1. What is informed choice?
In practice, informed choice means that individuals and couples decide freely the number and timing of their births, that they can decide whether or not to use contraception, and that they have access to a choice of contraceptive options to realize their reproductive intentions. It also means that they experience neither barriers nor coercion in putting their decision and intentions into practice. Further, choice exists when legal and social practices are in place to support this right, and the health system is able to provide the counseling, information, competent providers, and range of family planning (FP) methods required to ensure that adequate and appropriate options are available. Individuals and communities must also be effectively engaged in informing services and in continuous quality improvement.
Informed choice has long been a cornerstone of reproductive rights and a fundamental tenet of quality FP services. The concept emerged during the late 1970s and early 1980s as pertinent to ensuring the rights of female sterilization clients. In 1977, USAID issued Policy Determination 70 (PD-70) (later updated to PD-3 in 1982) to safeguard informed consent and voluntary sterilization. In response to PD-3, EngenderHealth (AVS at the time) developed a series of voluntarism/informed choice policies to guide FP programs that offered female and male sterilization services, including policies on counseling, informed consent, the availability of temporary FP methods, and compensation to personnel. These voluntarism policies were originally meant to guide sterilization, but later on supported a foundation for informed choice in family planning programs more broadly.
In 1994, the human right to informed choice in FP was asserted by the International Conference on Population and Development (ICPD) Programme of Action as essential to empowering women, spurring sustainable development, and eradicating poverty. Sixteen years later, the international community reaffirmed this right by committing at the United Nations 2010 World Summit to “ensuring that all women, men and young people have information about, access to and choice of the widest possible range of safe, effective, affordable and acceptable methods of family planning.” Yet, despite these commitments, reality has not caught up with the rhetoric in many countries where women and couples have few real FP options.
2. What are reproductive rights?
As expressed in the UN Programme of Action (adopted at the International Conference on Population and Development [ICPD] in Cairo in 1994), reproductive rights embrace certain human rights already recognized in national laws, international human rights documents, and other consensus documents. These rights rest on the recognition of the basic rights for all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children and to have the information and means to do so, and the right to the highest attainable standard of sexual and reproductive health. They also include the right of all to make decisions concerning reproduction free of discrimination, coercion and violence.
According to Erdman and Cook, there are three broad categories of reproductive rights under which family planning falls:
- Rights to reproductive self-determination (right to bodily integrity and security of person and the rights of couples and individuals to decide freely and responsibly the number and spacing of their children)
- Rights to sexual and reproductive health services, information, and education (including right to the highest attainable standard of health)
- Rights to equality and nondiscrimination (right to make decisions concerning reproduction free of discrimination, coercion, and violence)
Some experts include the rights to privacy and life to this list and note that a range of other rights, such as the right to education—while not reproductive rights per se—are also considered human rights and indivisible, greatly affecting reproductive health and fertility.
Erdman, J. N., and Cook, R. J. (2008). Reproductive Rights. International Encyclopedia of Public Health. Editor-in-Chief: Kris. Oxford, Academic Press: 532–538.
Cottingham, J., Germain, A., and Hunt, P. (2012). Use of human rights to meet the unmet need for family planning. The Lancet 380(9837): 172–180.
3. When did the concept of voluntary and human rights-based family planning emerge?
The foundation for voluntary and human rights-based family planning (FP) can be traced to the 1968 International Conference on Human Rights, which included in its proclamation that “parents have a basic human right to decide freely and responsibly the number and spacing of their children” (UN, 1968: 4). This right was reaffirmed at three subsequent international population conferences in Bucharest in 1974, Mexico in 1984, and Cairo in 1994. The landmark International Conference on Population and Development (ICPD), which took place in Cairo in 1994, affirmed that:
…reproductive rights embrace certain human rights that are already recognized in national laws, international human rights documents, and other consensus documents. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children, and to have the information and means to do so; and the right to attain the highest standards of sexual and reproductive health. It also includes their right to make decisions concerning reproduction free of discrimination, coercion and violence, as expressed in human rights documents (UNFPA, 1994, Programme of Action para. 7.3).
4. What is contraceptive method mix?
Method mix refers to the distribution of contraceptive methods used by a population and is considered a proxy measure for the existence of choice in family planning programs.
5. Is there an ideal contraceptive method mix for programs?
While the international community has not reached a consensus on an “ideal” contraceptive method mix, experts agree that there is reason for concern when only one or two methods predominate in a given country, resulting in “method skew.”[i] It is also recognized that overall contraceptive use increases with the number of options available[ii] and these options should include methods with a mix of characteristics that accommodate a range of client preferences and reproductive intentions (such as emergency, short-acting, long-acting or permanent; user- controlled or provider dependent; with hormones or not; protecting against HIV/STIs).
[i] Bertrand J T, Rice J, Sullivan T M, and Shelton J. 2000. Skewed Method Mix: A Measure of Quality in Family Planning Programs. USAID/MEASURE Evaluation.
[ii] Ross, J. A. et al. 2002. Contraceptive method choice in developing countries. International Family Planning Perspectives 28(1):32–40.
6. What international treaties, declarations, and conventions have particular relevance for reproductive health and rights, including family planning?
Treaties (have the status of international law)
- International Covenant on Economic, Social and Cultural Rights (1966)
- International Covenant on Civil and Political Rights (1966)
- Convention on the Elimination of all Forms of Racial Discrimination (1969)
- Convention on the Elimination of all forms of Discrimination Against Women (1979)
- Convention on the Rights of the Child (1989)
Conference Documents (add content and meaning to human rights)
- Tehran Conference on Human Rights (1968)
- World Population Plan of Action (1974, 1984)
- International Conference on Population and Development Programme of Action (1994)
- Fourth World Conference on Women Beijing Declaration and Platform for Action (1995)
- United Nations World Conference on Human Rights (1993)
Declarations (no legal status, but have “undeniable moral force and provide practical guidance to States in their conduct” [UNHCRH])
- Universal Declaration of Human Rights (1948)
- Millennium Declaration (2000) and related Millennium Development Goals (2001), which included Target 5b (universal access to reproductive health) in 2007
For a complete list of relevant treaties, conventions, and agreements related to reproductive health and rights, see UNFPA’s State of World Population 2012 – By Choice, Not By Chance: Family Planning, Human Rights and Development.
7. What is informed consent?
Informed consent is a medical, legal, and rights-based concept whereby clients agree to receive medical treatment, such as surgery for a contraceptive method or to take part in a study, ideally as a result of the client’s informed choice (The ACQUIRE Project, 2008). Informed consent should be the result of an informed and voluntary decision making process. Just having the written or verbal consent of the client does not mean that it was informed indeed and voluntary. So, the focus should be on the decision making process and the tool that facilitates it: counseling.
8. What is a rights-based approach to family planning?
The rights-based approach to family planning and sexual and reproductive health assumes that health and rights are inseparable and that individuals have the right and the capacity to make decisions about their lives. The rights-based approach was adopted at the 1994 International Conference on Population and Development (ICPD), hosted by the United Nations in Cairo, Egypt.