In India, women's contraceptive choices frequently differ from the recommendations of their health care providers.1 Of more than 8,000 women who received explanations of all methods available through the government family planning program, 59% requested the IUD, while health care providers recommended the method for 33%. Providers advised 36% of women to adopt the hormonal implant, yet only 6% of women preferred it. Fifteen percent of women requested tubal sterilization and 8% selected condoms, but providers recommended those methods for 19% and 3% of women, respectively. Nevertheless, more than 90% of the women ultimately obtained their method of choice.
To determine the relative acceptability of the available methods--the implant, the Copper T 200 IUD, combined oral contraceptive pills, condoms, vasectomy and tubal sterilization--investigators recruited 22,178 women who sought contraceptive services at one of 10 research centers at medical colleges around the country during the one-year study period. Of these women, 64% had already decided on a contraceptive method and did not receive further counseling.
The remaining 8,077 women discussed all of the available methods with their health care provider, including each method's benefits and liabilities. All information was presented in the patient's own language and in simple terms to ensure comprehension. In addition to verbal explanations, the staff provided pamphlets and brochures and exhibited the contraceptive devices. The presentations lasted an average of 10 minutes. The women then made their own choice.
All women were screened to rule out any contraindications to their chosen contraceptive, and, if necessary, they were counseled about a more appropriate option. Data were gathered on demographic characteristics, obstetric history and choice of contraceptive.
Women's initial choices frequently differed from their health care provider's recommendations for them. Overall, 59% wanted the IUD, 15% tubal sterilization, 8% condoms, 6% oral contraceptives, 6% the implant and 1% vasectomy; 5% preferred not to use a method. Health care providers, in contrast, recommended the implant for 36%, the IUD for 33%, tubal sterilization for 19%, oral contraceptives for 3%, condoms for 3% and vasectomy for 2%; they suggested that 3% of women use no method.
In total, 61% of the women received an IUD, with smaller proportions adopting tubal sterilization (16%), condoms (9%), oral contraceptives (5%), the implant (5%), other methods (1%) or no method (3%). More than 90% of the women received their method of choice--from 85% of those who wanted to be sterilized to 92% of those who preferred the IUD or the implant. Contraindications were the main reason cited when women did not receive the method they preferred.
To better understand women's contraceptive choices, the investigators examined their demographic and reproductive characteristics. Women were most likely to seek contraceptive services following a medical termination of pregnancy (50%) or in the interval between pregnancies (43%); small proportions adopted a method during the postpartum period or following a cesarean section. Women adopting a method following a medical termination or in the interval between pregnancies were most likely to choose the IUD (65% and 58%, respectively), while those seeking contraception following a cesarean section were most likely to prefer tubal sterilization (62%).
As might be expected, the proportion of women requesting permanent methods of contraception increased with age and family size and the proportion selecting spacing methods decreased. For example, as family size rose from one child to four or more children, the proportion of women adopting tubal sterilization climbed from 2% to 63%, while the proportion of women accepting the IUD fell from 75% to 21%. Women who chose spacing methods were 25-26 years old, on average, while those who adopted female sterilization were about 29 years old.
Women's area of residence (categorized as rural, urban or urban slum) did not reliably predict their choice of a contraceptive method. However, women who chose sterilization were more likely to live in rural areas (27%) than in urban areas (16%) or in urban slums (14%), and women who selected the contraceptive implant were slightly more likely to live in urban areas (6%) than in rural areas (3%) or in urban slums (2%).
Uneducated women were more likely than women with any level of schooling to select female sterilization (25% vs. 11-19%), possibly because uneducated women tended to have larger families. At all educational levels, women were increasingly likely to choose sterilization as family size increased. The proportion adopting sterilization ranged from less than 1% among women with more than a high school education and only one child to 73% among illiterate women with four or more children.
The investigators note that the great majority of the women in this study were able to make an informed contraceptive choice after receiving balanced information about their options. In addition, they point out, differences of opinion with the health care provider did not deter the women from selecting the contraceptive method that they felt best suited their particular needs. The investigators conclude that there is an urgent need for "a reorientation training program that makes available appropriate teaching and mass media materials both to family planning providers and potential clients to promote the concept and practice of informed choice in the national program."--L.J. Ninger
1. Baveja R et al., Evaluating contraceptive choice through the method-mix approach: an Indian Council of Medical Research (ICMR) Task Force study, Contraception, 2000, 61(2):113-119.