Consent, Confidentiality and Reproductive Coercion

Informed consent is the voluntary agreement of a patient with capacity to a method or procedure, given after understanding what it is, what the alternatives are, the benefits, risks and uncertainties, and the right to refuse or withdraw at any time. Confidentiality is the duty to protect the patient's information and privacy. Reproductive coercion is behaviour by a partner, family member or provider that interferes with a person's control over contraception or pregnancy.

Principles.

• Consent is specific to the method or procedure and can be withdrawn at any time.

• Consent must be free of pressure, incentive, penalty or deception.

• A patient with capacity is the only person who gives consent for a reversible method; partner consent is never required.

• Confidentiality extends to the fact of attendance, the method chosen and any disclosure.

• No person may be sterilised, fitted with a device or given a method without their consent.

Elements of valid consent.

• Capacity to understand and decide.

• Information on what the method is, its effectiveness, side effects, risks, benefits, alternatives, and what happens if the patient declines.

• Voluntariness: no coercion by a partner, relative or provider.

• Documentation of the discussion and the decision.

Capacity and supported decision making. Assume capacity unless shown otherwise. For patients with intellectual or psychosocial disability, adapt information, allow a support person of the patient's choice, and use supported decision making. Where a legal process allows decisions for a patient without capacity, use reversible methods and the least restrictive option; sterilisation is not appropriate without the patient's own consent except through lawful procedure.

Adolescents. Provide full information in an age-appropriate way. Where the law requires guardian consent for patients under 18, obtain the adolescent's assent and the guardian's consent while protecting the adolescent's confidentiality as far as the law allows. Where the law allows a mature minor to consent, the adolescent may consent alone. Do not deny methods because of age.

Permanent methods. Written, signed consent is needed. The patient should have time to reflect, no pressure and be informed that the procedure is permanent and that regret is possible, particularly at young age and low parity. Do not obtain consent during labour, while in severe pain, immediately after delivery in distress, or when the patient is in fear of losing other care. Spousal consent is not required.

Confidentiality.

• Examine and counsel in private; interview adolescents alone.

• Explain the limits of confidentiality at the start: serious risk of harm to the patient or others, mandatory reporting of child sexual abuse, and court order.

• Keep records secure and share information only with the patient's consent.

• Ask how the patient wants to be contacted for reminders and avoid messages that name the method.

Reproductive coercion. Examples include pressure to become pregnant, destroying pills, removing a ring or patch, interfering with condoms, forced sex, controlling the outcome of a pregnancy, and forced contraception or sterilisation by a partner, relative or provider. It is linked to intimate partner violence, repeated unplanned pregnancy and repeated use of emergency contraception.

Obtaining consent.

• Offer all methods suitable for the patient without steering.

• Use plain language and check understanding by asking the patient to explain in their own words.

• Record that the choice was voluntary.

• Offer time to decide and an interim method.

• Confirm consent again before a procedure such as implant insertion, IUD placement or sterilisation.

Screening for coercion. Ask privately, in a nonjudgemental way: "Has anyone ever pressured you to become pregnant, or prevented you from using contraception?" "Are you afraid of your partner or anyone at home?" Look for repeated emergency contraception use, concealed method use, injuries and missed appointments.

Response to coercion or violence.

• Believe the patient and avoid blame.

• Offer methods the patient can use without the partner knowing: DMPA injection, implant or IUD (strings can be trimmed at the patient's request after discussion of removal difficulty).

• Plan for safety and contact; do not inform the partner.

• Offer emergency contraception (copper IUD within 5 days, or levonorgestrel 1.5 mg or ulipristal acetate 30 mg orally within 120 hours), post-exposure prophylaxis within 72 hours, presumptive STI treatment, hepatitis B vaccination and tetanus prevention where indicated.

• Provide psychosocial support and referral to gender-based violence and legal services.

Removal on request. Remove an implant or IUD whenever the patient asks. Do not require the patient to wait, return with a partner, or accept an alternative.

Common errors.

• Requiring partner or guardian consent in all cases.

• Inserting an IUD, implant or doing sterilisation without prior counselling, for example immediately after delivery or abortion.

• Pressuring patients living with HIV, with disability or with many children to accept a long-acting or permanent method.

• Offering incentives or targets for particular methods.

• Discussing a patient's method with a partner or relative without consent.

Special groups. Patients living with HIV have the right to choose and to have children; never require sterilisation or a method as a condition of care. People with disability need information in accessible formats. Survivors of sexual violence need care before any legal process begins.

Referral and escalation. Refer survivors of sexual violence and intimate partner violence to services that provide medical, legal and psychosocial care. Report suspected child sexual abuse to the designated authority as the law requires, with the least harm to the child. Refer patients whose capacity is uncertain for assessment.