Many clinics and hospitals that provide reproductive health services face a difficult challenge: striking a balance between meeting clients' immediate medical needs and reaching those clients who also wish to plan ahead for future contraceptive use.

This challenge is particularly apparent for facilities that provide contraceptive counseling to women who come for treatment following an incomplete abortion. Though these women may be most immediately concerned with obtaining medical attention, they are also likely to be interested in learning about contraception so as to prevent unintended pregnancy and abortion in the future.

Striking a Balance

One agency that is really trying to balance these concerns is Oriéntame, a Colombian organization dedicated to providing reproductive and sexual health services and to defending and promoting sexual and reproductive rights. Loosely translated, oriéntame means "counsel me."

Along with its other services, Oriéntame provides high-quality, compassionate treatment of incomplete abortion. Oriéntame also offers counseling and services for postabortion contraception to all its clients.

Improving Postabortion Family Planning Services

According to a 1995-1996 study conducted at Oriéntame and at ProMujer and SiMujer (two other Colombian institutions that provide similar services), both clients and providers feel that when a woman comes to a clinic for treatment of an incomplete abortion, her first concern is to get treatment for the medical problem. Yet the study also showed that more than half of clients wanted to receive contraceptive information and a family planning method.

For the study, which was conducted with technical support from AVSC, researchers surveyed providers and clients and conducted in-depth interviews with clients. They also reviewed clinical records and conducted formal observations of each clinic's services to understand the day-to-day realities of providing care. After analyzing the data, each clinic convened its staff to translate the research results into recommendations for improving services.

Making Counseling and Information More Available

The challenge for providers at the sites has been to convey information and facilitate choices while being sensitive to clients' readiness to discuss contraception.

The study showed that, to best meet clients' needs, family planning counseling and information should be made available at any point during a client's visit.

For example, before the study, contraceptive counseling for clients took place before the medical procedure, at a time when some women are upset or nervous and cannot ask questions.

In addition, at Oriéntame only designated counselors participated in counseling - doctors and nurses were not trained in counseling skills.

As a result of the study findings, Oriéntame will extend training in counseling skills to all types of provider, so that each knows how to respond to a client's needs when the client is ready - not only during counseling sessions, but at any point during the visit. At SiMujer and ProMujer, doctors and nurses, who are already trained in counseling skills, will increase their participation in the counseling process.

All three institutions will also try to modify their services so that they can offer counseling after the procedure and during follow-up visits.

Clients Suffer When Providers Are Ill-Informed

Nearly all the women in the study reported that they felt the contraceptive counseling at the clinics was good. The majority of clients also said that counseling had helped them decide which method to use. However, about one in five women said they had not been given information on methods in which they were interested.

According to their survey responses, some providers were reluctant to recommend certain methods, including the rhythm method, Norplant implants, and injectables.

Providers said they avoided suggesting the rhythm method because they did not think it was an effective method. However, clients reported that rhythm played a major role in their contraceptive practice, especially at the beginning of their sexual relationships - half of the clients said they had used it at some time, and one-third said they were using it when they got pregnant. A substantial number of providers rated their knowledge of Norplant implants and injectables as "average" or "deficient," which may account for why some providers did not recommend the method.

All three institutions plan to update providers in contraceptive technology and work with them to examine their prejudices about certain methods. Providers at each institution will be trained in natural methods, including the rhythm method, so that they can provide more accurate information to clients.

Provision of Methods

The study found great inconsistencies in the way different methods are supplied and priced - even within the same institution.

At one site, for example, condoms and spermicides are free, but only to adolescents and only when supplies are available. Vasectomy is offered on a sliding fee scale at this site, but tubal ligation is available only by referral to a neighboring clinic. Neither injectables nor diaphragms are provided at this clinic, and there is no referral procedure for women who would like to get them.

All three institutions now plan to review their provision of contraceptive methods. They hope to expand the range of methods offered - either on-site or through formal referral relationships with nearby facilities.

The Role of Men

The study showed that men influence their partner's use of contraception. For example, some women said they did not use a contraceptive method because their partner said he was infertile or told them "nothing will happen." Some said they changed their minds about having a tubal ligation because their partner disagreed with the decision. Some women also reported that their partners refused to use a method.

Researchers concluded that men's positions on contraception fell into three categories: those who had strong opinions and sometimes overruled their partner's decision, those who were indifferent and wanted their partner to make the decision, and a small number who wanted to discuss methods with their partner.

In light of this finding, the three institutions are examining ways to involve both partners in contraceptive decision making. Oriéntame in particular is redoubling its efforts to include both partners in counseling - while at the same time ensuring women's autonomy. In this way, they hope to address men's fears or gaps in knowledge and help them support the couple's contraceptive use.

Looking Ahead

To keep services focused on the needs and wants of clients is an essential part of building high-quality reproductive health services. Using studies like this is one way caring, committed institutions can keep this focus and foster continual quality improvement.

In this study, each institution learned a great deal about how clients perceive services, about the kind of care clients want and need, and about how best to strengthen services.

By bolstering providers' knowledge of contraception and counseling, increasing the number of methods available, making them easier to get, and ensuring that clients have clear written information about family planning, the three institutions are working to help women in Colombia enjoy safer reproductive and sexual lives.

The authors would like to thank Margoth Mora and Cristina Villarreal of Oriéntame and Andrea Eschen of AVSC for their contributions to this article.

Pamela Bolton is a research associate for AVSC International. Martha Stella Castaño Osorio is a researcher for Oriéntame.