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Increasing Social Acceptance ofFamily Planning in Communities:The experience withFertility Awareness Methods              ...
Workshop Objectives Review basic information about SDM, TwoDay  Method and LAM, three simple fertility awareness  methods...
Fertility Awareness Methods (FAM) Modern FAM are effective options for many women  who want to space pregnancies without ...
How FAMs work Identify “fertile window” (days intercourse can result  in pregnancy) of the menstrual cycle Use one or mo...
Why develop new FAM? Very low use of current FA-based methods. Very poor understanding of fertility in the general    po...
Use of family planning remains low inmany countries                       Percentage aof married women using              ...
Use of periodic abstinence (with incorrector limited information) in many countries                   Percentage married w...
Context for FAM                  FAM in the context of:                   Healthy Timing and                    Spacing o...
What is HTSP? Is it different from birthspacing? Previous birth spacing recommendations refer to  when to give birth. HT...
Healthy Timing & Spacing of PregnanciesAfter a live birth: Couples should use an  effective family planning  method of th...
What is HTSP? Is it different from birth spacing? Previous birth spacing  recommendations refer  to when to give birth. ...
What are the advantages of waiting twoyears after having a baby to becomepregnant again? Increases likelihood of healthy ...
Natural Family Planning – Method Comparison                 Standard Days Method                          TwoDay Method   ...
Contraceptive Failure of User-Directed Methods *Percentage of women who became pregnant 1st year of use                  C...
Comparing effectiveness of FP methods                           Source: Family Planning: A Global                         ...
Lactational Amenorrhea Method(LAM)
LAM   A Family Planning Method based on the    physiological infertility experienced by    breastfeeding women   A “gate...
How does LAM prevent pregnancy?          LAM Mechanism of Action1.   Baby’s suckling stimulates     the nipple3.   Nipple ...
Effectiveness of LAM  LAM is 99.5% effective with consistent and   correct use and more than 98% effective as   typically...
What are the three criteria for LAM?        The 3 LAM criteria    • Mother’s menstrual bleeding has not    returned since ...
LAM Criteria     Mother’s menstruation has not returned since 1   the birth of the child (“Amenorrhea”)         Bleeding ...
LAM Criteria2     Baby is being only breastfed; The baby is not       receiving any other solid food or liquids; only     ...
LAM Criteria     The baby is less than 6 months old 3       Biologically appropriate cut-off point.       WHO recommends...
Be sure that your clients understand:BREASTFEEDING IS NOT  THE SAME AS LAM!                                        24
Why is contraception during thepostpartum period so important?  Fertility may return soon after delivery and            ri...
Transition to Another Method: An Essential  Component of LAM   LAM is a “gateway” to other modern methods    of contracep...
Postpartum Contraceptive Options           Adapted from Contraceptive Technology Update   27
Methods That Are Safe whileBreastfeeding    A number of contraceptive methods can be     safely used by the breastfeeding...
Emphasizing timely transition    Offer postpartum     women choice of all     appropriate FP     methods during first    ...
Job Aids           30
Case Studies Decide which women can rely on LAM for  contraception.    Read each case study    Discuss answers    Revi...
Optimal Breastfeeding Behaviors Allow newborn to breastfeed as soon as possible  after birth, and to remain with the moth...
Contraceptive Advantagesof LAM   Effectively prevents pregnancy up to six months   Is provided and controlled by the wom...
Contraceptive Advantagesof LAM (cont.)  Facilitates transition by allowing time for decision   to use/adopt another moder...
Benefits of Breastfeeding        Specific Health Benefits for Mother   Promotes involution (return of uterus to pre-    p...
Benefits of Breastfeeding   Specific Health Benefits for Baby Is more easily digested Adapts to needs of growing infant...
Limitations of LAM    Offers temporary contraceptive protection only for     six months    Is not usually appropriate if...
Can an HIV-positive woman use LAM?         A mother with HIV can use LAM… All HIV-positive women for whom replacement fee...
Special considerations for an HIV+woman wanting to use LAM?A mother with HIV who chooses to breastfeed or use LAMshould: ...
Where can LAM services be provided?          Opportunities to Provide             LAM Counseling     Antenatal clinic   ...
Two sides of Room: “Agree” and“Disagree” Colleagues’ position on: 2) LAM is a very reliable method of contraception, 3) He...
Integrating LAM into ExistingPrograms   Integrating LAM into FP or maternal & child health    programs is similar to prom...
Program Implications Wherever women breastfeed, LAM is an  appropriate FP method LAM uptake improves when included in a ...
Standard Days Method
Standard Days Method Identifies days 8-19 of the cycle as fertile Is appropriate for women with menstrual cycles  betwee...
CycleBeadsThe SDM is used with CycleBead®, a color-coded stringof beads to help a woman:   Track her cycle days   Know w...
SDM Offered WorldwideAlbania        Haiti         SenegalAngola         Honduras      TajikistanArmenia        India      ...
What is Involved in SDM Counseling?  Screening – Help client determine if the SDM is   appropriate for her. Screening Che...
ScreeningWho Can Use the SDM? Women with cycles 26 to 32 days long Couples who can avoid unprotected sex on days  8-19 ...
Screening to See if the SDM isAppropriate for the Woman Is her cycle within the 26 and 32-day range? Simple questions to...
Criteria for Starting the SDM Date of the last period known             Start immediately                                 ...
Teaching - How to use the SDM                                          Provider Cue Card Teach client how to use the SDM ...
Group work – Case studies for cycle length and regularity In pairs, spend 5 minutes resolving the case study  assigned to ...
Group workIn pairs, spend 5 minutes taking turns explainingeach other how to use CycleBeads. Use the beads,insert and cue ...
Supporting the Couple                     During counseling:                      Set the stage                      Enc...
Involving Men- Issues to Consider SDM is a couple method. If men understand it,  couples are more likely to use it correc...
Group Work Video Case StudiesIn small groups, discuss the short  vignette using the discussionpoints and be prepared to sh...
Group work              How would you engage this               couple in discussing how to               handle their fe...
When to contact the provider If she has sex on a white bead day If her period starts before the dark brown  bead (cycle ...
Lessons Learned Providers’ attitudes toward the SDM improve with  training and experience. The SDM can be offered by dif...
TwoDay Method
TwoDay Method Fertility Awareness method that relies on cervical  secretions as an indicator of fertility. The woman che...
TwoDay Method Algorithm    Did I note        YES       any                  I can get pregnant today    secretions     tod...
Cervical Secretions: a reliable     indicator of fertility
Cervical Secretions during the      Menstrual Cycle  Pre-ovulatory     Peri-ovulatory Postovulatory  Days              Day...
How Is the TwoDay Method Offered             to Clients?  Screening for method eligibility  Explaining secretions and th...
Screening Who can use the TwoDay MethodCan be used by:            Some women may need to• Women with cycles of      wait a...
When to start using the TDMNot using a method and meets             Start immediately          TDM criteria  Postpartum/br...
What a woman needs to know to   use the TwoDay Method What secretions mean, how they look and when  they appear How to n...
Steps to use TwoDay Method                           ●                           o                           x          As...
What are secretions?What does secretions look        How to tell if you have secretions?like?• Secretions are not always  ...
How to use the TwoDay Method 1)     CHECK for secretions                2)   RECORD , before        at least twice a day s...
Managing Fertile Days  During counseling, providers:Help women decide how to handlefertile days with partner   Identify ...
When to contact the provider• If she has difficulty determining whether  or not she has secretions• If she has less than 5...
TwoDay Method Study Findings Women want to know how their bodies work. Women had no problems observing  secretions. The...
TwoDay Method Resources• Counseling job aids• Client take-home card• Training curriculum and support  materials• IEC mater...
Guidance Documents IPPF Medical Bulletin – 2000, 2003 WHO Medical Eligibility Criteria – 2002, 2004 Contraceptive Techn...
Coming soon!     K4Health-TDM ToolkitFor More Information       www.irh.org• Access TDM client cards• Answer “frequently-a...
Included in SOTA documents           IPPF Medical Bulletin – 2000, 2003           IRH Reference Guide – 2002           ...
Why Offer FAM?       Increases choice       Expands coverage       Addresses unmet need       Empowers women       In...
Reference Materials Links to scientific  articles Technical Briefs SDM Service                 Training Materials  Prot...
Common Misconceptions about FAM           and SDM• “Natural methods don’t work”• “Is this a modern method? “• “Is there de...
“WOMEN WILL NOT HAVE THE POWER TODECIDE WHEN TO HAVE SEX.” FACT: FAM ARE BEST SUITED FOR COUPLES THAT CAN COMMUNICATE
“If we offer these methods, clients using      modern methods will switch.” Fact: FAM integration has no negative   effect...
“SDM counseling would take too much time,     just like other natural methods.”  Fact: SDM is easy to teach in about the  ...
“It would be hard for  illiterate women to use            SDM.”                                     Fact: SDM appeals to  ...
Increasing Social Acceptance of Family Planning in Communities
Increasing Social Acceptance of Family Planning in Communities
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Increasing Social Acceptance of Family Planning in Communities

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Increasing Social Acceptance of Family Planning in Communities: The experience with Fertility Awareness Methods

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  • By the end of this training, you will be able to: Explain how the Standard Days Method and CycleBeads work Summarize the scientific basis and efficacy of the method Explain how to provide the method the method Describe how and why the programs include this method
  • HTSP After a live birth: Couples can use an effective family planning method of their choice, continuously for at least 2 years before trying to become pregnant again The FAM can offer women and couples over 95% protection from pregnancy when the method is used correctly INFORMED CHOICE Offering FAM helps programs reach new clients FAM helps expand options for women who want to use a natural method. Simple FAM are feasible to integrate in a variety of programs FAM are effective when use correctly.
  • [For countries where “3 to 5 saves lives” has been promoted, facilitator may need to explain that waiting 2 years to become pregnant again results in births no closer than 57 months apart (2 years plus 9 months.)] Couples who wait at least two years after having a baby before becoming pregnant again: Are more likely to have a healthy outcome for their baby – Babies born more than 3 years after their sibling are generally healthier. Also, a baby is more likely to be healthy and have better nutritional status (breastfeeding) if its mother doesn’t have another baby for at least 3 years. The mother will be healthier – There are fewer complications for women who waited two years to become pregnant after their previous birth Reduces neonatal, infant and child mortality. – Few deaths among newborns, infants and children born more than 3 years after their sibling Improves nutritional status of children – Both babies benefit from breastfeeding more than infants born too close together Addresses unmet need for contraception among postpartum women – Most women do not want to become pregnant within two years of their previous birth Economic benefits to family – Fewer births reduce economic demand on families Postpartum contraception reduces the numbers of women becoming pregnant, and therefore at risk of dying from pregnancy-related complications. Pregnancy intervals of less than six months (15-month birth intervals) are associated with 150% increased risk of maternal death. These intervals are also associated with 70% elevated risk of third trimester bleeding, 70% increase of premature rupture of membranes, 30% increase of anemia, and 30% increased risk of postpartum endometritis in the next pregnancy. Fewer newborns, infants and children die if they have been conceived at least 2 years after their sibling was born (World Health Organization. 2006. Report of a Technical Consultation on Birth Spacing: 13-15 June 2005. Geneva) Source : Conde-Agudelo and Belizan 2000 More than 100 million women in less developed countries would prefer to avoid pregnancy, but are not using any form of FP. These women are considered to have an "unmet need" for FP . (Ross and Winfrey 2002) The message is to wait two years to become pregnant, not to wait two years to give birth to another baby
  • It is important to put this information about efficacy in the context of other user-directed methods. Of 100 women using no method of family planning for 1 year, 85 will become pregnant. Those who use spermicides, a diaphragm, or condoms correctly, every time they have sex, 18, 6, and 2, respectively will become pregnant during the first year of use. OCs, used correctly, are more effective, with less than 1 woman getting pregnant with correct use. Clearly, the SDM is as or more effective with correct and typical use than other user-directed methods.
  • So what is LAM? LAM is a family planning method based on the hormonal suppression of ovulation caused by breastfeeding. But of strategic importance is the fact that LAM serves as a “gateway” to other modern methods of FP. I want you to keep this in mind throughout this session. And we will discuss it in much more detail later.
  • LAM prevents pregnancy by interfering with the release of hormones that allow ovulation. Suckling stimulates production of a hormone that tells the brain/hypothalamus not to release the hormone necessary for ovulation. Regular and frequent nipple stimulation is necessary to ensure a continuous stimulation of the brain/hypothalamus. Frequent and intense breastfeeding prevents ovulation.   The baby’s suckling stimulates the nipple . The baby chews on the nipple with his gums and palate; this causes a mechanical/pressure stimulation on the nipple.   This physical stimulation of the nipple sends a signal to the mother’s brain. d The mechanical stimulation of the nipple triggers a neural signal to the mother’s pituitary.   This signal from the nipple to the mother’s brain disrupts the production of hormones which would normally stimulate the ovary . In response to the suckling stimuli, there is an increased production of prolactin; increased levels of prolactin inhibit the normal pulsatile secretion of GnRh by the hypothalamus. Disruptions in the release of GnRH in turn disrupt the production and pulsatile release of FSH and LH by the pituitary.   Thus, ovulation is prevented . Disruption in release of FSH impedes the normal maturation of the egg by the ovary; disruptions in the release of LH impede the release of a mature egg by the ovary. Prolactin controls the rate of milk production but it is not believed to play a major role in suppressing ovarian function. Please look in your reference manual for a more detailed description of this mechanism of action. Prolactin controls the rate of milk production, but it is not believed to play a major role in suppressing ovarian function.
  • What do we mean by “consistent and correct” and “typically used”? “Consistent and correct use” is the best rate a user can expect from this method. “Typical use” is the average rate of protection. Some will be more successful and some will be less successful than this. LAM is more than 98% effective with typical use. How do you think this compares with combined oral contraceptives? [Allow answer from participants] COCs are only 92% effective with typical use. LAM effectiveness reference: World Health Organization (WHO/RHR) and Johns Hopkins Bloomberg School of Public Health/Center for Communications Programs (CCP), INFO Project. Family Planning: A Global Handbook for Providers . Baltimore and Geneva: CCP and WHO, 2007.
  • [Read slide] LAM will not be effective if any one of the three criteria are not met. LAM is not just “breastfeeding.” While any breastfeeding may decrease fertility, LAM cannot be used as an effective method of contraception unless the other two criteria are also met.
  • Any bleeding beyond two months postpartum should be considered the return of menstruation and thus the client should start using another modern method. LAM can potentially be more effective if any bleeding is considered menstruation: This reduces or eliminates the probability that a true but scanty menstruation will be ignored Women experiencing pre-ovulatory bleeding would consider this the return of menstruation; (pre-ovulatory bleeding is a sign that the endometrium was hormonally stimulated by the ovary; even if no actual ovulation occurred, this must be considered a sign of the return of fertility). The lochial discharge that may occur during the first two months postpartum does not disqualify a woman from using LAM.
  • Breastfeeding should be “on demand” (not scheduled) and at least every 4 hours. Exclusively breastfed babies tend to breastfeed sooner than every 4 hrs. Breastfeeding should begin as soon as possible after birth. Can even begin breastfeeding before placenta is expelled. Breastfeeding includes feeding of colostrum. Colostrum is important to the newborn for immunity and to help “clean” its intestines. Also, should go no longer than 4 hours during the day and 6 hours during the night between feeds. Mechanical or hand pumping do NOT appropriately stimulate the nipples. “ Food or liquids” includes ANY substance except medicines. Milk substitutes, pap, herbal tea, all are considered food or liquids.
  • When the baby turns 6 months old, she/he should begin receiving supplemental food. So suckling will decrease and the mother’s fertility will return. Easy to remember
  • Breastfeeding alone cannot be relied upon to prevent pregnancy. Rather it is the period of lactational amenorrhea together with effective breastfeeding practices that provide this protection.
  • How soon after delivery do most women ovulate? Do most women get pregnant? Do women want to get pregnant? We have talked about timely transition to another modern method of contraception. Why is early initiation of LAM or any other contraceptive so important if the couple does not want to become pregnant right away? If not breastfeeding, ovulation will occur on average at 45 days; and it may occur as early as 21 days postpartum And the breastfeeding woman who is not practicing LAM is likely to ovulate before return of menses Between 5-10% of women conceive within the first year postpartum
  • As described earlier, LAM can provide a “gateway,” to other modern methods of contraception. For one thing, LAM provides the couple time to decide on another modern method of contraception that they might use when LAM criteria are no longer met or they choose to discontinue use of LAM. How do you ensure that LAM facilitates transition? How do you make sure that another modern method of contraception follows the cessation of LAM? Because another method should be started as soon as any one of the 3 criteria is not met, the woman should be counseled to decide on the method to which she should transition when LAM counseling is initiated How can providers facilitate the transition Providers mentioning the importance of transition from the very first contact with the mother and in all subsequent contacts. For programs that can afford it, consider providing the LAM user with advance contraceptive supplies How can programs facilitate transition: Training not only FP personnel in LAM and post-partum contraception but also MCH and MNH personnel; prepare materials, stock FP commodities in clinics where mothers take their babies for check-ups, etc.
  • We have just discussed the appropriate time for introducing various methods of contraception. This chart provides a graphic summary. [Review each row of the graph]
  • So options that are safe while breastfeeding may include: Condoms IUD Tubal ligation Vasectomy Natural methods (if criteria met) Progestin only pills Progestin only injection
  • Let’s take out three items from our package of materials: the provider job aid, the client counseling card and the checklist. [Help participants find/identify these materials from their package of learning resources] First, introduce the participants to the Provider Job Aid they can rely on when helping a woman know if she meets the criteria for using LAM. Review major sections of the job aid. Explain the front side of the job aid in preparation for the practice using case studies. Check if participants have any questions or concerns about this job aid. Tell them that when they are observing the demonstration in a few minutes, they should follow along with this job aid. Also, later, when they are practicing LAM counseling, they can use this job aid to remind them of all the essential points. Now look at the client education card which is, of course, for the client. As you are counseling the client on each part of the message, you should point out each message on the card. Then tell the client that she can take this home to remind her of each message and for her partner to read [if her partner is not with her today]. Review the client card, message by message. Now let’s look at the checklist. This can be used by you when you are assessing yourself or trying to remember each step of a client visit. It can also be used if you and a colleague are assessing each other or coaching each other. And it can be used by a supervisor or trainer. You can even use it when you are training someone else to remind you and the participant of each step. This checklist starts at the very beginning of a postpartum family planning visit before the woman has chosen a method of contraception. Let’s look at the steps. [Review steps on first page.] The remainder of the checklist provides step-by-step instructions for counseling a woman who has chosen LAM as a contraceptive method. Because of time limitations today, we are going to focus on the counsel needed by a woman who has already chosen LAM. This part of the information is also included in the job aid and in the client counseling card.
  • Now let’s look at some case studies, some real-life situations that you might encounter. [Read each of the first three case studies. Pause after each case study for answers from participants. Discuss each case study and provide correct answer to each before proceeding to the next case study. Following the completion of the third case study, instruct participants to turn to the person beside them. In pairs, they are discuss each of the last three case studies. After pairs have discussed all three case studies, reconvene the group to discuss the last three case studies together, one at a time. Again, before proceeding to each subsequent case study, clearly state the answer to the current case study. Correct answers can be found on the Case Study document in the Trainers Notebook.
  • Acknowledge any correct answers of participants. Summarize with this slide and next.
  • Emphasize these advantages, and explain: LAM facilitates transition by allowing time for the couple to decide on another method of contraception they will use after LAM LAM has been shown to facilitate modern contraceptive use by couples who have never used contraception before. Some couples have never wanted to use family planning methods. However, LAM is a natural way to introduce contraception into the postpartum period. Having used this modern method of contraception, they are then more likely to want to use another method when LAM is no longer effective. WHO and other global experts advise that babies should only receive breast milk for the first 6 months of life. A baby doesn’t need any other nutrition than breast milk until it is 6 months old. LAM supports this recommendation since exclusive breastfeeding is one of the three criteria.
  • This and the next slide are optional. In areas where providers are very familiar with the advantages of breastfeeding, these slides may be deleted. If slide is to be used: There are a number of benefits to breastfeeding, which is one of the three LAM criteria: LAM benefits the mother by: - Promoting involution (the return of uterus to pre-pregnancy state) - In early postpartum, breastfeeding stimulates uterine contractions. - Also, there is less anemia because there is less iron depletion due to no menses. - In addition, breastfeeding strengthens mother-baby bonding.
  • This and the previous slide are optional. In areas where providers are very familiar with the advantages of breastfeeding, these slides may be deleted. If slide is to be used: There are also many health benefits to the baby. - For instance, breast milk is more easily digested than artificial formulas. - Also breast milk adapts to needs of growing infant. As the infant grows and sucks more, more breast milk is produced. - Breast milk promotes optimal brain development. - And it provides passive immunity and protects from infections. Certain antibodies in breast milk provide immunity to many infections. - Researchers have also found that breast milk provides some protection against allergies. Bottle-fed babies are at higher risk for allergies. - Also, breastfeeding decreases risk of Sudden Infant Death Syndrome (SIDS) [This may be deleted if no one in this setting is familiar with SIDS]
  • There are some characteristics of LAM that are less desirable. For instance, LAM is only a temporary method. It can be used for 6 months at most . Also, LAM is not usually an appropriate method when a mother must be separated from her baby for long periods of time – for instance, when she works outside of the home. Also, an HIV-positive mother may have concerns about breastfeeding.
  • Yes, HIV-positive women may use LAM. In fact, all women (regardless of HIV status) for whom replacement feeding is not acceptable, feasible, affordable, sustainable and safe (you may have heard this as “AFASS” in PMTCT programs) should be encouraged to exclusively breastfeed their infant for six months Therefore, all mothers are eligible for LAM, regardless of their HIV status However, a woman should be supported in her infant feeding decision and in her contraceptive choice; the choice is hers
  • A study in Durban, South Africa, found that infants that were breastfed for 3 to 6 months of age had no excess risk of HIV infection at 6 months compared to infants who were not breastfed. However, infants who received other food or fluids in addition to breast milk had increased risk of transmission. The woman who is HIV-positive should be on ARV therapy if clinically eligible. ARVs taken by the mother greatly reduce the likelihood of transmission of the virus through breastmilk. The woman who is HIV positive should use condoms consistently.
  • [Allow participants to answer question and describe opportunities for LAM counseling.] Summarize discussion by reading this slide. You may list various community sites that are appropriate to the local setting.
  • Why this position? Understanding and advocacy important when communicating with colleagues
  • LINKAGES
  • The Standard Days Method identifies days 8 – 19 of the menstrual cycle as the fertile days, when there is a significant probability of pregnancy. On all the other days of the cycle, pregnancy is most unlikely. The method works best for women who have cycles between 26 and 32 days long. Therefore, to use the Standard Days Method to prevent pregnancy, couples avoid unprotected sex from day 8 through day 19 of each cycle. On all the other cycle days, they can have unprotected sex. To plan pregnancy, the Standard Days Method can help a couple identify the days to have sex. While this is not sufficient for all couples, it can be an important first step.
  • The Standard Days Method is used with CycleBeads TM , a color-coded string of beads to help a woman Track her cycle days Know when she is fertile Monitor her cycle length Many people also find that CycleBeads are an important factor in gaining the man’s support to use the method. It is very visual – he can literally see when the woman is on a fertile day.
  • Here are some of the places around the world where the SDM has been introduced.
  • Note: Show the SDM Job Aids Packet and direct participants to their personal copy of these job aids during the discussion below. Essentially, there are 3 components of SDM counseling Screening – Help client determine if the SDM is appropriate for her. A calendar and screening checklist for the initial visit are job aids that providers can use during screening. Teaching – Provide information and instructions to use the SDM correctly. The CycleBeads Cue Card highlights the key information providers should discuss with clients. Supporting – Explore and discuss couple issues and support correct method use.
  • Note: Brainstorm before showing these bullets The World Health Organization, in its publication “Medical Eligibility for Contraceptive Use”, states that the SDM, like other fertility awareness-based methods, poses no adverse risk to women who choose to use it. But the SDM is intended for women who meet certain criteria: What are they? The majority of her cycles should be between 26 and 32 days. If a woman does not know the approximate length of her menstrual cycles, this can be determined by a few simple questions. If she has more than 1 cycle outside this range during a year, she should be encouraged to use another method. She and her partner should be able to use the method together. The collaboration of the man is extremely important for the successful use of the method. He needs to understand and accept that on days 8-19 of each cycle, they will need to use a condom or not have intercourse. If the man (or the woman) cannot avoid unprotected intercourse during the fertile days, they should be encouraged to use another method. She should not be at risk of sexually transmitted infections. If either member of the couple is exposed to the risk of sexually transmitted infections, the Standard Days Method, as well as most other methods of family planning, will not protect against these infections. Condoms are the only method that provides protection from these infections.
  • It is important to assess whether the method is appropriate for the individual woman, primarily if most of her cycles are between 26 and 32 days long. To calculate the length of the cycle prospectively, count the days from the first day of her period until the day before the next period is expected to start. Studies in several countries have found that most women have a general idea of: When their last period came When their next period will come Whether it usually comes when they expect it Simple questions to assess cycle length and regularity have been well tested. Women who typically have cycles between 26 and 32 days long and know the day their last period started can begin to use the SDM right away. Those who are not sure about the day of their last period can use the method when they start their next period.
  • Now, to summarize, when can a woman start using the SDM: For women using no method, a barrier method, or a non-hormonal IUD – if they know the date they started their last period, they can begin using the method immediately. They simply count on the calendar to see which day of their cycle they are on and put the ring on the corresponding bead. Women who are not sure of the date they started their last period, are using the pill, implant or patch, have had a miscarriage or abortion, or have used EC can start on the first day of their next period. Breastfeeding and other postpartum women and those who have been using the 3-month injectable need to wait until their cycles become regular again and their most recent two periods are about a month apart. If a woman is unable to start the SDM right away, she can use CycleBeads to track her cycle length while using a back-up method
  • After screening for cycle length any possible special circumstances, the next step is to explain the client how to use the methods and how the beads work. Asking clients to explain back is a good way to determine whether the instructions are clear and clarify them as needed. Remind clients that the instructions for use also are included in the insert that accompanies the beads. A cue card to use during the teaching is available to help the provider remember the key points to cover.
  • March 2009 Combined Oral Contraceptives – Family Planning Training Resource Package Note to facilitator: Ask participants to share any strategies that they have developed or their clients have used to establish a daily routine in order to remember to move the ring on her CycleBeads and thus know if: (1) she’s on fertile or infertile day; and (2) if her cycles continue to be on the 26 to 32-day range required for the SDM. Possible strategies may be to move the ring at the same time every day, moving the ring at the time she wakes-up or as she gets ready for her first daily activity or, pairing moving the ring with another daily activity such as washing up before bed. Ask participants to describe how they would counsel a client who comes to the clinic after having unprotected sex on a white-bead day.
  • Providing counseling in the SDM involves teaching the client how to use CycleBeads to help her know on which days she can get pregnant and days pregnancy is unlikely. It also involves checking for client’s understanding and confirmation that she knows how to use CycleBeads and how to avoid getting pregnant if she so desires.   Finally, counseling involves helping the client use the method with her partner, i.e. helping her identify any potential issues that may prevent them from using the method effectively and exploring options for dealing with those issues.
  • Screening for behavioral criterion – Couple’s ability to handle fertile days   Note to the trainer : The following vignettes are designed to support training in the SDM and are part of a 45-minute video featuring a full counseling session (approx 20”) and other cases (approx 2 to 4 minutes each) where providers counsel clients who experience different special circumstances.   Introduce each episode before playing it. This will help viewers know what to look for as the action transpires. Ask them to pay close attention to each episode since there will be questions after viewing each one Show vignettes and stop the video prior to counselor’s recommendations to client Ask Px that while watching the video, think about how they would help the couple manage the fertile days (video ends before this discussion takes place) Divide Px into 2 to 3 groups to reflect and discuss on vignette. Ask Px to answer discussion questions. After each episode, ask the questions listed in the handout or develop your own. When the episode is over, help the audience summarize the main points before moving on. Make sure the participants have no additional questions before ending the discussion.   Discussion Questions for Participants   Maggie & John’s Case – Recent use of Emergency Contraception What are ways in which you could engage this couple in discussing how to handle their fertile days? What questions would you ask Maggie and John to help them figure out how they will handle the fertile days? How would you feel about this couple using the SDM If they decide to start using the method, would you schedule a follow-up visit? Why or why not?   Linda’s case – A Woman with Couple Communication Issues How would you feel asking these kinds of question to a client in a similar situation? Is there something else you would do as a counselor?    Tracy’s case – A Woman at Risk of a STI Please talk over this situation and continue with the counseling. Be prepared to share specifics with other participants on how you handled Tracy’s case.
  • Note: Ask participants to turn to the person next to them. The one who was the provider before is now the client, and vice versa. Ask the provider to engage the client in a discussion about how she and her partner will handle the fertile days. After about 5 minutes stop the activity and ask how they felt. What questions did the provider ask? How did he/she feel asking them? How did the client respond? How did she feel talking about this? Anything else? Other issues
  • About half of women in other countries had never used any method and about 1/3 had ever used condoms, pills, and injections, in the U.S., all women had contraceptive experience. 87% had used condoms and 96% hormonal methods. In studies conducted in several countries, - six countries plus the U.S. - we find that the overwhelming reason why women choose the SDM is that it doesn’t affect their health and has no side effects. We know that most contraceptives do not have negative health effects for the vast majority of women. Indeed, there is good evidence that some methods actually have health benefits. And we know that most side effects are transitory and manageable. Nonetheless, these are many women who want something natural . Couples in different settings and with different experiences and backgrounds will use different approaches to managing their fertile days. While there are a range of options, the 2 most frequently reported are abstaining from sex or using a condom. Many couples abstain sometimes and use a condom other times. Here we can see what couples report in 4 quite different settings.
  • We have seen that cervical secretions are a reliable indicator of fertility. This method is based on the presence of secretions to identify fertile days. The consistency, viscosity, lubricity, elasticity or any other characteristic of the secretions is not important. If the woman has noted secretions TODAY or YESTERDAY, she considers herself fertile TODAY and avoids unprotected sex TODAY if she wants to avoid a pregnancy. Thus the name of the method: the user takes two days (TODAY and YESTERDAY) into account in deciding whether she can have sex today.
  • This algorithm illustrates the method. The woman asks herself two questions every day: Did I note secretions TODAY? Did I note secretions YESTERDAY? If she noted secretions of any type today or yesterday, she is potentially fertile TODAY, and should not have unprotected sex today. They need to use a condom, or abstain. If she did not note secretions today or yesterday (two consecutive dry days), her probability of pregnancy today is very low, so she can have sex today. And the NEXT DAY she ask herself the same questions.
  • ¿Por qué las secreciones son un buen indicador? Las secreciones se originan dentro del proceso hormonal que ocurre en el ciclo menstrual de la mujer, como respuesta a los estímulos del hipotálamo, la glándula pituitaria anterior y los ovarios que generan cambios en el vario mismo, útero, cerviz, etc. Específicamente sabemos que la HFC y HL estimulan la producción del estrógeno y la progesterona que a su vez estimulan el canal cervical produciendo cambios en el moco cervical. Veamos como son estos cambios que son la base del Método de Dos Días, y que para efectos prácticos es el indicador que la mujer puede ver para determinar si esta o no fértil. Secretions have several functions: They facilitate the fertilization process: The sperm can live for several (up to 5) days in the woman’s reproductive tract, but only when cervical secretions are present. If there are no cervical secretions, the acid environment of the vagina wears away the sperm almost immediately (despite the semen’s alkalinity). They facilitate the sperm’s navigation towards the uterus: When secretions are more liquid (they have a greater water content, which occurs around the day of ovulation) they help the sperm to swim more efficiently towards the uterus. In contrast, when secretions are thicker (have a lower water content), they function like a thick plug that prevents the passage of the sperm, making the cervix more impenetrable. They nourish the sperm: The carbohydrates in secretions serve to nourish the sperm. Why are secretions so reliable as an indicator of fertility? Because they are not only a signal/indicator. Secretions are a FACTOR of fertility. Cervical secretions are actually necessary for the woman to be fertile. If there are no cervical secretions, she can not be fertile, she can not become pregnant.
  • In summary: During the preovulatory days (days before ovulation) secretions have a lower water content and are less detectable around the vulva. The periovulatory days (days around ovulation, including the day of ovulation itself), secretions have a higher water content and are more fluid. Secretions flow down the vaginal walls to the vulva where they are noticeable. On the postovulatory days, once again, secretions return to having a lower water content, are less fluid and less detectable. Thus, the TwoDay method is a prospective method: every day the woman can notice signals from her body that tell her what is happening in her body that day and what is going to happen in her body in a few days. So she can tell, on a day to day basis if she is fertile or not. If her cycle is slightly different from previous cycles (ex: on this cycle she will ovulate a few days earlier, or later), she will get these signals on slightly different days, always following what is happening in HER body on THIS cycle. Or if she will not ovulate this cycle, her body will very probably not give any fertility signals.
  • Adaptation Notes: This page can be copied and included in a “kit” for providers, as “take-home” information for clients. See notes on page FA1 (client side) regarding Standard Days Method.
  • When can a woman start using the TDM: For women using no method, a barrier method, or a non-hormonal IUD – if they know the date they started their last period, they can begin using the method immediately. They simply count on the calendar to see which day of their cycle they are on and put the ring on the corresponding bead. Women who have recently used the pill, implant or patch, have had a miscarriage or abortion, or have used EC can start on the first day of their next period. Breastfeeding and other postpartum women and those who have been using the 3-month injectable need to wait until their cycles become regular again and their most recent two periods are about a month apart.
  • Para usar el método la mujer debe hacer tres cosas Poner atención a sus secreciones Determinar si está en un día fértil Dependiendo de su intención reproductiva, decidir con su pareja si van a tener relaciones sexuales o no T: Ahora se deben estar preguntado que tan eficaz será este método? .
  • Adaptation Notes: This page can be copied and included in a “kit” for providers, as “take-home” information for clients. See notes on page FA1 (client side) regarding Standard Days Method.
  • Adaptation Notes: This page can be copied and included in a “kit” for providers, as “take-home” information for clients. See notes on page FA1 (client side) regarding Standard Days Method.
  • Encourage women to talk with their husbands or partners about SDM use and what kind of problems might come up during the fertile days. Brainstorm with her what problems she and her husband might have using the method, and how she might solve them. Do a role play to provide her the opportunity to practice talking with her husband. If necessary, offer to meet with her husband. The provider can help women plan how to manage the fertile days by asking questions such as: Have you talked about this method with your partner? How will you communicate about your fertile days? How might you and your partner handle the fertile days? Have you and your partner used condoms? How do you and he feel about using them? Perhaps the most important thing is to be sure that she leaves with a plan for talking with her partner and for handling her fertile days.
  • The women who participated in the study were typical clients of public programs (health ministries, NGOs working in rural communities). These women were not special clients nor were they selected based on any criteria of education or social class. We learned the following: Women want to know about their bodies and their fertility. We found that women who touched their secretions with their fingers were not uncomfortable doing so. They are definitely interested in knowing what is happening in their bodies. They had no problem observing their secretions. Partners were willing to cooperate. Couples are able to respect the fertile days. They know in advance when the fertile days will be and they have sex on the previous or following days, or they use some type of protection.
  • Any time we consider adding a new method to our program, we need to think seriously about what we expect to gain by offering this particular method. In the case of the SDM, it is very likely that providers don’t have any experience with it or even with any similar methods, so they may be very skeptical. Current clients may be adequately served by existing methods, and most clients – and potential clients – don’t know about the method. What are some reasons why we might want to offer the SDM? (Note: Ask audience/trainees this question before clicking on answers. Be prepared to address issues of provider bias.)
  • You have heard about how the SDM underlying science, research, program experiences and how it is offered to clients. You have seen what’s included in a training of service providers at the facility level and seen the methodology and practiced it. As master trainers, you’re probably thinking what other tools exist to help you adapt and use other resources in your respective programs and organizations. We would like to show you what other materials exist for clients, providers, programs, for addressing policy makers, but most importantly, for training different levels of providers. There is a large collection of materials both, generic and tailored by programs in different countries. All these are available in the CD included in your packet plus our website at www.irh.org. Some of those materials include: - online SDM training for providers - provider job aids - reference guide for counseling clients - informational SDM video - counselor training video - provider training manual - pamphlets, brochures, etc. As programs in the field continue to refine and adapt these resources, we collect them and disseminate them to a variety of audiences. As we close this workshop, w e hope we can stay in touch to share your experiences in training and for us to continue sharing new resources and information. In addition to including you in periodic updates, we are working on setting-up an online community on the ibp-initiative's knowledge gateway and our IEC Program Officer Susana Mendoza will contact you in a few weeks to invite you to join. In the meantime, please access our website for more information and here is Susana’s card in case you’d like to contact her directly.
  • Here are common issues that you will hear about FAM in general and the SDM in particular, and the arguments and evidence you have available to deal with them.
  • Fact : SDM is best suited for couples that can communicate about sex SDM is unlikely to succeed with couples whose relationship is characterized by gender inequity and gender-based violence For correct SDM use, it is important: That both the woman and man agree about whether or not they want a pregnancy That both understand how SDM works FP counselors encourage couples to decide how to manage the fertile days beforehand
  • Research shows that SDM brings new users to family planning In fact, in the state of Jharkhand, India, 87% of new SDM users are new to family planning
  • Comparison of SDM, sterilization, and pill counseling at government clinics (Jharkhand, India) - Session length” SDM 17 ; Pill 13 min.; Sterilization 15 min - Information exchange: SDM 64%; Pill 58%; Sterilization 44% (Simulated clients)
  • It is entirely possible for low literacy and illiterate women to use this method. There is no need for them to be able to read in order to use it. CycleBeads serve as a helpful visual tool for women, regardless of whether or not they are literate IRH has developed low-literacy inserts to support method use SDM is offered in over thirty countries worldwide, including the United States, in both the public and private sectors Women worldwide choose SDM because: It is natural and free of health side effects It teaches them about their fertility and helps them monitor their cycle lengths CycleBeads help women negotiate & discuss sex with their partners
  • Transcript of "Increasing Social Acceptance of Family Planning in Communities"

    1. 1. Increasing Social Acceptance ofFamily Planning in Communities:The experience withFertility Awareness Methods PRE-CONFERENCE WORKSHOP Durban, June 19, 2010 Jeannette Cachan, MA and Marie Mukabatsinda, BN Institute for Reproductive Health, Georgetown University
    2. 2. Workshop Objectives Review basic information about SDM, TwoDay Method and LAM, three simple fertility awareness methods. Learn about newest guidelines and training resources available for these three methods. Understand what is involved in the counseling and become familiar with simple tools for providing each of these methods. Learn how programs add these method to existing services
    3. 3. Fertility Awareness Methods (FAM) Modern FAM are effective options for many women who want to space pregnancies without using a hormonal method. FAM offer an opportunity to involve the partner in optimal birth spacing and timing. They have no side effects and are economical.
    4. 4. How FAMs 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
    5. 5. Why develop new FAM? Very low use of current FA-based 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.
    6. 6. Use of family planning remains low inmany countries Percentage aof married women using contraception 40 35 30 Modern Methods 25 20 15 Traditional or folk methods 10 5 0 Benin DR Congo Zambia India - UP Source: PRB 2005 World Population Data Sheet and ORC Macro DHS
    7. 7. Use of periodic abstinence (with incorrector limited information) in many countries Percentage married women using periodic abstinence 25.0 20.0 Incorrect knowledge 15.0 of fertile time 10.0 Correct knowledge of fertile time 5.0 0.0 Source: ORC Macro, 2006. MEASURE DHS STATcompiler
    8. 8. Context for FAM FAM in the context of:  Healthy Timing and Spacing of Pregnancies (HTSP)  Informed choice in family planning
    9. 9. What is HTSP? Is it different from birthspacing? 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. After a live birth, wait at least two years before trying to get pregnant again. Rather than wait two years between births.
    10. 10. Healthy Timing & Spacing of PregnanciesAfter 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, TwoDay Method and LAM can offer women and couples at least 95% protection from pregnancy when the method is used correctly.
    11. 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.
    12. 12. What are the advantages of waiting twoyears after having a baby to becomepregnant 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
    13. 13. Natural Family Planning – Method Comparison Standard Days Method TwoDay Method LAM with CycleBeadsMethod  Women with cycles between 26 • Women who are willing and able 3 LAM Criteria and 32 to monitor daily the presence or 2.Mother’s menstrual bleeding hasEligibility days long absence or secretions; not returned since the bay wasCriteria (who  Couples who can avoid • Couples who can avoid born unprotected sex on days 8 to19 unprotected intercourse during 2. Mother is only breastfeedingcan use the the days the method identifies as ANDmethod) fertile. 4.Baby is less than 6 months oldExceptions Women in postpartum or Postpartum or breastfeeding Women who don’t meet at least breastfeeding must have had at women, unless they have one of the criteria.(who cannot least 4 periods about a month completed three cycles since theiruse) apart. child was born. Women who recently used a Users of hormonal contraception or hormonal method must have 3 medication in the previous three periods about a month apart after months stopping hormonal.Effectiveness 95% with correct use 96% with correct use 99% with correct use 88% with typical use 86% with typical use 98% with correct use Pregnancies for every 100 woman-years Pregnancies for every 100 woman-years *6 months effectiveness rateHow it works The woman considers herself fertile The woman considers herself fertile • Put baby to breast as soon as on days 8-19 of the cycle if she notes secretions of any type possible after birth that day or noted them the day • Breastfeed as often as your baby before. wants, day and night •Women check everyday for the • Continue breastfeeding even if presence of secretions the mother or infant becomes ill •If she notices any secretions today • Do not give your baby any or yesterday, she considers herself foods, water, or other liquids fertile today and avoids • Do not use bottles, pacifiers or unprotected intercourse today other artificial nipples.Key Research • Multi-site prospective study • Prospective, multi-site study - Prospective 10-ciuntry multi- • Services provided in existing • 450 clients followed for up to 13 center study established 98%and Findings programs cycles effectiveness (Labbok, et al. 1997) • Clients followed monthly for 13 • Results: more than 96% effective -LAM Leads to Higher cycles preventing pregnancy Contraceptive Prevalence at 12 • Couples used the method • Results published: “Efficacy of a Months Postpartum and fewer
    14. 14. Contraceptive Failure of User-Directed Methods *Percentage of women who became pregnant 1st year of use Correct Use Typical Use OCs .3 8 Condom 2 15 **TwoDay Method 4 13 ***Standard Days Method 5 12 Diaphragm 6 16 Spermicides 18 29 No Method 85 85 6 month pregnancy rate Correct use Typical Use LAM 1.0 2.0 *Adapted from Contraceptive Technology, 18th edition, 2004 **Source: Arévalo et al. Fertility & Sterility, October 2004 ***Source: Arévalo et al. Contraception, 2002
    15. 15. Comparing effectiveness of FP methods Source: Family Planning: A Global Handbook for Providers 2007, WHO
    16. 16. Lactational Amenorrhea Method(LAM)
    17. 17. LAM  A Family Planning Method based on the physiological infertility experienced by breastfeeding women  A “gateway” to other modern methods of contraception 17
    18. 18. How does LAM prevent pregnancy? LAM Mechanism of Action1. Baby’s suckling stimulates the nipple3. Nipple stimulation triggers signals that affect hormones5. Disruption of hormones suppresses ovulation 18
    19. 19. Effectiveness of LAM  LAM is 99.5% effective with consistent and correct use and more than 98% effective as typically used  Effectiveness rates comparable to those of other modern methods 19
    20. 20. What are the three criteria for LAM? The 3 LAM criteria • Mother’s menstrual bleeding has not returned since the bay was born, AND 2. Mother is only breastfeeding, AND 6. Baby is less than 6 months old 20 20
    21. 21. LAM Criteria Mother’s menstruation has not returned since 1 the birth of the child (“Amenorrhea”)  Bleeding during the first 2 months post- partum does not count as menstruation  Bleeding after 2 months post-partum can be an indication of the return of fertility 21
    22. 22. LAM Criteria2 Baby is being only breastfed; The baby is not receiving any other solid food or liquids; only breast milk Why is this condition important? When baby receives any food, water, or other liquid:  The baby becomes full and will not want the breast as often.  The mother will not produce as much milk.  Infrequent suckling will make the mother’s  fertility return. She can get pregnant. 22
    23. 23. LAM Criteria The baby is less than 6 months old 3  Biologically appropriate cut-off point.  WHO recommends supplementing after 6 months.  Supplemental food will decrease suckling. 23
    24. 24. Be sure that your clients understand:BREASTFEEDING IS NOT THE SAME AS LAM! 24
    25. 25. Why is contraception during thepostpartum period so important? Fertility may return soon after delivery and risk of pregnancy emerges  If not breastfeeding, ovulation will occur at 45 days postpartum on average; may occur as early as 21 days  Breastfeeding women not practicing LAM are likely to ovulate before return of menses  Between 5% and 10% of women conceive within the first year postpartum 25
    26. 26. Transition to Another Method: An Essential Component of LAM LAM is a “gateway” to other modern methods of contraception LAM provides the couple time to decide on another modern method to use after LAMHow do you ensure that LAM facilitates transition? Another method should be started as soon as any one of the three LAM criteria is not met The woman should be counseled to decide on the method to which she should transition when LAM counseling is initiated 26
    27. 27. Postpartum Contraceptive Options Adapted from Contraceptive Technology Update 27
    28. 28. Methods That Are Safe whileBreastfeeding  A number of contraceptive methods can be safely used by the breastfeeding mother:  Abstinence – any time  Condom – any time  IUD – inserted before 48 hours or after 4 weeks  Combined oral contraceptives – after 6 months  Progestin-only (pills, implants, 3-month injection) – after 6 weeks  Tubal ligation – performed before 7 days or after 6 weeks  Vasectomy – any time 28
    29. 29. Emphasizing timely transition  Offer postpartum women choice of all appropriate FP methods during first post-partum visit  During this and subsequent visits, discuss what she will use after LAM  Encourage women to keep breastfeeding after LAM
    30. 30. Job Aids 30
    31. 31. Case Studies Decide which women can rely on LAM for contraception.  Read each case study  Discuss answers  Review answers as a group 31
    32. 32. Optimal Breastfeeding Behaviors Allow newborn to breastfeed as soon as possible after birth, and to remain with the mother after birth Breastfeed as often as baby wants, day and night Continue breastfeeding even if the mother or infant becomes ill Do not give your baby any foods, water, or other liquids for the first 6 months Do not use bottles, pacifiers or other artificial nipples. These discourage the baby from breastfeeding as frequently. Continue to breastfeed for the first two years, even though also providing complementary foods 32
    33. 33. Contraceptive Advantagesof LAM Effectively prevents pregnancy up to six months Is provided and controlled by the woman Can be used immediately after childbirth Is universally available to postpartum women Does not require supplies or procedures Is economical Has no hormonal, or other, side effects (for breastfeeding mother and her infant) Raises no religious objections 33
    34. 34. Contraceptive Advantagesof LAM (cont.)  Facilitates transition by allowing time for decision to use/adopt another modern contraceptive method  Facilitates modern contraceptive use by previous non-users  Supports and builds on infant-feeding recommendation to exclusively breastfeed for six months 34
    35. 35. Benefits of Breastfeeding Specific Health Benefits for Mother Promotes involution (return of uterus to pre- pregnancy state) Stimulates uterine contractions in early postpartum Leads to less anemia because of less iron depletion due to no menses Strengthens mother–baby bonding enhanced 35
    36. 36. Benefits of Breastfeeding Specific Health Benefits for Baby Is more easily digested Adapts to needs of growing infant Promotes optimal brain development Provides passive immunity and protects from infections Provides some protection against allergies 36
    37. 37. Limitations of LAM Offers temporary contraceptive protection only for six months Is not usually appropriate if mother will be separated from baby for periods of time May pose concerns for HIV-positive mothers 37
    38. 38. Can an HIV-positive woman use LAM? A mother with HIV can use LAM… All HIV-positive women for whom replacement feeding is not acceptable, feasible, affordable, sustainable and safe (AFASS) should be encouraged to exclusively breastfeed their infant for six months. A woman should be supported in her infant-feeding decision and in her contraceptive choice; the choice is hers(WHO. HIV and Infant Feeding: Report of a Technical Consultation. 25-27 October 2006. Geneva.) 38
    39. 39. Special considerations for an HIV+woman wanting to use LAM?A mother with HIV who chooses to breastfeed or use LAMshould:  Breastfeed exclusively for the first six months before switching completely to replacement foods if possible  Receive care and treatment for herself  Use condoms consistently  Feed from unaffected breast (and express and discard milk from affected breast) if she experiences cracked nipples  Seek immediate care for baby with thrush or other lesions in mouth 39
    40. 40. Where can LAM services be provided? Opportunities to Provide LAM Counseling  Antenatal clinic  Child health (well-baby) clinic  Postpartum ward  Postpartum clinic  Family planning clinic  Labor ward (in early labor or after birth)  Community health visits 40
    41. 41. Two sides of Room: “Agree” and“Disagree” Colleagues’ position on: 2) LAM is a very reliable method of contraception, 3) Healthcare providers should counsel on LAM because it is as effective as other methods of contraception, 4) Counseling about LAM is easy, 5) LAM requires too much time in counseling to be offered in busy settings, 6) LAM is a difficult method for postpartum women to understand. 41
    42. 42. Integrating LAM into ExistingPrograms Integrating LAM into FP or maternal & child health programs is similar to promoting any other contraceptive method Education and advocacy at policy, facility and community levels may be necessary to clarify that LAM and breastfeeding are not interchangeable terms
    43. 43. Program Implications Wherever women breastfeed, LAM is an appropriate FP method LAM uptake improves when included in a broad integrated program Community involvement is important Training alone is not sufficient Provider bias influences counseling Importance of supervision, monitoring & evaluation
    44. 44. Standard Days Method
    45. 45. 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
    46. 46. CycleBeadsThe SDM is used with CycleBead®, a color-coded stringof beads to help a woman:  Track her cycle days  Know when she is fertile  Monitor her cycle length
    47. 47. SDM Offered WorldwideAlbania Haiti SenegalAngola Honduras TajikistanArmenia India TanzaniaAzerbaijan Kenya Timor EsteBangladesh Malawi TurkeyBenin Mali UgandaBolivia Mauritius UkraineBurkina Faso Mozambique United StatesDR Congo Nicaragua ZambiaEcuador NigeriaEl Salvador PakistanEthiopia PeruGhana PhilippinesGuatemala Romania Rwanda
    48. 48. What is Involved in SDM Counseling?  Screening – Help client determine if the SDM is appropriate for her. Screening Checklist  Teaching – Provide information and instructions to use the SDM correctly. CycleBeads Cue Card  Supporting – Explore and discuss couple issues and support correct method use. Screening Checklist
    49. 49. ScreeningWho Can Use the SDM? Women with cycles 26 to 32 days long Couples who can avoid unprotected sex on days 8-19 Couples not at risk of STIs
    50. 50. Screening to See if the SDM isAppropriate 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.
    51. 51. Criteria for Starting the SDM Date of the last period known Start immediately Start on first day of next period Date of last period unknown Wait 90 days after lst injection, 2 most Contraceptive Injection recent periods about 1 month apart OC, patch, implant, IUD/IUS Wait until last 3 periods are about a month apart (after stopping the Pregnancy loss hormonal method) Wait until she has 4 periods and the Postpartum/breastfeeding two most recent are about a month apart
    52. 52. Teaching - How to use the SDM Provider Cue Card Teach client how to use the SDM with CycleBeads Confirm client knows how to use the method and when to return to the provider Check the woman and her partner know 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
    53. 53. Group work – Case studies for cycle length and regularity In pairs, spend 5 minutes resolving the case study assigned to your team.
    54. 54. Group workIn pairs, spend 5 minutes taking turns explainingeach other how to use CycleBeads. Use the beads,insert and cue card to follow key points. Thendiscuss the following points:How to help women remember to move the ringevery day?Why is it important for her to move the ring daily?How can a woman know if her cycles are withinright range to use CycleBeads?What should a woman do if she’s not sure if shemoved the ring on any given day?
    55. 55. Supporting the Couple During counseling:  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  Identify possible challenges and solutionsBE SURE SHE LEAVES  Role play talking with her WITH A PLAN! partner  Offer to talk with her partner
    56. 56. 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.
    57. 57. Group Work Video Case StudiesIn small groups, discuss the short vignette using the discussionpoints and be prepared to share in the larger group.
    58. 58. Group work  How would you engage this couple in discussing how to handle their fertile days?  How would you feel about this couple using the TwoDay Method?  If they decide to start using the method, would you schedule a follow-up visit? Why or why not?
    59. 59. When to contact the provider If she has sex on a white bead day If her period starts before the dark brown bead (cycle shorter than 26 days) If her period has not started the day after moving the 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
    60. 60. 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
    61. 61. TwoDay Method
    62. 62. TwoDay Method Fertility Awareness method that relies on cervical secretions as an indicator of fertility. The woman checks daily for the presence or absence of secretions (of any type). If she notes secretions TODAY or YESTERDAY, she is considered to be fertile TODAY. To prevent pregnancy, avoid unprotected sex TODAY.
    63. 63. TwoDay Method Algorithm Did I note YES any I can get pregnant today secretions today? NO YES Did I note any I can get pregnant today secretions yesterday? NO Pregnancy is not likely today.
    64. 64. Cervical Secretions: a reliable indicator of fertility
    65. 65. Cervical Secretions during the Menstrual Cycle Pre-ovulatory Peri-ovulatory Postovulatory Days Days Days More Water Less Water More Fluid Less Water Less Fluid More Less Fluid Less detectable detectable Less detectable Detectable secretions = Sign of Fertility
    66. 66. How Is the TwoDay Method Offered to Clients?  Screening for method eligibility  Explaining secretions and the menstrual cycle  Teaching method use: observing and recording observations  Discussing couple’s ability to manage fertile days.  Explaining when to return to provider
    67. 67. Screening Who can use the TwoDay MethodCan be used by: Some women may need to• Women with cycles of wait a while before using any length the method if:• Women with healthy secretions  They had a recent• Women willing to check pregnancy or are for secretions breastfeeding.• Couples who can use  Recently used a condoms or abstain for hormonal method. several consecutive days each cycle
    68. 68. When to start using the TDMNot using a method and meets Start immediately TDM criteria Postpartum/breastfeeding Wait until she has 4 periods Wait until 4 months have passed 3-month contraceptive after last injection, and her periods Injection have resumed Wait until she has 4 periods after OCs, patch, implant, IUD/IUS stopping the hormonal method
    69. 69. What a woman needs to know to use the TwoDay Method What secretions mean, how they look and when they appear How to notice secretions and when When is pregnancy likely and unlikely How to prevent pregnancy on fertile days When to return to her provider
    70. 70. Steps to use TwoDay Method ● o x Asks herself if sheIdentifies had secretions secretions Asks herself if she today or yesterday. had secretions Decides if she can and records them. or cannot have sex today.
    71. 71. What are secretions?What does secretions look How to tell if you have secretions?like?• Secretions are not always • You can see them when youthe same and they look and go to the bathroom.feel different as days go by.• Once they start theycontinue for several days in arow. • You can feel them by paying attention for moisture in your genital area while doing daily• Even if they change in activities.quantity or appearance, ALLsecretions tell you that youcan get pregnant.
    72. 72. How to use the TwoDay Method 1) CHECK for secretions 2) RECORD , before at least twice a day starting going to bed, at noon. whether you had secretions. If you forget to check secretions, consider yourself fertile today. 3) DECIDE if you can get pregnant today. If you had secretions today or yesterday, You can get Ask yourself these two questions: pregnant today. Use a - Did I have secretions today? condom or avoid sex. - Did I have secretions yesterday? If you are menstruating or if you did not have secretions today and yesterday, you can have sex without using a condom.
    73. 73. Managing Fertile Days During counseling, providers:Help women decide how to handlefertile days with partner  Identify potential problems and solutions  Encourage women to discuss SDM use with their partners  Role play talking with her partner  Offer to talk with her partner
    74. 74. When to contact the provider• If she has difficulty determining whether or not she has secretions• If she has less than 5 days with secretions• If she has more than 14 consecutive days with secretions• If she has difficulty avoiding unprotected sex during the fertile days• If her secretions are smelly or itchy• If her period has not returned and thinks she might be pregnant
    75. 75. TwoDay Method Study Findings Women want to know how their bodies work. Women had no problems observing secretions. They could identify their secretions in the first cycle of method use. Most women in all three study countries were able to note secretions and differentiate between healthy and unhealthy secretions. Most women were not aware of the relationship between fertility and secretions and thus ignored them; they were not paying attention to these. Arevalo et al, Efficacy of the new TwoDay Method of family planning. Fertility and Sterility, Vol. 82, No. 4, Oct 2004
    76. 76. TwoDay Method Resources• Counseling job aids• Client take-home card• Training curriculum and support materials• IEC materials• Supervision tool• FAQs
    77. 77. Guidance Documents IPPF Medical Bulletin – 2000, 2003 WHO Medical Eligibility Criteria – 2002, 2004 Contraceptive Technology - Contraceptive Technology – 2004, 2007 USAID Global Health Technical Briefs – 2010 (coming soon) Pocket Guide to Managing Contraception – 2004 Pop Report (New Contraceptive Methods) – 2005 WHO Global Handbook for Family Planning – 2006 Pop Council Balanced Counseling Strategy – 2006
    78. 78. Coming soon! K4Health-TDM ToolkitFor More Information www.irh.org• Access TDM client cards• Answer “frequently-asked questions”• Down-load published papers, materials• Link to related sites
    79. 79. Included in SOTA 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
    80. 80. Why Offer FAM?  Increases choice  Expands coverage  Addresses unmet need  Empowers women  Involves men  Offers low-cost method
    81. 81. Reference Materials Links to scientific articles Technical Briefs SDM Service Training Materials Protocol  Trainers’ Manual Sample Norms  Participant Handbook Frequently Asked  Training Video Questions  Online Training www.irh.org
    82. 82. Common Misconceptions about FAM and 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
    83. 83. “WOMEN WILL NOT HAVE THE POWER TODECIDE WHEN TO HAVE SEX.” FACT: FAM ARE BEST SUITED FOR COUPLES THAT CAN COMMUNICATE
    84. 84. “If we offer these methods, clients using modern methods will switch.” Fact: FAM integration has no negative effects on FP use and method mix
    85. 85. “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
    86. 86. “It would be hard for illiterate women to use SDM.” Fact: SDM appeals to women from a range of socio-economic backgroundsFact: Low literacy or illiterate women can learn how to “More educated women would use SDM correctly not be interested in using SDM.”
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