Defining counselling in contraceptive information and services: outcomes from an expert think tank.

As a global public health good, contraception is a core component of the Sustainable Development Goal 3.7 (universal access to sexual and reproductive healthcare services, including family planning). Fundamentally, access to contraceptive information and services is a human right that advances other human right aspects. Quality contraceptive information and services reinforce people’s freedom to determine the number and spacing of their children and offer a range of potential benefits encompassing women’s empowerment, economic development, education and improved health outcomes, including maternal and child health. However, in low- and middle-income countries, around 218 million women of reproductive age still have an unmet need for contraception in 2019 – meeting this need could drop annually an estimated 111 to 35 million unintended pregnancies, 35 to 10 million unsafe abortions, and 299 000 maternal deaths to 113 000.1

Many contraceptive users discontinue their methods or fail to use them optimally.2 3 Quality contraceptive counselling has the potential to play a key role in supporting individuals select a method that matches their needs and expectations, mitigate any side effects, continue their method, or turn to other options, thereby reducing the unmet need for contraception, among other factors.4 There is, however, no standard definition of contraceptive counselling, although the centrality of quality counselling is underscored in different frameworks and programmatic and policy recommendations, as illustrated below.

Relevant documents include the Bruce framework, which was published in 1990 and identified six dimensions of quality for family planning services: technical competence, follow-up and continuity mechanisms, and the appropriate constellation of services, in addition to three dimensions that are specifically related to counselling – choice of methods, the information given to clients, and interpersonal relations.5 Other quality components of contraceptive counselling – given in a client-centred approach – were outlined in recent years, including needs assessment, trust-building with clients, tailored communication, shared decision-making (by eliciting and responding to client preferences), method choice, and follow-up.4 6 Attention has been called to the specific counselling needs of adolescents, such as dual protection against pregnancy and sexually transmitted infections and respect for adolescents’ autonomy.7 As for the World Health Organization (WHO), its 2016 Selected Practice Recommendations for Contraceptive Use include guidelines for counselling content for each contraceptive method (focusing primarily on side effects and dual protection), while its 2018 Global Handbook for Family Planning Providers made further recommendations on interpersonal qualities, including respect and confidentiality.

Counselling can either occur face-to-face, using digital technology, or a combination thereof. For example, the definition of the Population Council includes only face-to-face interactions involving a two-way communication between a counsellor and an individual or couple, or a counsellor and a group. The counsellor gives evidence-based information and assists the individual, couple or group to make a decision about behaviour change, taking into account the feelings and concerns of the client.8 Other authors define counselling as an interactive process between a provider and a client intended to help the client achieve a reproductive health goal.9

Drawing from the extant literature on the different dimensions of contraceptive counselling and following a systematic review on the effectiveness of counselling strategies for modern contraceptive methods,10 a think tank on the topic was held at WHO, Geneva in May 2019. The think tank gathered representatives from academia, implementing agencies and international organisations working in the contraception field (see Acknowledgements) and had the objective of identifying research and guidance gaps and other opportunities for improving the quality of contraceptive counselling. Notably, the discussions culminated in the development of a comprehensive definition of counselling, which can hopefully serve as a benchmark for further development, update and use by academia and implementing agencies. The definition reads as follows:

Contraceptive counselling is defined as the exchange of information on contraceptive methods based on an assessment of the client’s needs, preferences, and lifestyle to support decision-making as per the client’s intentions. This includes the selection, discontinuation or switching of a contraceptive method. The key principles are based on: coercion-free and informed choice; neutral, understandable and evidence-based information; collaborative and confidential decision-making process; ensuring respectful care, dignity, and choice.

The definition took into consideration the core dimensions articulated in the literature and mirrors the principles that were deliberated by the think tank: a two-way discussion and decision-making process between the client and provider, sharing objective and user-friendly information, and an approach fundamentally grounded in the rights to autonomy, dignity, privacy, respect and participation, among others.

Operationalising this comprehensive definition into clinical services will require a practical balance between the constraints inherent to resource-challenged settings and achieving programmatic goals. Based on our client-oriented definition, reaching traditional programmatic goals, such as increasing couple-year protection and modern contraceptive prevalence, should be questioned from the perspective of clients’ autonomy, freedom from coercion, and satisfaction. However, further research is needed to develop and test metrics that capture our definition dimensions of quality counselling and focus on clients’ reproductive autonomy and empowerment in decision-making.