In family planning, the provision of services is often a bidirectional process; clients have preferences for the contraceptives that they want, while providers seek to guide clients to achieve those preferences. This describes the urban Malawi setting, where family planning counselling usually involves group counselling followed by individual counselling. As part of this process, counsellors introduce all family planning methods available using the ‘Kulera’ flipchart that is recommended by the Ministry of Health.
Research has shown that contraceptive prevalence in Malawi has increased significantly from 46% in 2010 to 59.2% in 2015. This jump can be attributed to increased funding from donors and a prioritization of family planning service provision by the Ministry of Health. However, 37% of women in Malawi discontinued use of their preferred contraceptive within a year, which implies that frictions may still exist to prevent women from realizing their contraceptive preferences.
Within this context, researchers Mahesh Karra and Kexin Zhang from Boston University conducted a study that aimed at exploring how effective user-centered counselling approaches may be to help women make informed decisions when considering contraceptive methods. The study tested elements of user-centered counselling and investigated two channels through which user centered counselling can affect concordance between women’s preferences and choices over contraceptive methods. The study was funded by the Hewlett Foundation and was conducted in Lilongwe, Malawi from 2018 to 2019. The study sample was 782 married women aged 18-35. Their hypothesis set out to prove two things, 1.) short-tailored counseling approaches would allow women to express and realize their contraceptive preferences more effectively 2.) male involvement in contraceptive counseling may allow women to more effectively express their contraceptive preferences and, in turn, translate their preferences into behavior.
In this study, women were randomly assigned into four groups based on two interventions, 1) a short tailored counseling session, and 2) husband invitations (T0: long counseling, no husband invitation; T1: long counseling, with husband invitation; T2: short tailored counseling, with no husband invitation; T3: short tailored counseling with husband invitation). Women assigned to the husband invitation intervention could choose whether or not to invite their husbands/partners to family planning counseling sessions. This approach to male involvement differs from prior studies, which required husbands to attend counseling sessions, and leaves it up to the woman to decide whether she wants her husband to participate. The short, targeted, and tailored counselling approach allowed for the women’s preferred methods to be elicited based on their preference for method attributes. Women or couples who were assigned to this intervention were counseled on up to 5 methods that aligned the most with their preferred attributes.
Following the initial counselling session, women received family planning services for a month including follow up surveys, free private transportation to the Good Health Clinic in Kauma, coverage of all family planning related costs incurred and free mobile credit to make appointments with field manager / taxi driver. Women who did not seek services at the Good Health Clinic were followed up by phone or through home visits.
Preliminary results show that women who received the short, targeted counseling procedure were slightly more likely to change their stated ideal method but less likely to be using their stated ideal method at follow-up. They were also more unsatisfied with their currently used method at follow-up. Women who were encouraged to invite their husbands/partners to counseling were less likely to change their ideal method from counseling to follow-up, more likely to switch from their currently used method to another method, and slightly more likely to be using their stated ideal method at follow-up. However, they were no more likely to be satisfied with their current method at follow-up.
Both interventions adopted user-centered approaches to counseling, and both aimed to prioritize women's preferences in order to move closer towards the goal of informed choice in contraceptive decision-making. However, neither approach seems to give a strictly preferred outcome. Specifically, the short-tailored counseling encouraged women to express and revise their contraceptive preferences, but over time, their preferences were no more likely to be realized. On the other hand, encouraging women to invite their husbands to counselling sessions seemed to allow women to realize their stated preferences but may have also potentially crowded out the women's expressions of their own individual preferences.
In the future, Karra and Zhang propose to further explore the trade-off that women face between: 1) making independent choices that reflect their individual preferences versus 2) incorporating their partner's preferences to make "jointly, but not necessarily individually better off" decisions over contraceptive methods.
