversely affect use and compliance.

21. 3. The first consultation broaching contraception should, if possible, be devoted entirely to the subject. If this is not possible because of lack of time (eg in an emergency), the matter should nevertheless be allotted a few moments and a second appointment to discuss just contraception should be scheduled soon afterwards.

22. 4. Teenage girls A teenage girl should be seen without her parents. The interview is confidential but must raise the subject of her parents. The health professional should remain neutral and have no preconceived ideas. The first choice methods for teenage girls are the male condom and hormonal methods of contraception, especially the combined pill.

23. 5. Scope of the interview • Published articles emphasise the need for health professionals: • to adapt their advice and prescriptions to each individual woman • to extend the scope of the interview beyond medical considerations alone • and take psychological, sociological or even economic factors into account • to explore the woman’s motivation in relation to contraception • to help women or couples to weigh up and choose the form of contraception best suited to their current and future personal situation. • A consultation based on the WHO GATHER model could be appropriate.

24. G — GreetA — AskT — TellH — HelpE — ExplainR — Return Counseling often has 6 elements, or steps. Each letter in the word GATHER stands for one of these elements. Good counseling is more than covering the GATHER elements, however. A good counselor also understands the client's feelings and needs. With this understanding, the counselor adapts counseling to suit each client.

25. 6. Tests If the clinical examination findings are normal and if no personal or family medical problems (hypertension, diabetes, hyperlipidaemia, migraine, thromboembolism) are identified during history-taking, the health professional can schedule gynaecological examinations and blood tests for a later visit (in 3 to 6 months) particularly for teenage girls. They should however provide relevant information on the tests at the first visit. It is only worth carrying out a smear test if sexual relations have already taken place.

26. “the physical examination may be deferred until after initiation of oral contraceptives if requested by the woman and judged appropriate by the clinician." Food and Drug Administration. Fertility and Maternal Health Drugs Advisory Committee US Department of Health and Human Services; May 20, 1993.

27. 7. The combined pill is one of the first choice methods for women with no specific risk factors (for cardiovascular disease, liver disease, cancer, etc). In addition to its contraceptive effect, it offers other potential benefits, eg prevention of some cancers(endometrial, ovarian and colorectal cancer). An increased risk of thromboembolism is associated with all generations of combined pills. The greatest danger in prescribing a combined pill, whether second or third generation, is being unaware of the presence of associated cardiovascular risk factors that are contraindications. Published reports have described a potential increase in the risk of some cancers, especially breast and cervical cancer. These cancers are still relatively rare in the age groups involved. Breast cancer in combined pill users is discovered at an earlier stage than in non-users. No difference in mortality has been observed between users and nonusers.

28. 8. Progestogen-only contraception may be used in certain situations where the combined pill is contraindicated, in particular in cases of cardiovascular risk. However, it is not just a second choice method. Like the combined pill, it should be regarded as an effective method in everyday use and a very effective method on optimum use. The main type of progestogen-only pill is the “minipill” which must be taken according to a strict timetable, at the same time every day, even during menstrual periods. The efficacy of progestogen-only methods must be weighed up against their side effects (poor cycle control, increased risk of bleeding etc).

29. 9. The intrauterine device (IUD) is not only for multiparous women. It is a very effective first choice method of contraception, with a long-term action and no established risk ofcancer or cardiovascular disease. The risk of pelvic inflammatory disease (PID) is present mostly during the 3 weeks following insertion only. No risk of tubal infertility has been demonstrated, even in nulliparous women. The risk of extrauterine pregnancy with an IUD is very low (10 times lower than that associated with non-use of contraception). There is no conclusive evidence on whether this risk is greater than that of other methods of contraception.

30. The intrauterine device (IUD) • An IUD may be offered to any woman: • after taking into account any contraindications to its insertion; • - after the risk of infection and extrauterine pregnancy have been assessed and at-risk • situations have been eliminated; • - when the woman has been informed of the risk of PID and extrauterine pregnancy • and of the potential but unsubstantiated risk of tubal sterility. • Nulliparous women, inparticular, should be informed of these risks, and IUD insertion should be weighed up carefully, taking any future desire for children into account.

31. 10. Sterilisation may be an appropriate contraceptive method, in either men or women, in certain specific medical, social or cultural situations, whether requested by the couple ora partner, or proposed by the doctor. An advantage of the method is that contraindications are not permanent. It should be presented as a usually irreversible method. The French Public Health Code forbids tubal ligation or vasectomy for contraception in minors. There should be a 4-month period for reflection after an initial decision to be sterilised has been made and consent obtained. A declaration of informed consent must be signed.

32. 11. Condoms (for both men and women) are the only method with proven efficacy in preventing sexually transmitted disease (STD). If the woman is considered to be at-risk because she has or has had several partners, may have or have had casual sex or is not in a stable relationship (this applies especially to teenage girls), the health professional should recommend that she uses condoms, on their own or together with another medical method. She will need to be taught how to use the methods chosen. The use of spermicides alone is not effective in preventing STD.

33. 12. Natural methods The efficacy of lactational amenorrhoea during exclusive or almost exclusive breastfeeding is similar to that of oral contraception. Other natural methods have a high risk of failure in everyday use. They should be reserved for women who are familiar with their cycle, who have mastered the method, who accept the risk of pregnancy or for whom pregnancy has no medical risk.

34. 13. Emergency methods. When contraceptives are prescribed and supplied, the woman should be informed of the two emergency measures she can use if she should have unprotected sexual intercourse, how effective they are and how to obtain them: • the copper IUD is the most effective method after unprotected sexual intercourse; • (ii) emergency progestogen-only contraception is not 100% effective. • The earlier it is used after unprotected sexual intercourse, the more effective it is. • Unlike the copper IUD, it can be obtained without prescription from pharmacists (anonymously and free • of charge by minors), from family planning centres or from school nurses. • The opportunistic and repeated use of this method as the only method of contraception is less effective than a continuous method. After progestogen-only emergency contraception has been used, the user should be advised: • - to use an effective method of contraception (condoms) until the end of her • current cycle; • - to have a pregnancy test if her menstrual period does not start within 5 to 7 • days of the expected date. • When a woman repeatedly forgets to take a pill – either accidentally or because the • method is inappropriate - a method less subject to problems of compliance should be • considered (IUD, transdermal hormonal systems, hormone implants, etc).

35. 14. Assessment on ageing Because the risks of cancer and cardiovascular disease increase with age and with the approach of the menopause, the suitability of any contraceptive method should be re-assessed after the age of 35-40 years.

36. Effective communication empowers people to seek what is best for their own health and to exercise their right to good-quality health care Reconceptualizing the “patient”: Health care promotion as increasing citizens’ decision-making competencies. Health Communication 9(1),1997.

37. What is counselling? Counselling is a face-to-face process of communication by which one person helps another individual, couple, family or group to identify her/his or their needs and to make appropriate decisions and choices. Counsellors encourage people to recognise and develop their own coping capacity, so they can deal more effectively with issues ofconcern. IPPF Medical and Service Delivery Guidelines for Sexual and Reproductive Health Services Third edition (2004)

38. Contraceptive counselling Choice of method Women should make their own decision on which contraceptive method is appropriate for them. The counsellor should help each woman to match her contraceptive needs and preferences to a safe and appropriate method.

39. If the woman is visiting the clinic to start using a method of contraception, ask her if she has a particular method of contraception in mind Try to determine by discussion and review of the client’s medical and social history if the method is appropriate - If the method is appropriate, determine if the woman knows about other contraceptive options. - If the method is not appropriate (e.g., if she is breastfeeding, is less than 6 months postpartum and wants to use combined oral contraceptives; or if a barrier is unlikely to be used properly when an unwanted pregnancy would be a high risk), explain the disadvantages of using such a method and inform the client about other more appropriate contraceptive options.

40. If the woman is not considering a particular method • Ask the woman which methods of family planning she knows about. • Thisgives an opportunity to determine the level of knowledge as well • as an opportunity to correct any misinformation • Briefly describe each method to the woman • Provide additional information on the methods in which she is interested. • Show her the methods and let her examine them. • Make sureinformation on all the following is included: • - How the method works • - Effectiveness of the method • - Medical contraindications • - Possible side-effects • - Advantages • - Disadvantages

41. Encourage questions • Advise the woman that except for barrier methods no other method • provides protection against STIs and that the condom is the only method • demonstrated to protect against HIV • Determine if the woman is ready to make her decision by specifically • asking “What method have you decided to use?” • After listening to all the contraceptive options available, the woman may • still be unable to decide and may ask you to recommend a method • Suggest a method which is best suited to the woman’sparticular characteristics • and needs • If there is still some hesitation, give her some more time to consider before • making her choice.

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