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Bringing New People to Family Planning: The Broader Impact of Fertility Awareness Methods
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Bringing New People to Family Planning: The Broader Impact of Fertility Awareness Methods


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Overview of the Standard Days Method, why integrating it into all FP services is important, and common misconceptions.

Overview of the Standard Days Method, why integrating it into all FP services is important, and common misconceptions.

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  • 1. Bringing New People to Family Planning: TheBroader Impact of Fertility Awareness Methods 1
  • 2. FAM INTRODUCTION Slides 4 to 18© 2004 Eileen Dietrich, Courtesy of Photoshare 2
  • 3. Fertility Awareness Methods• Modern FAMs are effective options for many women who want to space pregnancies without using a hormonal method.• FAMs offer an opportunity to involve the partner in optimal birth spacing and timing.• They have no side effects and are economical. 3
  • 4. How FAM work• Identify “fertile window” (days intercourse can result in pregnancy) of the menstrual cycle• Use one or more “indicators” to identify beginning and end of fertile window. FAM method users: monitor indicators to identify fertile window avoid unprotected intercourse (use barrier methods or abstain) on fertile days 4
  • 5. Why develop new FAM?• Very low use of current FAM methods.• Very poor understanding of fertility in the general population.• Significant unmet need for family planning.• Most health providers do not have time to counsel their patients/clients in FAM.• Many women/couples who express interest in a FAM do not actually use them• FAM can contribute to efforts to reduce the gap between contraceptive commodity needs and donor capacity. 5
  • 6. Use of family planning remains low in many countries Percent of married women using contraception 40 30 Modern Methods 20 Traditional or folk 10 methods 0 Benin DR Congo Zambia India - UPSource: PRB 2005 World Population Data Sheet and ORC Macro DHS
  • 7. Family Planning Use Worldwide (Women in Union) 43% 8% 8% Natural No methods 42% methods 49% 50% Modern methodsLevels and Trends of Contraceptive Use as Assessed in 1998. United Nations, ReportESA/P/WP.155 New York, 1999
  • 8. Percentage of Married Women Using Contraception Source: PRB 2005 World Population Data Sheet and ORC Macro DHS 8
  • 9. Percentage of Married Women Using Periodic AbstinenceSource: ORC Macro. 2006. MEASURE DHS STATcompiler 9
  • 10. Context for FAM FAM in the context of: • Healthy Timing and Spacing of Pregnancies (HTSP) • Informed choice in family planning 10
  • 11. What is HTSP? Is it different from birth spacing?• Previous birth spacing recommendations refer to when to give birth.• HTSP is about pregnancy spacing: when to become pregnant – rather than when to give birth. 11
  • 12. What are the advantages of waiting two yearsafter having a baby to become pregnant again?  Increases likelihood of healthy outcomes for the baby and the mother  Reduces neonatal, infant and child mortality  Reduces maternal mortality  Improves nutritional status of children  Addresses unmet need for contraception among postpartum women  Benefits family economically 12 12
  • 13. Healthy Timing & Spacing of Pregnancies • After a live birth couples should use an effective family planning method of their choice, continuously for at least 2 years before trying to become pregnant again. • The SDM can offer women and couples at least 95% protection from pregnancy when the method is used correctly. 13
  • 14. Method Characteristics Standard Days Method with CycleBeadsMethod Eligibility  Women with cycles between 26 and 32Criteria (who can use days longthe method)  Couples who can avoid unprotected sex on days 8 to19Exceptions (who Women in postpartum or breastfeeding must have had at least 4 periodscannot use) about a month apart. Women who recently used a hormonal method must have 3 periods about a month apart after stopping hormonal.Effectiveness 95% with correct use 88% with typical use Pregnancies for every 100 woman-yearsHow it works The woman considers herself fertile on days 8 to19 of the menstrual the cycle. She and her partner use condoms or abstain on those days to prevent pregnancy.Key Research and • Multi-site prospective studyFindings • Services provided in existing programs • Clients followed monthly for 13 cycles • Couples used the method correctly in 97% of cycles • 478 women in the study, 43 got pregnant • With correct use, the failure rate is 4.8 • With typical use the failure rate is 12.0
  • 15. Contraceptive Failure of User-Directed Methods *Percentage of women who Correct Use Typical Use became pregnant 1st year of use OCs .3 8 Condom 2 15 **Standard Days Method 5 12 Diaphragm 6 16 Spermicides 18 29 No Method 85 85 *Adapted from Contraceptive Technology, 18th edition, 2004 **Source: Arévalo et al. Contraception, 2002
  • 16. Comparing effectiveness of FP methods Source: Family Planning: A Global Handbook for Providers 2007, WHO
  • 17. STANDARD DAYS METHOD® OVERVIEW Slides 49 to 66 17
  • 18. What is the Standard Days Method• Identifies days 8-19 of the cycle as fertile• Is appropriate for women with menstrual cycles between 26 and 32 days long• Helps a couple avoid unplanned pregnancy by knowing which days they should not have unprotected sex• Helps a couple plan pregnancy by knowing which days they should have sex 18
  • 19. CycleBeadsThe SDM is used with CycleBeads®, acolor-coded string of beads to help awoman:• Track her cycle days• Know when she is fertile• Monitor her cycle length 19
  • 20. SDM Offered Worldwide Albania Guinea Rwanda Angola Haiti Senegal Armenia Honduras Tajikistan Azerbaijan India Tanzania Bangladesh Kenya Timor Este Benin Malawi Turkey Bolivia Mali Uganda Burkina Faso Mauritius Ukraine Burundi Mozambique United States DR Congo Nicaragua Zambia Ecuador Nigeria El Salvador Pakistan Ethiopia Peru Ghana Philippines Guatemala Romania 20
  • 21. Determining the Fertile Window Ovulation 5 days (sperm life) 12 to 24 hours (ovum life) Day 8 Day 19 21
  • 22. Efficacy Study of the SDM• Multi-site prospective study• Services provided in existing programs• Clients were followed monthly for 13 cycles• Couples used the method correctly in 97% of cycles• 478 women in the study, 43 got pregnant• With correct use, the failure rate is 4.8• With typical use the failure rate is 12.0 Source: Arevalo, M. et al. 2002. Contraception 65:333-338. 22
  • 23. Contraceptive Failure of User-Directed Methods % of women who became pregnant during 1st year of use Correct Use Typical Use OCs .3 8 Condom 2 15 Standard Days Method 5 12 Diaphragm 6 16 Spermicides 18 29 No Method 85 85Source: Hatcher, R.A. et al. 2004. Contraceptive Technology. New York: Ardent Media, Inc. 23
  • 24. The Road to Scaling-up SDM Impact OR Studies Studies 2003- 2005 2005 - Pilot 2007 Introductions Method FP programs Efficacy 2000-2004 2002 MethodConcept 1999 24
  • 25. What Have We Learned About Offering SDM to Clients? 25
  • 26. SDM User Profile Six Countries1 U.S.2Mean Age 29 27Mean Parity 2.8 .4Previous use of:Nothing/ineffective method 52% 0%Condom (inconsistent) 38% 87%Pills/injection 96% 33%IUD 2% 10% 1 Interviews with users in 6 countries 26 2 Survey of internet purchasers
  • 27. Reasons for Choosing the SDM Six Countries1 U.S.2Doesn’t affect health 70% 80% No side effects 20% 30% Economical 30% 5% Easy to learn/use 10% 45% 1 Interviews with users in 6 countries 2 Survey 27 of internet purchasers
  • 28. How Couples Manage the Fertile Days Abstain Condom Rural India 70% 30% Urban India 13% 87% Philippines 70% 30% U.S. 15% 85% Rwanda 67% 20%** **Rwanda 13% used withdrawal. 28 Source: Project reports and U.S. Survey
  • 29. Counseling Time at GoJ Clinics Comparison of SDM, Sterilization, and Pill SDM Pill Sterilization (n=59) (n=59) (n=59)Interpersonal 78% 78% 83%relationsInformation 64% 58% 44%exchangeSession length 17 min. 13 min. 15 min. Source: Simulated clients, endline Jharkhand, India 29
  • 30. SDM AttributesWho might be interested in using SDM?• Someone who has never used a FP method• Woman who doesn’t desire hormonal method or devices• Adolescent woman• Woman who has little to no access to a health care facility• Couple who uses condoms to delay pregnancy• Breastfeeding woman with regular menses 30
  • 31. Reasons for Choosing the SDM Six Countries1 U.S.2Doesn’t affect health 70% 80% No side effects 20% 30% Economical 30% 5% Easy to learn/use 10% 45% 1 Interviews with users in 6 countries; 2 Survey of internet purchasers 31
  • 32. Lessons Learned• Providers’ attitudes toward the SDM improve with training and experience.• The SDM can be offered by different kinds of providers.• The SDM can be taught in clinic and community settings.• Involving men increases method satisfaction and continuation.• Women can learn to use the SDM during a 20-minute session.• Offering the SDM helps programs reach new clients.• Many couples use condoms on fertile days. 32
  • 33. SDM COUNSELING Slides 67 to 82 33
  • 34. How is the SDM offered to Clients?• Screening• Teaching• Support couple’s use• When to return 34
  • 35. ScreeningWho Can Use the SDM?  Women with cycles 26 to 32 days long (women who have their monthly periods are within this range)  Couples who can avoid unprotected sex on days 8 to19 SDM does not protect against STIs or HIV 35
  • 36. Key Points - Screening• Ask simple questions to know if client has her monthly periods regularly.• Determine if client and partner will be able to manage 12 fertile days.• Women who recently had a baby or are breastfeeding must wait to have regular cycles before using SDM.• Ask when last period started to determine if client can start using SDM now or must wait for next period to start. 36
  • 37. Screening to See if the SDM is Appropriate for the Woman Is her cycle within the 26 and 32-day range? Simple questions to assess cycle length and regularity.  Do you get your periods about once a month?  Do you get your periods when you expect them?  When did your last period start? Most women have a general idea of when their periods will come. Women who know when their last period started can use the SDM right away. Women who do not know can begin the SDM when their next period starts. 37
  • 38. Criteria for Starting the SDM Date of the last period known Start immediately Date of last period unknown Start on first day of next period Wait 90 days after injection and to have Contraceptive Injection two periods about a month apart Wait until last 3 periods are about a Pill, patch, implant, IUD month apart (after stopping the hormonal method) Postpartum/breastfeeding Wait until she has 4 periods and the two most recent are about a month apart 38
  • 39. Key Points - Teaching• Explain CycleBeads represent the cycle and each bead is a day in the cycle.• Red is the first day of bleeding. Brown means no pregnancy. White means fertile days when pregnancy is very likely. Use condoms or abstain on white bead days.• How to use: 39
  • 40. Teaching - How to use the SDM• Teach client how to use the SDM Provider Cue Card with CycleBeads• Confirm client knows how to use the method and when to return to the provider• Check client knows how to use a condom• Both, the CycleBeads instructional insert and the provider cue card include essential information to help women use the method. CycleBeads Insert 40
  • 41. Teaching-Monitoring Cycle Length• Periods must always come between darker brown bead and last bead.• If period comes early (before darker brown bead) or late (does not start the day after the last bead) more than once in a year, switch to another method. Source: Package Instructions 41
  • 42. Supporting the Couple During counseling, a service provider should: •Set the stage •Encourage women to discuss SDM use with their partners •Engage client in a discussion on how she/partner will handle the fertile days BE SURE SHE •Identify possible challenges andLEAVES WITH A solutions PLAN! •Role play talking with her partner •Offer to talk with her partner 42
  • 43. Involving Men- Issues to Consider• SDM is a couple method. If men understand it, couples are more likely to use it correctly.• Special efforts should be made to involve men.• Counseling men is ideal, but men can also be taught about the method through: posters, flyers, radio, TV and community networks. 43
  • 44. When to contact the provider• If couple has sex on a white bead day• If couple has difficulty managing fertile days• If her period starts before the dark brown bead (cycle shorter than 26 days)• If her period has not started by the day after moving ring to the last brown bead (cycle longer than 32 days)• If her period has not returned and thinks she might be pregnant• If she wants to use another method 44
  • 45. Review Slides 83 to 93 45
  • 46. Why Offer SDM  Increases choice  Expands coverage  Addresses unmet need  Empowers women  Involves men  Offers low-cost method 46
  • 47. Guidance Documents  IPPF Medical Bulletin – 2000, 2003  IRH Reference Guide – 2002  WHO Medical Eligibility Criteria – 2002, 2004  WHO Selected Practice Recommendations – 2004  Contraceptive Technology – 2004, 2007  USAID Global Health Technical Briefs – 2004  Pocket Guide to Managing Contraception – 2004  Pop Report (New Contraceptive Methods) – 2005  WHO FP Decision-Making Tool – 2005  WHO Global Handbook for Family Planning – 2008  Pop Council Balanced Counseling Strategy – 2006  Ministries of Health norms and policies 2003 – 2010 47
  • 48. K4Health-SDM ToolkitReference Materials Links to scientific Training Materials articles Technical Briefs Trainers’ Manual SDM Service Participant Handbook Protocol Training Video Sample Norms Online Training Frequently Asked Questions
  • 49. Common Misconceptions about SDM• “Natural methods don’t work”• “Is this a modern method? “• “Is there demand for this method?”• “Natural methods take too much time in counseling”• “Men don’t collaborate, women have no power to decide when to have sex”• “If we offer this method clients will start switching from more effective methods”• “Illiterate women cannot use this method” 49
  • 50. Myth: “Women will not have the power todecide when to have sex.” Fact: FAM are best suited for couples that can communicate about sex 50
  • 51. Myth:“If we offer this method, clients using modern methods will switch.”Fact: FAM integration has no negative effects on FP use and method mix 51
  • 52. Myth:“SDM counseling would take too much time, just like other natural methods.” Fact: SDM is easy to teach in about the same amount of time as other methods 52
  • 53. Myth: "It would be hardfor illiterate women to use SDM.” Fact: SDM appeals to women from a range of socio- economic backgrounds Fact: Low literacy orilliterate women can learn Myth: "More educatedhow to use SDM correctly women would not be interested in using SDM.” 53