Setting global standards: The paramount importance of considering contraceptive values and preferences of clients and providers

Universal access to sexual and reproductive health services and information, including access to the full range of safe and effective contraceptive methods, is fundamental to the rights and well-being of adolescents and adults of all genders [1], [2]. The benefits to society and life-saving consequences when quality contraceptive services and information are available, accessible, and acceptable cannot be understated. In developing regions alone, use of modern contraception prevents an estimated 308 million unintended pregnancies each year, and estimates indicate that satisfying the unmet need for modern contraception would result in 76,000 fewer maternal deaths worldwide each year [3]. Recently, a landmark analysis of the impact of family planning noted that achieving the Sustainable Development Goal (SDG) themes (people, planet, prosperity, peace, and partnership) will require investments directed towards family planning [4]. Specifically, use of modern contraceptives and met demand for family planning represent key indicators within SDG target 3.7 [5] which also measure progress on other global health initiatives and frameworks, such as the United Nation’s Every Woman, Every Child initiative [6] and Family Planning 2020 [7].

Despite advances and global momentum to improve contraceptive access, there has been limited recognition on the part of policy makers that delivery of contraceptive services cannot solely rely on a health care provider recommending a course of action and/or treatment that they consider to be in the best interest of the patient. Such an approach is not justified as contraception uniquely straddles a space where decisions about two socially sensitive topics – fertility and reproduction – take place. For contraception, the provider counsels the client on their contraceptive options but generally does not recommend one particular method over another method: contraceptives are within the purview of the individual instead of the provider [8]. There is growing acknowledgement that clinicians and other experts are not always the best judges of what matters to patients or other service users. Fundamentally, it is the right of contraceptive users to exercise their own reproductive rights. To this end, World Health Organization (WHO)’s contraceptive guidance does not recommend specific methods for different types of individuals, rather, WHO recommendations respond to whether certain methods are deemed safe and effective according to an individual’s characteristics. Ultimately, contraceptive choice for the individual based upon his or her own values and preferences lies at the very heart of this discussion. Additionally, social pressures, sanctions, and approval from community and family members have long been recognised as playing a significant role in shaping fertility preferences [9].

When considering the views and preferences of individuals, there are additional important aspects that distinguish contraception from other health services or interventions. First, reproductive age can span 30–40 years, beginning from early adolescence and extending to menopause in the case of a woman (approximately age 15–49). It is entirely understandable that the contraceptive needs and preferences of an adolescent will be different from an adult. Second, the importance of pregnancy prevention is influenced by life circumstances and situations, which can change significantly throughout the life course. Additionally, preferences around contraception may vary depending upon a particular method’s characteristics and features: e.g., hormonal vs. non-hormonal, long-acting versus short-acting, delivery system, effectiveness and whether there are side effects or other concerns. Again, the relative importance of these aspects of contraception may vary both between individuals and across an individual’s lifespan. With more than 15 different forms of safe and effective forms of contraception available, one cannot assume a ‘one size fits all’ approach.

Within its mandate as a global normative body, WHO produces evidence-based guidance on family planning/contraception. Building upon the 1994 International Conference on Population and Development, WHO’s Department of Reproductive Health, in collaboration with a network of international partners, issues evidence-based guidance on: (a) the safety of various contraceptive methods in the context of specific health conditions and characteristics (the Medical eligibility criteria for contraceptive use or MEC) [10] and (b) how to use contraceptive methods safely and effectively once they are deemed to be medically appropriate (the Selected practice recommendations for contraceptive use or SPR) [11]. Periodically, WHO reviews the recommendations published in these guidelines, providing policy makers and programme managers access to the most updated information available when they develop their national policies and programmes.

Development of the latest MEC and SPR documents entailed several adjustments to align more closely with requirements set forth in the WHO Handbook for Guideline Development [12], authored by the Guidelines Review Committee Secretariat¹. Explicit consideration of the values and preferences of end-users of the MEC and SPR recommendations – women, girls, men, and boys – as part of applying the Grading Recommendations, Assessment, Development and Evaluation (GRADE)² approach to evidence review and recommendation formulation, was a pivotal change. Thus, the relative importance that people assign to the benefits and harms of contraception were incorporated into the development of the new MEC and SPR recommendations. WHO remains wholeheartedly committed to assuring that values and preferences of end-users are a central aspect of all future revisions of these guidelines.

A recent review of the evidence of the risk of HIV acquisition with the use of hormonal contraception highlights the crucial role that values and preferences must play in informing recommendations [13]. As noted in the executive summary:

In formulating these recommendations, the individuals most affected by the guidance were kept at the centre of the GDG’s deliberations – those women wanting to prevent pregnancy who are at high risk of HIV acquisition. At the core of the group’s decision-making were the sexual and reproductive health and rights of women and girls, and, in particular, the human rights principles of ensuring informed decision-making and a choice of contraceptive methods. Women have their own individual preferences and values concerning contraception, and their perceptions of the risks and consequences of unintended pregnancy and HIV acquisition may vary. All women have the right to evidence-based information on contraceptives, to quality services and to the assurance of opportunities to make an informed choice without discrimination. (pages 1-2)

The Guideline Development Group noted that “WHO encourages [the global health community to undertake] research that clearly elucidates women’s preferences and values in contraceptive decision-making” (page 10).

In this issue of Contraception, WHO and collaborating colleagues are pleased to publish a series of systematic reviews which present a qualitative synthesis of evidence addressing contraception values and preferences among a diverse range of populations. These reviews were prepared to inform and guide the development of WHO’s latest recommendations regarding contraceptive eligibility and provision, and will continue to serve as background information for future revisions of these recommendations. We wholeheartedly acknowledge that contraceptive values and preferences will continue to evolve and vary over time, depending upon socio-cultural and socioeconomic factors as well as changing norms related to gender, sexuality, reproduction, and fertility. The series starts with a paper detailing the protocol and methods used to conduct the systematic reviews. These subsequent reviews provide an overview of the results gleaned from more than 300 articles identified from a comprehensive search of the literature, as well as focused analyses among the following groups: sexually active women; women with specific medical conditions; men; young people and adolescents; women living with HIV; health care providers; and people living in humanitarian contexts or special social conditions.

We encourage readers to consider the findings presented in this series of reviews as informative to health policy and the development of new contraceptive methods to expand method choice, as well as having the potential to stimulate ongoing and new research. Improving our understanding of the values and preferences of individuals and populations that influence contraceptive decision-making has far-reaching benefits for all of us, and will be a giant leap towards meeting globally agreed-upon development goals.