Quality Family Planning Counseling Munir Kassa, MD CIRHT- Ethiopia

Outline Objectives Definition of quality family planning counseling Uses of quality family planning counseling Principles of family planning counseling Reproductive life plan Summary

Objectives Define counseling Articulate uses of family planning counseling Identify principles of family planning counseling

Definition Family Planning Counseling Process that enables clients to make and follow through on their decisions concerning contraceptive use

Question – True or False? “Practicing good family planning counseling take a lot of time.”

Use of Family Planning Counseling Help clients make better choices Help clients use, improve and continue their use their method properly Increase their satisfaction Facilitate their participation Increase return for follow-up

Principles for Providing Quality Counseling Establish and maintain rapport Assess the client’s needs and personalize discussions accordingly Work with the client interactively to establish a plan Provide information that can be understood and retained Confirm client understanding

1. Establish and Maintain Rapport Create a welcoming environment Rapport-building: happens the moment an encounter begins Good rapport requires client-centered communication skills that: Help build and maintain rapport throughout a client encounter. Aims to listen for client’s goals and preferences to communicate with empathy Ensure privacy and confidentiality

OARS Communication Model during Family Planning Counseling O - Open-Ended Questions A - Affirming R - Reflective Listening S - Summarizing

Ask Open-ended Questions Build a trusting and respectful professional relationship Help gain an understanding about the client and the “client’s world” Example: How regularly do you use your contraception method?

Affirm Find out about healthy behavior like adherence to the method Compliment: “You ask really great questions!” Doing this Helps build trust Makes them feel that you are on their side Engages their best self

Listen with Reflection Listening to what the client says, then briefly reflecting key words: To check accuracy and understanding To show that you are listening To help the client explore her/his own thoughts and feelings Example: “So I hear you saying… (ie: your husband wants to have more children, but you are not sure?)… Do I have that right?” Format Introduction Re-phrase End

Summarize Transition - Reflecting what’s been said so far and moving to a new topic Closing - Reflecting what’s been said during the session and moving to a plan of action

2. Assess the Client’s Needs and Personalize Discussions Accordingly Does the client have any health issues and/or safety considerations that would rule out certain methods? What is the client’s reproductive life plan and pregnancy intention? What is important to the client in a birth control method? (These factors will likely have been raised during the brainstorm on the previous slide.) When thinking of all of the different areas of assessment you could explore with a client, it’s helpful to think about where you might start. Here are three key questions to consider at the start of an assessment conversation: (Click the mouse for each bullet to appear.) Does the client have any health issues and/or safety considerations that would rule out using any methods? What is the client’s reproductive life plan or pregnancy and parenting intentions, both now and in the future? What’s important to your client in a method? This will be different for every client. Some clients don’t want hormones and others just want the most effective method, some need their method to be private, etc. This key question helps you start to identify how your client values different method characteristics. (Trainer Tip: Characteristics of birth control methods are reviewed in detail in Module 3, Activities 3.1 and 3.2.)

Reproductive Life Plan (RLP)

RLP: What is it? A self-assessment of life goals Goals in several broad categories (based on the social determinants of health) Education Work/Career Family Planning We assist or guide as needed

What to Consider in Developing a Reproductive Life Plan Age Educational goals Career plans Living situation Financial situation Social support Relationship with partner Readiness to become a parent Medical history Current health status Health behaviors Contraceptive use You can add some more specific questions – how old would you like to be? What type of job do you plan to have? Could you support a baby now – emotionally, physically, financially. How will having a baby affect your relationship with your partner, etc. How is your health now? Do you have any chronic conditions like diabetes? What about your medical history? Does anything run in your family? Do you have any health risk behaviors like tobacco use? Are you currently using contraception? Are you able to use your method consistently? 17 17 17

When Pregnancy is Desired - Preconception Care Women/men who are currently seeking pregnancy need preconception health and STD services as well as counseling on how to achieve pregnancy – This is a high priority population! For addressing “achieving pregnancy” and “possible basic infertility services”- Providers should ask the client (or couple) how long they have been trying to get pregnant, and when she hopes to get pregnant. If the client’s situation does not meet one of the standard definitions of infertility, then counseling about how to maximize fertility should occur. If a couple needs basic infertility care, the provider focuses on determining potential causes of their inability to achieve pregnancy and make referrals to specialists. Preconception health services should be offered to male and female clients. This includes medical history and sexual health assessment; intimate partner violence; alcohol and drug use; tobacco use; immunizations; depression; nutrition including folic acid (for women only); height, weight, and body mass index; blood pressure; diabetes; and of course STD testing services. Related preventive health services should also be delivered, as appropriate.

When Pregnancy is Not Desired - Contraception The woman in this picture is someone who has decided she is not ready for children now! If this woman’s answers to the reproductive life planning questions indicate she is sexually active, and doesn’t want to get pregnant now, this would lead to a discussion of contraceptive services, beginning with the most effective methods first, such as IUDs or implants. Preconception health services should also be offered especially true for those using the less effective methods or inconsistent method use, as this puts them at a higher risk of pregnancy.

CDC Reproductive Life Plan Tool Questions Do you plan to have any (more) children at any time in your future? If Yes How many children would you like to have? How long would you like to wait until you or your partner becomes pregnant? What family planning method do you plan to use until you or your partner are ready to become pregnant? How sure are you that you will be able to use this method without any problems? CDC’s recommendation is that all persons capable of having a child should have a reproductive life plan. Basically, do you want to have children, the timing and spacing of healthy children and what can I do to help you achieve these goals. The additional two questions, #4 and #5 on this slide are asked if pregnancy is NOT desired. PUT REFERENCE AT THE BACK SLIDE: http://www.cdc.gov/preconception/documents/rlphealthproviders.pdf

CDC Reproductive Life Plan Tool Questions (cont’d) Do you plan to have any (more) children at any time in your future? If No: What family planning method will you use to avoid pregnancy? How sure are you that you will be able to use this method without any problems? People’s plans change. Is it possible you or your partner could ever decide to become pregnant?

3. Work with the Client Interactively to Establish a Plan Shared decision-making We all have goals and obstacles Obstacles: Potential side effects Fear of negative health effects Risk of unplanned pregnancy Concern for future fertility Perception of risk Concealing contraception from a partner

What is Important to the Client about the Method? Effectiveness Frequency of use Different ways of method delivery Return to fertility Specific side effects

4. Provide Information that can be Understood and Retained Strategies to give patient education Simple language Give balanced information on benefits as well as risk Limit the amount of information Best time is when they ask Be stingy Highlight the most important information Use educational materials

We don’t need to go through each method with each client Tiered Effectiveness We don’t need to go through each method with each client

5. Confirm Client Understanding Use the teach-back method to ensure the client understands Asking clients to use their own words An indication of how well YOU communicated, NOT a "test" of the patient Help evaluate if you did a good job of explaining  Last: provide the service

Summary Family planning counseling is not only about providing information Family planning counseling helps clients make their own decisions about methods and continued use The five principles in family planning counseling include establishing rapport, assessing client needs, helping to reach a shared decision, providing education and ensuring understanding Returning to our steps for closing the session, here are some key things to cover with the client: We’ve talked about teach back, which is a helpful tool both for confirming understanding and summarizing key points for the client to remember at the close of a session You also want to help the client solidify a plan to use their method. What do you think the plan should include? Pause for responses before clicking to show slide text How the client will access their chosen method; ideally you’ll be able to provide it onsite, but you may need to give them a referral; How the client plans to use their chosen method effectively – that is, consistently and correctly; What the client should do if they have questions or problems; and How to use back-up and/or emergency contraception You also will want to provide your contact information and any other information related to follow-up appropriate for that particular client and their chosen method. This should include a genuine invitation to return to see you at any time for any reason, including if they are wanting to change methods. Lastly, provide any additional services and/or referrals needed to address any other stated client needs. 28