Bringing New People to Family Planning: TheBroader Impact of Fertility Awareness Methods                                  ...
Workshop Objectives• Review basic information about the Standard  Days Method (SDM) and Lactational  Amenorrhea Method (LA...
FAM INTRODUCTION                                                 Slides 4 to 18© 2004 Eileen Dietrich, Courtesy of Photosh...
Fertility Awareness Methods• Modern FAMs are effective options for  many women who want to space  pregnancies without usin...
How FAM work• Identify “fertile window” (days intercourse can  result in pregnancy) of the menstrual cycle• Use one or mor...
Why develop new FAM?•   Very low use of current FAM methods.•   Very poor understanding of fertility in the general    pop...
Context for FAM       FAM in the context of:       • Healthy Timing and         Spacing of         Pregnancies (HTSP)     ...
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 two yearsafter having a baby to become pregnant again?   Increases likelihood of healt...
Healthy Timing & Spacing of Pregnancies  • After a live birth couples should use an    effective family planning method of...
Method Characteristics                        Standard Days Method with CycleBeadsMethod Eligibility       Women with cyc...
Contraceptive Failure of User-Directed Methods  *Percentage of women who                                                  ...
Comparing effectiveness of FP methods                                   Source: Family                                   P...
STANDARD DAYS METHOD®      OVERVIEW                 Slides 49 to 66                               14
What is the Standard Days         Method• Identifies days 8-19 of the cycle as  fertile• Is appropriate for women with men...
CycleBeadsThe SDM is used with CycleBeads®, acolor-coded string of beads to help awoman:• Track her cycle days• Know when ...
SDM Offered Worldwide  Albania        Guinea        Rwanda  Angola         Haiti         Senegal  Armenia        Honduras ...
Determining the Fertile Window                                 Ovulation        5 days (sperm life)          12 to 24 hour...
Group Work: How Effective Is the     Standard Days Method?• How effective do you think SDM is?• What do you think may be s...
Efficacy Study of the SDM• Multi-site prospective study• Services provided in existing programs• Clients were followed mon...
Contraceptive Failure of             User-Directed Methods        % of women who became pregnant during 1st year of use   ...
What Have We Learned About Offering          SDM to Clients?                                  22
SDM User Profile                                              Six Countries1   U.S.2Mean Age                              ...
Reasons for Choosing the SDM                                              Six Countries1   U.S.2Doesn’t affect health     ...
How Couples Manage the Fertile Days                                           Abstain   Condom         Rural India        ...
Counseling Time at GoJ Clinics Comparison of SDM, Sterilization, and Pill                         SDM                Pill ...
Reasons for Choosing the SDM                                                     Six Countries1          U.S.2Doesn’t affe...
Group Work: SDM AttributesWho might be interested in using SDM?• Someone who has never used a FP method• Woman who doesn’t...
Lessons Learned• Providers’ attitudes toward the SDM improve with  training and experience.• The SDM can be offered by dif...
SDM COUNSELING                 Slides 67 to 82                              30
How is the SDM offered to Clients?•   Screening•   Teaching•   Support couple’s use•   When to return                     ...
ScreeningWho Can Use the SDM?  Women with cycles 26 to 32 days long    (women who have their monthly periods are within t...
Screening to See if the SDM is   Appropriate for the Woman Is her cycle within the 26 and 32-day range? Simple questions...
Criteria for Starting the SDM Date of the last period known              Start immediately Date of last period unknown    ...
Group work: Case studies for   cycle length and regularity• In pairs, spend 5 minutes resolving the  case study assigned t...
Key Points - Screening• Ask simple questions to know if client has her  monthly periods regularly.• Determine if client an...
Teaching - How to use the SDM• Teach client how to use the SDM      Provider Cue Card  with CycleBeads• Confirm client kno...
Teaching-Monitoring Cycle Length• Periods must always come  between darker brown  bead and last bead.• If period comes ear...
Group Work:          Teaching Cycle Beads• In pairs, spend 5 minutes taking turns explaining each  other how to use CycleB...
Key Points - Teaching• Explain CycleBeads represent the cycle and each bead is  a day in the cycle.• Red is the first day ...
Supporting the Couple                During counseling, a service                provider should:                •Set the ...
Involving Men- Issues to Consider• SDM is a couple method. If men understand  it, couples are more likely to use it  corre...
Group Work:        Video Case Studies• In small groups, discuss the short video  case you just saw.• Use the discussion po...
Group Work – How to discussing the fertile         days with a partner?                 • How would you engage this       ...
When to contact the provider• If couple has sex on a white bead day• If couple has difficulty managing fertile days• If he...
Review         Slides 83 to 93                           46
What have we learned?• Mary wants to use SDM. What will you ask her  in order to know if she can use it?• Abena is going h...
What have we learned? (cont.)• Lucy and Abebe have used condoms sometimes but  Abebe now refuses to use them. How will you...
Why Offer SDM       Increases choice       Expands coverage       Addresses unmet need       Empowers women       Inv...
Guidance Documents    IPPF Medical Bulletin – 2000, 2003    IRH Reference Guide – 2002    WHO Medical Eligibility Crite...
K4Health-SDM ToolkitReference Materials Links to scientific                              Training Materials  articles Te...
Common Misconceptions about SDM• “Natural methods don’t work”• “Is this a modern method? “• “Is there demand for this meth...
Myth: “Women will not have the power todecide when to have sex.”   Fact: FAM are best suited for couples that           ca...
Myth:“If we offer this method, clients using modern methods will switch.”Fact: FAM integration has no negative  effects on...
Myth:“SDM counseling would take too much time, just like other natural            methods.” Fact: SDM is easy to teach in ...
Myth: "It would be hardfor illiterate women to        use SDM.”                             Fact: SDM appeals to women    ...
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SDM Training Workshop: Bringing New People to Family Planning

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SDM Training Workshop focusing on the broad impact of Fertility Awareness-based Methods (FAM)

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  • Welcome to this two-hour workshop on Fertility Awareness Methods of family planning.
  • 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.
  • 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.
  • Suggested script: You may be wondering how cycle days 8 through 19 were selected as the fertile window for the Standard Days Method. Researchers applied various formulae to over 7500 cycles in an existing data set from the World Health Organization, and looked at probability:... the probability of pregnancy on different days around ovulation (from up to 5 days before ovulation…until 24 hours after ovulation taking into consideration the viability of sperm and ovum during this time), and they also looked at the probability of ovulation on different days of the cycle (usually occurring close to the middle of the cycle, give or take a day or two.) As a result they determined that for cycles between 26 to 32 days, a fertile window of cycle days 8 through 19 (shown here in green in the lower graph) provided maximum coverage for efficacy while minimizing the number of days for avoiding unprotected intercourse.
  • Ask participants about what they’ve heard of the Standard Days Method. Ask what they think is the effectiveness of the method and any concerns they may have. Often providers have concern about the efficacy of natural methods of family planning and it is important to address those concerns with evidence on the method. To be prepared to discuss information and evidence, the facilitator can rely on: The SDM Technical Brief found at: www.irh.org/SDM_Implementation/pdfs/SDM Technical%20Brief%20SPA.pdf The SDM Fact Sheet 20 Most Frequently Asked Questions on the SDM
  • Suggested script: An international multi-center study was conducted. The Standard Days Method was provided to clients of public and private sector family planning programs. Health personnel were trained to offer the Standard Days Method to their clients. Clients who were interested in using the method were screened according to specific criteria. They were taught how to use the method. They were followed every month for a little over one year, to collect data about their menstrual regularity, their use of the method, their satisfaction with the method, whether they had gotten pregnant, etc. Results of the efficacy trial were published in Contraception. References: Arevalo M, Jennings V, Sinai I. Efficacy of a new method of family planning: the Standard Days Method. Contraception . 2002;65:333-338.
  • 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.
  • Results from operations research and introduction studies tell us about a variety of profiles for women using this method. Some interesting differences between the U.S. and other countries in terms of previous contraceptive use. The countries included here are Ecuador, El Salvador, Honduras, Benin, India, and the Philippines. Whereas 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. It appears that in the U.S., some women who have used other methods may be looking for a different kind of method.
  • 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.
  • Intervention clinics only
  • In studies conducted in several countries, - six countries plus the U.S. – it was found 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 .
  • Instructions for facilitator: The purpose of this activity is to ensure that participants understand how the characteristics of the SDM might affect a client’s choice of or eligibility for this method. Ask participants for reasons why women might prefer or avoid this method. Then, click the mouse to reveal the next example. Move through each case quickly and mention the following points. Many women who have never used a method before or who distrust some methods might find SDM attractive because she can control it and does not require taking anything. If she meets the SDM criteria, starting with this method might help her transition to other methods in the future as she starts to trust the concept of spacing with an effective approach. █ Similarly, SDM might appeal to women who are not interested in hormonal methods for any reason. SDM can help young women learn about their menstrual cycles and keep track of when their period starts. They need counseling on consistently using condoms to prevent pregnancy and ITS, including HIV. It is important that information on the SDM as a method of birth control is explained in the context of other existing methods that are also appropriate for young women. █ A woman who uses the SDM with CycleBeads does not need to return to a clinic for resupplies, except to obtain condoms if she chooses to use a barrier method during the fertile days. █ Couples who use condoms sometimes are excellent candidates for the SDM if the woman has regular cycles. Couples who may not want to use condoms all the time can limit their use during the fertile window. █ Once a woman who is breastfeeding has four periods that are about a month apart, she can consider using the SDM. █ Note to facilitator: Distribute the handout: SDM Fact Sheet . Some providers might have biases against providing the SDM to adolescents because they believe their cycles are not regular. However, once a young woman’s cycles become regular, there is no reason younger clients cannot use it with appropriate counseling.
  • 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.
  • Facilitators will deliver a demonstration of a counseling session in which the SDM is being offered. Take 15 min to role play as a counselor with another facilitator (or a volunteer participant) as a client. Use the provider job aid and the CycleBeads packet instructions when demonstrating the screening, teaching and supporting couple use aspects of the SDM counseling. Below are more detailed notes to guide you; feel free to use/adapt as needed. Read the demonstration case study that you will role play as an SDM counselor or provider. Practice the demonstration case study and adapt the script as necessary. Become proficient in the use of the SDM provider job aids and familiar with all aspects covered during an SDM counseling session. Assign a volunteer participant the role of client in advance. Give the volunteer a description of the client's profile and ask her to play this role. Explain that this activity will begin with a demonstration followed by a general discussion in which the whole group will analyze the components of an SDM counseling session. Ask the participants to observe the demonstration and to write down any questions or comments so that they can share them when the demonstration is completed. Indicate that during this activity you as a counselor will be using the provider job aid and the instructions for CycleBeads. Before you start demonstrating the counseling session, set the stage for the case. Indicate the following: • The client has arrived at the center; she has been greeted and asked the reason for her visit. Her biographical information has been taken and her clinical history has been filled out, if applicable. She has also been given general information about all available contraceptive methods. In this case, she has decided that she would like to use the SDM. • The demonstration of the SDM counseling starts here. 4. Start the demonstration of the counseling session by screening to see if the method is suitable for the client, continue by informing the client how to use it, and conclude by exploring aspects of couple communication and offering support to the client in using the method with her partner. Throughout, make use of the respective provider job aids, making them visible to the participants. 5. After completing the demonstration, open the group discussion by asking participants to describe what they have just seen in the demonstration. Lead a group discussion to identify and analyze each component of the counseling session that you have just demonstrated using the “Components of the SDM Counseling” flipchart paper. If necessary, relate the SDM counseling to the counseling model of the participants’ service delivery programs (for example, the GATHER model). 6. Go over each of the three components of the SDM counseling (Screen, Teach, Support Couple Use) using the flipchart or PowerPoint slide and referring participants to the job aid and feedback checklist. Ask them which of the points in the checklist were addressed and if any was left out. Let participants know they will have an opportunity to role play the counseling and use the feedback checklist to assess each other.
  • Follow the notes to the facilitator in the previous slide. The objective of this activity is to give a general overview of counseling in the SDM. Each of the three components—screen, teach, and support—will be explored in depth by the end of the workshop. This session is the first opportunity participants have to become familiar with the job aids. If necessary, discuss with participants how the SDM counseling fits within the general process of family planning service delivery in their programs. Stress that this is not an additional task but one more method to offer within their existing services. Analyze the similarities and differences between SDM counseling and counseling in other methods.
  • 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 participants complete the activity of problem solving with case studies, answer any questions they may have and close this topic of counseling with key “take-home” messages related to screening.
  • 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.
  • Note to facilitator: Both the video animation of how CycleBeads work and the script for a demonstration mention how a woman can continue to monitor that her periods come on time. However, emphasis on this aspect is critical to ensure the method is appropriate for her in the future. While a woman’s cycle may be within the correct range to use the Standard Days Method, it is possible that over time her cycles may change. Thus, she needs to continue to know that her periods should always come between the dark brown bead and the last brown bead ( show that section of the necklace ). To the extent possible avoid language about “needing to have cycles within 26 to 32-day range”. Rather, show on the necklace when she must get her periods to know they’re coming on time and be able to have this method work for her. Explain that: • If you start your period before you put the ring on the DARK BROWN bead, it means it has come too soon to use the method. • If you have not started your period by the day after you put the ring on the last BROWN bead, it means your period is too late to use this method. • Contact your provider if you have more than on cycle out of range.
  • 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.
  • After participants complete the activity of practicing teaching a client how CycleBeads work, summarize the key messages related to teaching the mechanics of how the beads work on a daily basis to know if the woman is on fertile or infertile 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
  • 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
  • SDM Training Workshop: Bringing New People to Family Planning

    1. Bringing New People to Family Planning: TheBroader Impact of Fertility Awareness Methods 1
    2. Workshop Objectives• Review basic information about the Standard Days Method (SDM) and Lactational Amenorrhea Method (LAM), two simple fertility awareness methods.• Understand what is involved in the counseling in SDM and LAM and practice of using simple tools for providing these methods.• Learn about newest guidelines and training resources available for SDM and LAM 2
    3. FAM INTRODUCTION Slides 4 to 18© 2004 Eileen Dietrich, Courtesy of Photoshare 3
    4. 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. 4
    5. 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 5
    6. 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. 6
    7. Context for FAM FAM in the context of: • Healthy Timing and Spacing of Pregnancies (HTSP) • Informed choice in family planning 7
    8. 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. 8
    9. 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 9 9
    10. 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. 10
    11. 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
    12. 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
    13. Comparing effectiveness of FP methods Source: Family Planning: A Global Handbook for Providers 2007, WHO
    14. STANDARD DAYS METHOD® OVERVIEW Slides 49 to 66 14
    15. 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 15
    16. 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 16
    17. 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 17
    18. Determining the Fertile Window Ovulation 5 days (sperm life) 12 to 24 hours (ovum life) Day 8 Day 19 18
    19. Group Work: How Effective Is the Standard Days Method?• How effective do you think SDM is?• What do you think may be some benefits of a natural method like the SDM?• What some of the constraints or challenges of the SDM? 19
    20. 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. 20
    21. 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. 21
    22. What Have We Learned About Offering SDM to Clients? 22
    23. 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 33% 96%IUD 10% 2% 1 Interviews with users in 6 countries 23 2 Survey of internet purchasers
    24. 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 24 2 Survey of internet purchasers
    25. 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. 25 Source: Project reports and U.S. Survey
    26. 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 26
    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 of internet purchasers 27
    28. Group Work: 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 28
    29. 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. 29
    30. SDM COUNSELING Slides 67 to 82 30
    31. How is the SDM offered to Clients?• Screening• Teaching• Support couple’s use• When to return 31
    32. 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 32
    33. 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. 33
    34. 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 34
    35. Group work: Case studies for cycle length and regularity• In pairs, spend 5 minutes resolving the case study assigned to your team.• Use the case studies handout and answer sheet.• Be prepared to share your response to the cases 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. 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 Insert37
    38. 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 38
    39. Group Work: Teaching Cycle Beads• In pairs, spend 5 minutes taking turns explaining each other how to use CycleBeads. Use the beads and the package instructions to explain key points.• In your group, discuss the following questions:− How to help women remember to move the ring every day?− How can a woman know if her periods are coming on time so CycleBeads continue to work for her?− How would you help a women know what to do if she’s not sure if she moved the ring on any given day?• Be prepared to discuss in the larger group your experience− How did you feel teaching how to use CycleBeads?− Did you have any challenges?− Did you use the Cue Card or the insert? Was it helpful? 39
    40. 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: 40
    41. 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 41
    42. 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. 42
    43. Group Work: Video Case Studies• In small groups, discuss the short video case you just saw.• Use the discussion points in your handout and be prepared to share your conclusions in the larger group.• Spend no more than 10 min. discussing. 43
    44. Group Work – How to discussing the fertile days with a partner? • How would you engage this couple in discussing how to handle their fertile days? • How would you feel if this couple used the SDM? • If they decide to start using SDM, would you schedule a follow-up visit? Why or why not? 44
    45. 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 45
    46. Review Slides 83 to 93 46
    47. What have we learned?• Mary wants to use SDM. What will you ask her in order to know if she can use it?• Abena is going home with CycleBeads. What will you tell her about checking her monthly bleeding is on time to use the SDM.• How can you tell if a client has cycles of the right length to use SDM• Jane had a baby 7 months ago that stills breastfeeds. Can she use SDM?• Nana wants to know what the beads are for. What would you tell her about the beads and the colors? 47
    48. What have we learned? (cont.)• Lucy and Abebe have used condoms sometimes but Abebe now refuses to use them. How will you help Lucy decide if SDM is appropriate for her.• Claire is concerned she might forget to move the ring. What can she do if she is forgets one day.• Adai and Chidi had sex on a white bead day. What can they do? Can they continue to use SDM?• Mina started her period before reaching the dark brown bead. This happened in November last year and again this month (April). Can she still use SDM? 48
    49. Why Offer SDM  Increases choice  Expands coverage  Addresses unmet need  Empowers women  Involves men  Offers low-cost method 49
    50. 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 50
    51. 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 www.irh.org http://archive.k4health.org/toolkits/sdm51
    52. 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” 52
    53. Myth: “Women will not have the power todecide when to have sex.” Fact: FAM are best suited for couples that can communicate about sex 53
    54. 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 54
    55. 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 55
    56. 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 56 interested in using SDM.”

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