March 2001, Vol. 7, No. 1

Family Planning
Investigating Informed Choice in Peruvian Clinics

In order for family planning clients to make informed choices about contraceptive methods, clinicians need to determine their clients’ wishes and provide them with a selection of appropriate methods. Moreover, providers must detail side effects that might result from each method and instruct clients on how to use the chosen method. Studies have shown that in a number of countries, including Peru, these basic requirements are not always met. Urban family planning providers in Peru have stated that short counseling sessions resulting from case overload in clinics prevent them from giving clients complete information. Population Council researcher Federico León and his colleagues tested this claim by investigating the exchange of information in Peruvian clinics using women trained to act as clients.

Simulated clients
The researchers investigated 19 randomly chosen large urban health centers throughout Peru. Each clinic was visited on different days by six trained simulated clients. These clients were 28 healthy women aged 20 to 30 years, each of whom had previously given birth to one child. The women were trained to present the same client profile. When asked about their reproductive intentions, the women said they wanted to postpone pregnancy. When asked about their current use of contraception, the women said that they were using the rhythm method but did not feel secure with it and wanted a new method. They were also instructed to say that they did not want to take oral contraceptives or receive an intrauterine device. They also stated that their husbands would not consent to using condoms on a regular basis.

The women were told to choose the injectable contraceptive Depo-Provera. The researchers carefully trained the simulated clients to assume the characteristics of a healthy woman with no contraindications to the use of Depo-Provera. If the provider appeared ready to administer the injection, the client was instructed to say that she wanted to discuss the matter with her husband first, thank the provider, and leave. After leaving the clinic, each woman documented whether the clinician had exchanged information with her on each of 46 specific topics, ranging from asking her age to telling her that Depo-Provera might cause irregular menstruation. The client also estimated the amount of time she had spent with the provider and registered other observations.

Inefficient use of time
The evaluation revealed that in more than 90 percent of cases providers asked about the client’s age, number of children, and last date of menstruation; asked the client to select a method; and told the client that Depo-Provera is administered every three months. In less than 10 percent of cases, however, were clients asked whether they wanted more children, given pelvic exams, given more specific information about the timing of the Depo-Provera shots, or asked about their current menstrual bleeding patterns.

Providers were inefficient in the use of their time. In 64 percent of the cases, for example, they discussed condoms extensively, despite the fact that the client was not interested in this method. (This figure does not include the 18 percent of providers who mentioned condoms as a method to use until the client could begin using Depo-Provera.)

“Providers should be more practical in assessing the needs of clients and helping them choose appropriate methods,” says León. “They should also focus more thoroughly on the method chosen by the client.”

The researchers found that in counseling sessions lasting 8 minutes or less, providers typically exchanged information with clients on roughly 14 of the 46 topics. When sessions lasted from 9 to 14 minutes, providers exchanged information with clients on about 19 of the 46 topics, a statistically significant increase. Further increases in the duration of sessions resulted in statistically insignificant improvement in information exchange.

“While very short sessions do limit the amount of information exchanged, it appears that the efficiency of information exchange diminishes when counseling sessions last more than 14 minutes. Changes in counseling strategy are needed,” explains León.

The researchers found that most providers spent a lot of time showing clients a flip chart depicting every available contraceptive method. Although they commend the intent to provide full contraceptive choice, the investigators also emphasize the importance of informing patients in detail about the side effects and use of their chosen method. They propose that providers explore the beliefs and attitudes of clients and their partners that are relevant to the use of family planning methods. Then the provider can focus on the few methods that are pertinent to the client’s situation and ask the client to make a choice. With the time saved in describing unsuitable contraceptive methods, providers could address all the important issues relating to the chosen method.

Source
León, Federico R., Rosa Monge, Adriana Zumarán, Ingeborg García, and Alex Ríos. 2001. “Length of counseling sessions and amount of relevant information exchanged: A study in Peruvian clinics,” International Family Planning Perspectives 27(1):28–33, 46.

Outside funding
United States Agency for International Development

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