Is informed choice in family planning practised in India?

G Prakasam -

The success of any public health initiative or programme depends to a very great degree on the involvement of the community. Community’s involvement in health has acquired a key role in the recent years in the wake of the 1994 ICPD at Cairo the programme of action of which states that ’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 information and means to do so and to ensure informed choice and make available a full range of safe and effective methods.’

The truncated success of the family planning programme in India in the past resulting in the need to postpone the health goals a few times, and the community involvement as the vehicle for faster progress have since been well recognised all over. ’Informed choices’ in the family planning have to be intensively practiced if community involvement has to give a meaningful direction and momentum to the Reproductive & Child Health Programme. The best decisions, undisputedly, about family planning are those that people make for themselves rather than those that others, however component they (latter) be, make for the people. These decisions therefore ought to be arrived on accurate and comprehensive information and a wide range of contraceptive options. People who make an informed choice can use family planning more effectively and safely.

Programmes and providers have the fundamental responsibility of enlightening people with full information on contraceptives to enable the most appropriate choices. The decisions about child bearing and contraceptive fulfill a person’s needs only when they reflect individual desires and their values and are based on accurate and relevant information and are medically appropriate. To make informed choices, people need to know thoroughly about family planning, to have access to the range of methods, and need support for individual choice from social policies and community norms.

There are a multiple benefits from informed choices: people use family planning longer if they choose the methods for themselves, access to a range of methods makes it easier for people to choose a method they like and to switch to other methods whenever needed. They invite and establish a trusting partnership between clients and providers and enables people to take more responsibility for their own health. The process by which an individual arrives at a decision about health care is an informed choice, when it is based upon access to and full understanding of all necessary information from his or her own perspective. The process should result in a free informed conscious decision by the individual about whether or not she or he desires to obtain health services and if so what method or procedure she or he will choose and consent to receive.

The concept of informed choices can be applied to a wide range of sexual and reproductive health decisions. The focus will be on whether to seek to avoid pregnancy; whether to space and time one’s child bearing, whether to use contraception, which of the methods to use and whether and when to continue to switch methods. It refers to a decision that a person can make for himself or herself and definitely not to a process that a family planning provider carries out. Nonetheless, policy makers, programme managers and service providers had important roles to play. The Reproductive Health Programme can facilitate people make informed choices best by adopting a strategy that covers five areas: policy, communication or programs, access, leadership and management and client-provider communication. Being informed is necessary to take a well-considered decision, but by itself not sufficient.

A person needs choices also including access to a range of contraceptive methods, convenient sources of supply, good quality services and the ability to continue and discontinue using the method, as desired. Informed choices are possible only when prevailing social policies and community and gender norms support personal decision making as regarding family planning. Such support helps people have the confidence and opportunity to make their own family planning decisions rather than have these decisions imposed on them whether by medical personnel, family members, community pressures, or others. The levels of access to family planning information and choices fully obtaining upon educational attainment, family background, social class and providers attitudes.

In this background it is necessary to analyse the development for the National Family Welfare Programme in the country and judge whether the crucial ’informed choice’ that exists at all to any degree. Analyses of the contraceptive prevalence rate, effective couple protection rate across the states over a span of time very clearly exposes that the programme is far too predominantly sterilisation oriented, that too female-sterilisation oriented. In the country as a whole and in majority of states including Karnataka, the share of the three spacing methods under the Government programme namely: IUD insertions, conventional contraceptives and oral pills does not exceed one-tenth in the total acceptance (10%).

The Government programme of family planning itself is a very small kit of only four methods namely: sterilisation, IUD insertion, distribution of conventional contraceptives (Nirodh) and oral pills. Traditional and natural methods are not a part of the government campaign. It is doubtful if the service providers are trained to talk about these indigenous methods. The following statement indicates the composition of the couple protection rate during the last few years.

Not only acceptance levels, but also awareness levels of spacing methods, which are a part of the Government programme are extremely poor. Even after five of decades implementation of the programme and even after half a decade of the launching of the Reproductive and Child Health programme, the family welfare scheme in the country is dominated by one only one method, sterilisation. There is no dent in the method-composition. It is a well-known fact that adequate emphasis on spacing methods has twin advantages of improving the health of the mother and child and of reducing the facility rates. Had ’informed choice’ been sincerely practiced in India, the method matrix of the FP Programme would have been much different than what it actually is, and spacing methods would have enjoyed a much greater share. The reversible (spacing) methods are relegated to the background. The inevitable conclusion drawn from the analyses is that informed choice in family planning is conspicuous by its near total absence in India.

Instead the one-point programme of sterilisation totally dominates the scenario. There is need to set the situation right. National governments have responsibility for ensuring that the principle of informed choice becomes reality. Policies that establish demographic targets, incentives and disincentives in family planning Programmes are undesirable because they focus more on achieving numerical goals instead of meeting people’s health needs, with quality and satisfaction. Such strategies would not result in reducing facility levels also fast.

(The writer is State Demographer, Directorate of Health & Family Welfare Services, Bangalore)