During the past 20 years, much has been done to build a strong global policy consensus for informed choice in family planning. This consensus rests on a commitment to the health and rights of individuals, coupled with the knowledge that family planning services do not meet clients' family planning needs when individual choice is not respected.

But despite this consensus, there continues to be a wide gap between policy objectives and the realities of informed choice at the service-delivery level. This year, widely published accounts of coercion regarding family planning in general and sterilization in particular surfaced. In June, ABC's Nightline aired testimony from a former Chinese birth control official, Kiao Duan Gao, who reported that women resisting sterilization were jailed until they agreed to undergo the procedure.

In addition, the Peruvian government is reported to have used a variety of means to coerce women to undergo sterilization. On February 15, The New York Times quoted a village woman: "They always look for the poorest women. . . . They make them put their fingerprint on a sterilization paper they don't understand because they can't read. If the women refuse, they threaten to cut off the food and milk programs."

While overt, policy-level violations of informed choice occur less often than they did in the past, these accounts make clear that even at this level, informed choice remains a major concern. But even where policies are beyond reproach, many practices that threaten informed choice exist beneath the surface--at the service-delivery level--and are complex, difficult to document, and challenging to address.

Key Issues

Informed choice refers to the process by which an individual arrives at a decision about health care. It must be based upon access to, and full understanding of, all necessary information from the client's perspective.

Informed choice is affected by a complex interrelationship of factors, including formal government policies, availability of commodities (such as a range of contraceptive methods), geographic access to health care services, protocols and procedures, attitudes of health care workers, culture, and gender. The following are some key areas in which informed choice problems persist and some of the issues and questions that must be addressed before choice can be assured.

Interaction between Clients and Providers

How can providers adequately counsel clients when they have only minutes to spend with each individual? To what extent do individual clients actively seek advice or guidance about what to do? What can be done to reduce the social distance between providers and clients? How do prevailing attitudes about medical authority, gender, and power affect informed choice?

Providing Information

How do providers decide what information, or the minimum information, clients need in order to make an informed choice? How do clients and providers understand and communicate the concept of "risk"?

Informed Consent Protocols

In some circles, the term informed consent has come to mean a signed, written form used to document the individual's decision to have a sterilization or other surgical procedure. But informed consent refers more broadly to the act of consenting to health care services, whether or not the consent is written. Is oral consent sufficient for other reproductive health services? How can local systems ensure that consent is the result of a true informed choice process?

Targets and Other Evaluation Measures

Some programs continue to have quantitative objectives for overall contraceptive use or for use of particular methods. The use of such measures can bias the provision of services when providers perceive them as performance targets. What alternatives to such objectives can be used?

Eligibility Criteria

Such criteria may be imposed by institutions or governments, or they may originate with providers. Denying or promoting services on the basis of age, sex, marital status, religion, or ethnic background may violate an individual's right to informed choice.

Provider Bias

Most providers come from a medical tradition that expects them to give guidance about options to clients. How can the client's right to information and method choice be balanced against protectionism, the provider's preference, and professional judgment?

Much progress has been made to ensure that women and men make informed and voluntary choices about family planning and other reproductive health choices. But the complexities of human interaction mean that this area will always require sustained vigilance on behalf of clients, providers, and informed choice advocates.

Rachael N. Pine is AVSC's director of public affairs.