1999_4_contraceptive choice

Contraceptive choice as a reproductive right

Georgeanne Neamatalla Kumar

The term "reproductive rights" refers to an individual's right to exercise control over his or her own body, sexuality and reproduction. These rights have been affirmed in a number of laws and international conventions and "rest on the recognition of the basic rights of all couples and individuals to decide freely and responsibly on the number, spacing and timing of their children and to have information and means to do so" (Par. 7.3, ICPD Programme of Action). Contraception, the chief means of controlling fertility, enables people to space and limit childbearing.

Condoms are sold from the counter inside a bar adjoining a roadside hotel

The right to contraceptive choice implies the ability to choose whether and when to use family planning, the right to a choice of methods, to information about the methods and the freedom to decide which method to use. Respecting individual choice and autonomy, successful family planning programmes recognise clients as individuals and make an array of contraceptive choices available to all clients, regardless of age or marital status. No single contraceptive method can meet the different needs and preferences of all clients, nor the changing needs of individual clients as they move through their reproductive life cycle.

Family planning programmes should ensure access to comprehensive information and employ trained professionals who respect clients as individuals with different needs and circumstances. The service provider's role is to support the client's right to choose, to facilitate client decision-making without bias for or against specific outcomes, and to inform and fulfil the client's request for services.

Constraints and challenges

For various reasons, the reality of contraceptive choice often falls short of the ideal. Contraceptive choice can be limited by the larger social and economic context with all of its inequities. Clients' status within culture and the family (economic, education, gender, age and marital) influences their awareness of and ability to exercise their reproductive rights. Members of marginalised groups in society are less able to assert their rights than more privileged citizens, as they often lack access to choices and are less able to make autonomous decisions, even when options are presented. Clients' literacy level and social mobility influence their access to contraceptive information and services. At the clinic, their capacity to make autonomous decisions is also influenced by the imbalance of knowledge and power between clients and providers. Lack of education and low status make some people, especially women and youth, ill-prepared to assert their right to make their own health care choices. In many settings, the "medical model" of service delivery still prevails over a more client-centred approach: providers tend to focus on medical considerations and often fail to address the client's feelings and personal circumstances. Also, many providers direct their clients' choice, "pushing" a particular contraceptive method, rather than helping them choose for themselves.

Even when clients have the wherewithal to exercise their right to choose, a number of factors related specifically to the family planning programme itself may limit contraceptive choice:

resource constraints;
policies and practices at the service delivery level that limit method mix, either by programme design or because of the absence of trained providers or supplies;
limited or inconvenient hours or scheduling that limit the availability of certain methods to certain days;
fee structures that make certain methods economically inaccessible to poor clients;
geographic inaccessibility;
eligibility criteria such as age, parity and marital status that deny some clients choices they might want;
parental or spousal consent requirements that override client decision-making.

Safeguards

Family planning programmes can put safeguards in place to ensure individuals' reproductive rights and to make contraceptive choice real. Programmes should include an explicit policy statement on informed choice as the client's right and they can protect this right through staff training and supporting practices: effective family planning counselling services ensure that clients understand their options and help them to exercise their right to make decisions. They should involve and consult clients in programme design and elicit their feedback for programme monitoring and evaluation. Further, they can ensure real method choice, either at the individual service site or through an effective referral system, to give clients the widest possible range of options to meet their individual needs.

The challenge for family planning programmes is to keep their role in perspective with the broader health, rights and cultural context in which they operate. Their mission should be to meet individual clients' contraceptive needs to fulfil their reproductive intentions as an expression of their basic human and reproductive rights, respecting their autonomy and upholding their right to choose.

Georgeanne Neamatalla Kumar, Senior Director AVSC International, 440 Ninth Avenue, NY, NY 10001, USA; Tel: +1-212-561.8070; Fax: +1-212- 779.9489; e-mail: jkumar@avsc.org