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Family Planning Module: 3. Counselling for Family Planning

Study Session 3  Counselling for Family Planning

Introduction

The primary objective of counselling in the context of family planning is to help people in your village decide on the number of children they wish to have, and when to have them. You can help them to choose a contraceptive method that is personally and medically appropriate. Through your counselling sessions with them, you will make sure that they understand how to use their chosen method correctly, to ensure safe and effective contraceptive protection.

In this study session, you will learn about the general concepts and principles of family planning counselling, the steps for conducting family planning counselling, and the factors affecting counselling outcomes.

Learning Outcomes for Study Session 3

When you have studied this session, you should be able to:

3.1  Define and use correctly all of the key words printed in bold. (SAQ 3.1)

3.2  Discuss the general principles of counselling for family planning and describe the contexts in which counselling can take place. (SAQs 3.1 and 3.2)

3.3  Explain the special nature of family planning counselling. (SAQ 3.3)

3.4  Describe the steps of family planning counselling. (SAQ 3.4)

3.5  Describe the factors influencing family planning counselling outcomes. (SAQ 3.5)

3.1  Concepts of counselling

In Study Session 11 of the Health Education, Advocacy and community Mobilisation Module, you learnt that counselling is a face-to-face communication that you have with your client or couple in order to help them arrive at voluntary and informed decisions. It is somewhat different from advice, in which you try to solve a client’s problem by giving information and your personal opinion.

  • Who makes the decision: (a) when advice is given, and (b) after a counselling session?

  • (a)  When giving advice, you are making the decision for the client who has come to see you.

    (b)  After a counselling session, the client, or couple should make their own informed decision.

Family planning counselling is defined as a continuous process that you as the counsellor provide to help clients and people in your village make and arrive at informed choices about the size of their family (i.e. the number of children they wish to have).

Informed choice is defined as a voluntary choice or decision, based on the knowledge of all available information relevant to the choice or decision. In order to allow people to make an informed choice about family planning, you must make them aware of all the available methods, and the advantages and disadvantages of each. They should know how to use the chosen method safely and effectively, as well as understanding possible side-effects.

Always remember that family planning counselling is not a type of lecture from you to those who have come to you for help. In the process of family planning counselling there should be mutual understanding. You should show respect to the client who has come to see you, and deal with their problems and concerns about contraception in a straightforward way. There are a variety of approaches for different types of family planning counselling. For example, the way you would approach a session with a group would be different from the way you would work with an individual. The most common settings in which family planning counselling can take place are described below.

A Health Extension Practitioner is sitting on a bench opposite a woman and giving individual counselling.
Figure 3.1  A Health Extension Practitioner giving individual counselling.

3.1.1  Individual counselling

You will find that in most cases individuals prefer privacy and confidentiality during communication or counselling with you. It is important to respect the needs and interests of a client by finding a private room or place where you can talk with them (Figure 3.1).

  • When do you think that individual counselling is important?

  • When dealing with the confidential matters that relate to family planning and other reproductive health issues, individual counselling is best.

3.1.2  Couple counselling

Couple counselling is when you give a counselling service to a couple or partners together (Figure 3.2). This is particularly common when they are thinking of using irreversible family planning measures, such as voluntary surgical methods.

A couple are seated opposite a Health Extension Practitioner who is giving them advice.
Figure 3.2  A Health Extension Practitioner counselling a couple.

3.1.3  Group information sharing

A group of people are seated around in a circle.
Figure 3.3  Group counselling and information sharing.

Group information sharing is used when individual counselling is not possible, or if there are people in your village who are more comfortable in a group (Figure 3.3). In this situation, after greeting everyone in a friendly manner, you would explain to them the benefits of family planning, discuss briefly common myths and mistaken beliefs about family planning, and then inform the group about how to obtain appropriate contraception. It is a cost-effective way of information sharing and answering general questions, but people are not likely to share their more personal concerns with you in this setting.

3.2  General principles of counselling and counsellor characteristics

You have already learnt about the general principles of counselling in the Health Education, Advocacy and Community Mobilisation Module, and about what characteristics and skills you need to display to ensure a successful outcome to your counselling sessions. In this section, you will check your understanding of these principles and characteristics before considering the additional requirements for successful family planning counselling.

3.2.1  General principles of counselling

Stop reading for a moment and think about the general guidelines for effective counselling that you learnt before.

  • What are the general principles that you should follow for a successful outcome to a counselling session?

  • These are the important principles and conditions necessary for effective counselling:

    • Privacy — find a quiet place to talk.
    • Take sufficient time.
    • Maintain confidentiality.
    • Conduct the discussion in a helpful atmosphere.
    • Keep it simple — use words people in your village will understand.
    • First things first — do not cause confusion by giving too much information.
    • Say it again — repeat the most important instructions again and again.
    • Use available visual aids like posters and flip charts, etc.

You need to remember these guidelines when you are counselling for family planning, but there are additional considerations because family planning is a particularly sensitive issue. You will learn about these in Section 3.3.

3.2.2  Skills and characteristics of a counsellor

Once again, remind yourself of the general skills and characteristics you need to be a successful counsellor.

  • What are the most important characteristics you should bring to your counselling role?

  • The most important characteristics are:

    • Respect the dignity of others.
    • Respect the client’s concerns and ideas.
    • Be non-judgmental and open.
    • Show that you are being an active listener.
    • Be empathetic and caring.
    • Be honest and sensitive.

3.3  The special nature of counselling for family planning

Many people have strong ideas about family planning, but some of the ideas they have may be based on myth or mis-information. You need to be respectful and welcoming when sharing ideas, and demonstrate commitment to the necessary values and principles of family planning.

Try to find out your clients’ views by encouraging them to talk. Do not ask them direct and judgmental questions such as: ‘Are you one of those people who believe that modern family planning is forbidden for religious people?’ Such questions sound critical and can make people feel inferior, or may make them mistrust you because they may ask themselves, ‘Why should I believe this person when all my relatives share my belief?’

Always try to understand, and be sensitive to, cultural and psychological factors that may affect clients in your village adopting and using family planning methods. For example, there may be opposition to the idea of controlling the size of the family from some cultures and religions. Some methods may be unpopular with clients, for example a woman might not like the idea of having to insert a contraceptive into her body before having sex, or a man may think that a condom will take away the pleasure of sex.

  • Can you give clients contraceptives if they do not want to use them?

  • There is no point in supplying a contraceptive if a client will not use it. So you must listen carefully to what you are being told, and be sure to answer all questions clearly and accurately when helping clients in their contraceptive choice.

This means that you should have good scientific knowledge of all the contraceptive methods, and understand the practical part of family planning methods. Also, you should be prepared to answer questions comfortably and without embarrassment in relation to contraceptive myths, rumours, sexuality, sexually transmitted infections (STIs), reproductive and personal concerns.

3.4  Overview of the stages of counselling for family planning

3.4.1  General counselling

The first contact usually involves counselling on general issues to address the client’s needs and concerns. You will also give general information about methods, and clear up any mistaken beliefs or myths about specific family planning methods. All this will help the client in your village arrive at an informed decision on the best contraceptive method to use. During this session you would also give information on other sexual and reproductive health issues, like sexually transmitted infections (STIs), human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) and infertility.

3.4.2  Method-specific counselling

In method-specific counselling, you give more information about the chosen method. In this case, you can explain the examination for fitness (screening), and instruct on how and when to use the given method (see Box 3.1). You will also tell the client when to return for follow-up, and ask them to repeat what you have said on key information.

Box 3.1  Family planning counselling — the BRAIDED approach

The acronym BRAIDED can help you remember what to talk about when you counsel clients on specific methods. It stands for:

B  Benefits of the method

R  Risks of the method, including consequences of method failure

A  Alternatives to the method (including abstinence and no method)

I  Inquiries about the method (individual’s right and responsibility to ask)

D  Decision to withdraw from using the method, without penalty

E  Explanation of the method chosen

D  Documentation of the session for your own records.

3.4.3  Return/follow-up counselling

Follow-up counselling should always be arranged. The main aim of follow-up counselling is to discuss and manage any problems and side effects related to the given contraceptive method. This also gives you the opportunity to encourage the continued use of the chosen method, unless problems exist. Also use this opportunity to find out whether the client has other concerns and questions.

3.5  Steps in family planning counselling: the GATHER approach

When you counsel a new client in your village about family planning, you should follow a step-by-step process. GATHER is an acronym that will help you remember the 6 basic steps for family planning counselling (see Box 3.2). It is important to know that not every new client in your village needs all the steps — you need to use the GATHER approach sensitively so that it is appropriate to each client’s need. Within your community you may need to give more attention to one step than another.

Box 3.2  Family planning counselling — the GATHER approach

G  Greet the client respectfully.

A  Ask them about their family planning needs.

T  Tell them about different contraceptive options and methods.

H  Help them to make decisions about choices of methods.

E  Explain and demonstrate how to use the methods.

R  Return/refer; schedule and carry out a return visit and follow up.

It is important to give more emphasis to the points under each counselling step.

3.5.1  G — Greet the client

  • In the first case, give your full attention to your clients.
  • Greet them in a respectful manner and introduce yourself after offering seats.
  • Ask them how you can help them.
  • Tell them that you will not tell others what they say.
  • If the counselling is in a health institution, you have to explain what will happen during the visit, describing physical examinations and laboratory tests if necessary.
  • Conduct counselling in a place where no-one can overhear your conversation.

3.5.2  A — Ask the clients about themselves

  • Help them to talk about their needs, doubts, concerns and any questions they might have.
  • If they are new, use a standard checklist or form from your Health Management Information system to write down their name and age, marital status, number of pregnancies, number of births, number of living children, current and past family planning use, and basic medical history.
  • Explain that you are asking for this information in order to help you to provide appropriate information, so that they can choose the family planning method which is the best for them.
  • Keep questions simple and brief, and look at her/them as you speak.
  • Many people do not know the names of diseases or medical conditions. Ask them specific questions. Say, ‘Have you had any headaches in the past two weeks?’, or ‘Have you had any genital itching?’, or ‘Do you experience any pain when urinating?’ Do not say, ‘Have you had any diseases in the recent past’.
  • If you have seen the client(s) previously, ask if anything has changed since the last visit.

3.5.3  T — Tell them all about family planning methods

  • Tell them which methods are available.
  • Ask which methods interest them and what they know about the methods.
  • Briefly describe each method of interest and explain how it works, its advantages and disadvantages, and possible side-effects.

3.5.4  H — Help them to choose a method

  • To help them choose a method of contraception, ask them about their plans and family situation. If they are uncertain about the future, begin with the present situation.
  • Ask what the spouse/partner likes and wants to use.
  • Ask if there is anything they cannot understand, and repeat information when necessary.
  • When the chosen method is not safe for them, explain clearly why the method may not be appropriate and help them choose another method.
  • Check whether they have made a clear decision and specifically ask, ‘What method have you decided to use?’

3.5.5  E — Explain how to use a method

After a method has been chosen:

  • Give supplies if appropriate.
  • If the method cannot be given immediately, explain how, when and where it will be provided.
  • For methods like voluntary sterilisation the client will have to sign a consent form. The form says that they want the method, have been informed about it, and understand this information. You must help the individual understand the consent form.
  • Explain how to use the method.
  • Ask the client to repeat the instructions.
  • Describe any possible side-effects and warning signs, and tell them what to do if they occur.
  • Ask them to repeat this information back to you.
  • Give them printed material about the method to take home if it is available.
  • Tell them when to come back for a follow-up visit and to come back sooner if they wish, or if side-effects or warning signs occur.

3.5.6  R — Appoint a return visit for follow-up

At the follow-up visit:

  • ask the client if she is, or they are, still using the method, and whether there have been any problems.
  • ask if there have been any side-effects.
  • reassure the client/s concerning minor side-effects. Explain that the side effects are not dangerous and suggest what can be done to relieve them.
  • refer for treatment in the case of severe side-effects.
  • ask the client if they have any questions.

If the clients want to use a different method, tell them about other methods and help in this choice. It is important to remember that changing methods is not bad. The main thing is that they can choose a method which is acceptable and appropriate. If the clients now want to have a child, help them to discontinue the use of their current method of family planning. Make sure the clients know when and where to go for prenatal care when the spouse becomes pregnant.

3.6  Factors influencing family planning counselling outcomes

There are different factors that affect the quality and effectiveness of communication in counselling. You should identify and address these factors in order to have successful family planning counselling sessions. These factors are divided into three broad categories.

3.6.1  Factors related to you

As a provider of family planning services, your ability to engage in effective communication, your technical knowledge, skills, attitudes and behaviours can influence the effectiveness of the counselling process. You will have your own values and beliefs on specific methods, and you must try not to let this show or you can affect the other person’s choice.

Stop reading for a moment and think about this from your own experience.

  • Sometimes you will be communicating with someone who differs from you in terms of their social status, gender or education. How will this affect the counselling process?

  • Irrespective of gender, social and educational status, you have to show every client respect, help them feel at ease, and encourage them to explain their needs, express their concerns and ask questions.

Respecting the rights of the client is essential to the quality and continuity of family planning services, including counselling. Box 3.3 below summarises the principles of the client’s rights in all aspects of family planning services.

Box 3.3  Summary of the rights of the client

Every client has the right to:

  1. Information — to learn about their reproductive health, contraception and abortion options.
  2. Access — to obtain services regardless of religion, ethnicity, age, and marital or economic status.
  3. Choice — to decide freely whether to use contraception and, if so, which method.
  4. Safety — to have a safe abortion and to practise safe, effective contraception.
  5. Privacy — to have a private environment during counselling and services.
  6. Confidentiality — to be assured that any personal information will remain confidential.
  7. Dignity — to be treated with courtesy, consideration and attentiveness.
  8. Comfort — to feel comfortable when receiving services.
  9. Continuity — to receive follow-up care and contraceptive services and supplies for as long as needed.
  10. Opinion — to express views on the services offered.

(Adapted from Huezo and Diaz, 1993)

3.6.2  Factors related to the client

The client’s level of knowledge and understanding may affect their choice. What they choose to do may also be affected by the extent to which they trust and respect you (Figure 3.4). Their personal situation may make it difficult for them to choose some methods, for example if their spouse or another family member has a different preference to them.

Contraceptives are being shown to a group gathered in the village.
Figure 3.4  Handing out contraceptives in a village; success depends on trust between clients and the provider. (Photo: Marie Stopes International)

3.6.3  External/programmatic factors

In most developing countries like Ethiopia, reproductive health services in general, and family planning programmes in particular, are limited and cannot be accessed by everyone. You may learn about some methods that you cannot offer to people in your community because of its unavailability. Moreover, the supplies of the family planning materials may not be regular and reliable.

In most health facilities the space or room for the provision of family planning is integrated with other reproductive health programmes. This can make it really difficult for you to find a place where privacy and confidentiality can be maintained.

You may have to work hard to overcome these various difficulties and provide an effective family planning service for your community, but the benefits of success will have a huge impact on future generations.

Summary of Study Session 3

In Study Session 3, you have learned that:

  1. Family planning counselling is the process whereby you help clients and people in your village to make informed and voluntary choices about the number of children and the spacing of the children within their family.
  2. There are different ways of providing effective family planning counselling. You may work with individuals, couples or with a group. Usually working with an individual works best.
  3. At the first contact meeting, focus on general counselling to establish trust, and address the needs and concerns of reproductive health and family planning.
  4. Method-specific counselling is provided once a person has chosen a specific family planning method. Use the BRAIDED approach to help you remember what to say when you counsel clients on specific methods.
  5. Follow-up counselling is given to discuss and manage any problems or side-effects, and to discuss alternatives if the original method has not been satisfactory.
  6. GATHER is an acronym to help remember the 6 basic steps in the counselling process:
    • G  Greet
    • A  Ask
    • T  Tell
    • H  Help
    • E  Explain
    • R  Return.
  7. Factors which can affect counselling outcomes can be viewed from different perspectives: yours, your clients, and the reproductive health services in your country. Thinking about potential problems can help you to work around them to deliver an effective service.

Self-Assessment Questions (SAQs) for Study Session 3

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 3.1 (tests Learning Outcomes 3.1 and 3.2)

Which of the following statements is false? In each case, explain what is incorrect.

The family planning counselling process may be described as a:

A  Two-way communication process actively involving both people.

B  One-way communication process in which you ask the questions.

C  One-time process in which a person in your village learns everything about the family planning method.

D  Process that enables a person to be informed about different methods, ask questions, make an informed choice about a method, and leave the clinic feeling confident about how to use the method correctly.

E  Ongoing communication process that takes place at every health and family planning service encounter.

Answer

B is false because family planning counselling is a discussion between two people, and not a question and answer session between the counsellor and the client.

C is also false because counselling is a continuous process in which a client learns about family planning step by step.

A, D and E are true because counselling is an ongoing, two-way communication process that takes place in every health and family planning service encounter. This enables a person to be informed about different methods, ask questions, make an informed choice about method, and leave the clinic feeling confident about how to use a contraceptive method correctly.

SAQ 3.2 (tests Learning Outcome 3.2)

Why is counselling an important part of family planning?

Answer

The importance of counselling in family planning is to help the client to make, and arrive at, informed and well-considered voluntary choices about their fertility, or help a client to decide on the number of children they want and when to have them.

SAQ 3.3 (tests Learning Outcome 3.3)

What are the most important principles when counselling members of your community?

Answer

The most important principles in counselling are:

  • Being in a private room and quiet place.
  • Taking sufficient time.
  • Maintaining confidentiality.
  • Conducting counselling in a tolerant/non-judgmental, accepting and conducive/helpful way.
  • Using direct and simple words.
  • Using good interpersonal communication skills.
  • Telling the most important messages first.
  • Using available visual aids.

SAQ 3.4 (tests Learning Outcome 3.4)

Wozero Misgane, a married woman who has one child, wants to space her second pregnancy, and comes to you for the first time to have family planning. You want to counsel her effectively, using the appropriate steps of counselling for family planning.

How would you counsel Wozero Misgane using the GATHER approach?

Answer

Wozero Misgane is a new client, so you need to counsel her on family planning using the acronym GATHER to remember all the six steps:

G  Greet Wozero Misgane in a friendly, helpful and respectful manner.

A  Ask Wozero Misgane about her family planning needs, concerns and previous use.

T  Tell Wozero Misgane about different contraceptive options.

H  Help Wozero Misgane to make a decision about which method she prefers.

E  Explain to Wozero Misgane how to use the method chosen; ask her to repeat the instructions.

R  Arrange a return visit and follow-up with Wozero Misgane.

SAQ 3.5 (tests Learning Outcome 3.5)

What are the factors that can affect family planning counselling outcomes?

Answer

The factors that can affect family planning counselling outcomes are:

  • Provider factors, such as your ability to engage in effective communication, your technical knowledge, skills, attitudes and behaviours.
  • Client factors, such as a client’s level of knowledge and understanding.
  • External and programmatic factors which you cannot control, such as lack of availability of certain methods or equipment, or irregular supplies of family planning materials.