Bringing New People to Family Planning with LAM and SDM

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IRH Georgetown University presented an orientation at the International Conference on Family Planning in Kampala, Uganda on Fertility Awareness‐based Methods (FAM) and their integration into family planning, health, and development programs operating in the public and private sector.

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  • Globally, there is an enormous demand for natural family planning methods; 8% of all women in union report that they use such methods. Of these, most are practicing some type of periodic abstinence. However, the vast majority of couples using periodic abstinence really do not know which days the woman is at risk of pregnancy. Sometimes they abstain based on incorrect or incomplete information. Many couples have intercourse on the woman’s fertile days, when there is a high probability of pregnancy. . Statistics also show that 42% of couples are not using any method of family planning. This includes many who do not want a pregnancy. Some of them would also benefit from a simple natural method. It important to offer a method that does not require expensive commodities, that can be provided by clinics and at the community level, and that makes family planning a shared responsibility for both members of the couple. ESD COLLEAGUES. IN THIS SLIDE WE HAVE AN OPPORTUNITY TO HIGHLIGHT IMPORTANCE OF HTSP. DO YOU HAVE SUGGESTIONS FOR MESSAGES & DATA TO INCLUDE IN THE SPEAKER NOTES? Why Develop FAB Methods? High contraceptive prevalence rate worldwide High use of periodic abstinence 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 FAB method do not actually use. FAM can contribute to efforts to reduce the gap between contraceptive commodity needs and donor capacity.
  • 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.
  • 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
  • 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.
  • 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.
  • So now we understand the importance of LAM and of spacing pregnancies. Let’s think about how we can integrate LAM counseling with services you, or others, provide. [Read questions on slide.]
  • [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.
  • 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.
  • [At this point, use one of the three optional exercises for transition according to the instructions provided.]
  • 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] A number of contraceptive methods can be safely used by the breastfeeding mother: Abstinence – any time Condom – any time IUD – 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 – before 7 days or after 6 weeks Vasectomy – any time
  • 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.
  • For bullet 2: Fertile window for SDM, days 8 to 19 of the cycle, is based on computer analysis of 75000 cycles and analysis using a combination of probabilities – the probability of pregnancy on different cycle days related to ovulation, and the probability of the timing of ovulation -- it was possible to identify the days when pregnancy is VERY LIKELY and the days when it is MOST UNLIKELY. In menstrual cycles between 26 and 32 days long (which accounts for more than 80% of all cycles), the days pregnancy is very likely are days 8 through 19. On all the other days, pregnancy is very unlikely.
  • 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.
  • Note: Play video, insert video clip or give the following explanation: CycleBeads CycleBeads represent the menstrual cycle There are 32 beads, each representing a day of the cycle The red bead represents the first day of menstruation – which also is the first day of the cycle The brown beads represent when pregnancy is very unlikely The white beads represent fertile days A moveable rubber ring marks each day of the woman’s cycle The cylinder, with an arrow, indicates the direction in which the ring should be moved To use CycleBeads you put this ring (indicate ring) on the red bead the day you get your period. Then each day after that you move the ring forward, one bead per day, in the direction of the arrow. When the ring is on the red bead or a brown bead, you are on a day when it is very unlikely to get pregnant if you have unprotected sex. When the ring is on a white bead, you are on a day when pregnancy is very likely. Most women will get their periods somewhere in this area (indicate days between dark brown bead and last bead) and when they do they simply move the ring forward to the red bead and start the process over. Because this method works best for women with cycles between 26 and 32 days long, there is a darker bead to let you know if you have a shorter cycle (indicate darker bead). If you get your period before reaching this dark brown bead, your cycle is shorter than 26 days and this may not be as effective for you. There are also 32 beads here so if you don’t get your period by the day after the ring is put on the last bead, your cycles may be longer than 32 days and again, this method may not be as effective for you. The medical recommendation is that if you have a cycle outside this range more than once in a given year that you use a different family planning method. But, most women do get their periods in this range (indicate) and when you do, you simply move that ring forward to the red bead and start the process over.
  • Note: Add slide with country data if available 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.
  • Note: Add slide with country data if available 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.
  • The woman’s partner plays a critical role in using the SDM. Clearly, it is a “couple method”. Research has shown that when men understand the method, the couple is much more likely to be satisfied with it and use it correctly. So special efforts should be made to involve men. CycleBeads help men and women talk about how to manage the fertile days. And , even if they don’t discuss it, CycleBeads are a visual aid – the man can see when to use a condom or abstain. Although counseling men is ideal, and attempts should be made to do so, other strategies to raise men’s awareness of the method have been shown to be effective. These include providing general information to men through the media and in the community, and helping women talk with their partners.
  • Clinical, para-clinical and community health workers can all offer the method effectively, with appropriate training and supervision.
  • Essentially, there are 3 components of SDM counseling Screening – Help client determine if the SDM is appropriate for her Teaching – Provide information and instructions to use the SDM correctly. Supporting – Explore and discuss couple issues and support correct method use.
  • 11/23/09 A STUDY OF PROVIDER COMPETENCY IN NGOs AND THE MOH IN EL SALVADOR, HONDURAS AND INDIA SHOWED THAT CLINICAL AND COMMUNITY PROVIDERS ARE EQUALLY WELL ABLE TO OFFER THE METHOD. THIS SUGGESTS THAT THE SDM FITS WELL INTO COMMUNITY-BASED PROGRAMS.
  • Some programs have women return after a month to see if they’re using the method correctly. Studies have shown that this is not necessary for most women, although it does improve continuation and correct use. What we really need to do is gear our management to each woman’s or couples’ needs, and encourage her/them to call or return if she/they have questions.
  • Intervention clinics only
  • 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.)
  • Since publication of the SDM efficacy study in 2002, there has been a growing interest in the method in many, very different, countries. These are some of the countries where it is available – through public, private, and non-profit family planning providers. In some of these countries it is widely available – in others it’s available in very limited settings. But demand and use are growing. Around the world, a number of different service delivery strategies are being implemented. We wanted to spend a few moments sharing lessons on wide scale efforts to integrate a new FP method (SDM) into existing FP programs.
  • IRH involvement since 2006. Also finding spontaneous diffusion. Led by Ministry of Health and Social Protection CPR modern method: 14% (DHS 2003-4)  CPR traditional method: 7.6% (DHS 2003-4)  Most popular methods: Injectables (7.5%), Pill (2.9%) (DHS 2003-4)  TFR: 5.19 children born/woman (CIA 2008 est.)
  • Congo SM program Have a hotline. Also in congo program: avail thru pharmacies, community based groups/ngos/community mobilizers.
  • In the U.S., several state health departments, Planned Parenthood groups, and private practitioners are offering it, and it is available at an increasing number of retail settings – pharmacies, natural food stores, etc. And it is available over the internet at www.cyclebeads.com.
  • In addition, 120 local governments in the Philippines (municipal, regional or provincial) are covering the costs of the CycleBeads and/or trainings.
  • As you can see, we have a large number of partners. Did all of these groups come to us spontaneously? Or was it the result of concerted efforts on our part? As for examples from field partners (Marie – MSH) Arsene etc At HQ level we have given numerous presentations to organizations; Marcos and Victoria attend meetings at WHO on selected practice recommendations and Medical Eligibility Crieria; Marcos has presented to the IMAP of the IPPF in London; we attend numerous conferences and meeting to have opportunities to promote our work. In the future, we would like to extend this to the field- what meetings are coming up that we could submit abstracts to (in collaboration with Ministry or NGO partners). What support could we provide local instutiions that would help us in the long run (volunteer to be on IEC committee, curriculum committee, etc).
  • People often say that a FP method is integrated once it is found in the MOH’s FP norms and procedures and when providers have been trained in offering the method. But full scale integration of a new method (or any other kind of new service) touches on many systems elements in order to be sustained. As the slide shows, systems and services are interlinked. Political support and technical leadership provide the forward momentum.
  • Integrating any new method into a program is not an easy task. There may be resistance by providers who feel more comfortable with current methods, or providers may be overly enthusiastic, wanting to offer the method to everyone. Programs need to consider how they’re going to offer the method – who will provide it, where, and to whom. And they need resources – manuals, brochures, contraceptives, trained providers, CycleBeads, etc. For the Standard Days Method, what do you think will be the attitudes of providers in your program? Note: Brainstorm, discuss Let’s look at reactions of some providers to other methods. Essential Steps in Integrating and Sustaining the SDM Incorporate SDM in norms and policies; create supportive environment Train and supervise providers Pre-and in-service training Facility- and community-based SDM integrated into supervision systems Increase awareness about the SDM Among men, women, and stakeholders Ensure support for CycleBeads procurement and in-country distribution Include SDM in reporting systems
  • 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, we 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.
  • In closing, the SDM is a new “fertility awareness-based” method that is easy to use, easy to teach others to use, and shown to be effective through a clinical trial. It offers one more family planning option for women and couples.
  • Bringing New People to Family Planning with LAM and SDM

    1. 1. Bringing New People to Family Planning with LAM and SDM
    2. 2. Institute for Reproductive Health <ul><li>IRH is affiliated with Georgetown University Medical Center and receives support from USAID, bilateral & regional programs and US Office of Population Assistance </li></ul><ul><li>IRH’s goals are to: </li></ul><ul><li>D evelop and test models to achieve sustainable, accessible, high-quality FAM services. </li></ul><ul><li>Increase commitment by programs, governments, and donors to support FAM services. </li></ul>
    3. 3. Session Objectives <ul><li>Provide an overview of FAM </li></ul><ul><li>Share results of research to practice efforts followed for the SDM </li></ul><ul><li>Describe contributions of SDM and LAM to family planning programs worldwide </li></ul><ul><li>Discuss how FAM can contribute to FP program goals to reposition and expand access to FP </li></ul><ul><li>Identify opportunities for FAM integration in your programs </li></ul>
    4. 4. Fertility Awareness Methods <ul><li>Identify “fertile window” of the menstrual cycle </li></ul><ul><li>Use one or more “indicators” to identify beginning and end of fertile window </li></ul><ul><li>Users avoid unprotected intercourse (use barrier method or abstain) on fertile days </li></ul>
    5. 5. Two Simple FAM Methods <ul><li>Standard Days Method® </li></ul><ul><li>(SDM) </li></ul><ul><li>Lactational Amenorrhea </li></ul><ul><li>Method (LAM) </li></ul>
    6. 6. Why develop new FAM methods? <ul><li>Very poor understanding of fertility in the general population. </li></ul><ul><li>Many women/couples who express interest in a FAM do not actually use other methods. </li></ul><ul><li>FAM can contribute to efforts to reduce the gap between contraceptive commodity needs and donor capacity. </li></ul><ul><li>Significant unmet need for family planning . </li></ul>
    7. 7. Worldwide Use of Family Planning Methods (Women in Union) Levels and Trends of Contraceptive Use as Assessed in 1998. United Nations , Report ESA/P/WP.155 New York, 1999 8% 49% 43% Natural methods Other methods No method 8% 50% 42%
    8. 8. Use of family planning remains low in many countries Source: PRB 2005 World Population Data Sheet and ORC Macro DHS
    9. 9. FAM Contributes to Healthy Timing & Spacing of Pregnancies <ul><li>After a live birth: </li></ul><ul><li>Couples can use an effective family planning method of their choice, continuously for at least 2 years before trying to become pregnant again. </li></ul><ul><li>FAM can offer women protection from pregnancy when the methods are used correctly: LAM 98% and SDM 95% </li></ul>
    10. 10. LAM: >98% effective FP when all 3 criteria are met <ul><li>Breastfeeding </li></ul><ul><li>No menses </li></ul><ul><li>Infant is less than 6 months </li></ul><ul><ul><li>LAM users need to transition to another modern FP method if any one of these criteria no longer is true. </li></ul></ul><ul><ul><li>Women need to know about their choices while using LAM. </li></ul></ul>
    11. 11. LAM Working Group Goal <ul><li>Enable use of LAM as a family planning method and as a gateway to continued use of (appropriate) methods of FP </li></ul>
    12. 12. LAM Working Group Objectives <ul><li>Increase awareness among stakeholders that LAM is a safe, effective, practical and cost-effective FP option for postpartum women. </li></ul><ul><li>Outputs: LAM Position Paper; Strategy for building momentum around LAM </li></ul><ul><li>Promote evidence & heighten awareness about role of LAM in transition to other modern FP methods. </li></ul><ul><li>Outputs: Dissemination of existing research, tools and manuals </li></ul><ul><li>Help with integration of LAM into FP, MCH, MNH, and other programs at the community level. </li></ul><ul><li> Outputs : Integration Guide </li></ul><ul><li>Develop consensus around LAM measurement including defining LAM User and LAM transition and measurement </li></ul><ul><li>Outputs: Clarification of LAM user, Clarification of transition </li></ul>
    13. 13. L A M <ul><li>A Family Planning Method based on </li></ul><ul><li>the physiological infertility </li></ul><ul><li>experienced by breastfeeding women </li></ul><ul><li>A “gateway” to other modern </li></ul><ul><li>methods of contraception. </li></ul>
    14. 14. Return to Fertility and Risk of Pregnancy <ul><ul><li>If not breastfeeding, ovulation will occur at 45 days postpartum on average; may occur as early as 21 days </li></ul></ul><ul><ul><li>Breastfeeding women not practicing LAM are likely to ovulate before return of menses </li></ul></ul><ul><ul><li>Between 5% and 10% of women conceive within the first year postpartum </li></ul></ul>
    15. 15. LAM Mechanism of Action <ul><li>Baby’s suckling stimulates the nipple </li></ul><ul><li>Nipple stimulation triggers signals that affect hormones </li></ul><ul><li>Disruption of hormones suppresses ovulation </li></ul>
    16. 16. Effectiveness of LAM <ul><ul><li>LAM is 99.5% effective with consistent and correct use and more than 98% effective as typically used </li></ul></ul><ul><ul><li>Effectiveness rates comparable to those of other modern methods </li></ul></ul>
    17. 17. The 3 LAM criteria <ul><li>Mother’s menstrual bleeding has not returned since the bay was born </li></ul><ul><li>2. Mother is only breastfeeding AND </li></ul><ul><li>Baby is less than 6 months old </li></ul>
    18. 18. <ul><ul><li>Where can LAM services be provided? </li></ul></ul>
    19. 19. Opportunities to Provide LAM Counseling <ul><ul><li>Antenatal clinic </li></ul></ul><ul><ul><li>Child health (well-baby) clinic </li></ul></ul><ul><ul><li>Postpartum ward </li></ul></ul><ul><ul><li>Postpartum clinic </li></ul></ul><ul><ul><li>Family planning clinic </li></ul></ul><ul><ul><li>Labor ward (during early labor or after </li></ul></ul><ul><ul><li>birth) </li></ul></ul><ul><ul><li>Community health visits </li></ul></ul>
    20. 20. How can transition to other modern methods be facilitated? Why is transition important?
    21. 21. Transition to Another Method: An Essential Component of LAM <ul><ul><li>LAM is a “g atewa y” to other modern methods of contraception </li></ul></ul><ul><ul><li>LAM provides the couple time to decide on another modern method to use after LAM </li></ul></ul><ul><li>How do you ensure that LAM facilitates </li></ul><ul><li>transition? </li></ul><ul><ul><li>Another method should be started as soon as any one of the three LAM criteria is not met </li></ul></ul><ul><ul><li>The woman should be counseled to decide on the method to which she should transition when LAM counseling is initiated </li></ul></ul>
    22. 22. What are possible methods for “transition” at various times during the postpartum?
    23. 23. Postpartum Contraceptive Options Adapted from the MAQ Exchange: Contraceptive Technology Update
    24. 25. Standard Days Method ® <ul><li>Based on the fact that there is a fertile window in the woman’s menstrual cycle when she can become pregnant. </li></ul><ul><li>Fertile window for SDM, days 8 to 19 of the cycle, is based on computer analysis of 7,500 cycles. </li></ul><ul><li>An efficacy trial found SDM with correct use the failure rate is 4.8 and with typical use 12.0 </li></ul>1 M. Arevalo et al. “A fixed formula to define fertile window of menstrual cycle. Contraception 60 (1999); M. Arevalo et al. Efficacy of a new method of family planning.: the Standard Days Method”. Contraception 65 (2002)
    25. 26. Contraceptive Failure of User-Directed Methods Adapted from Contraceptive Technology, 18 th edition, 2004 % of women who became pregnant during 1 st year of use Correct Use Typical Use No Method 85 85 Spermicides 18 29 Diaphragm 6 16 Condom 2 15 OC .3 8 Standard Days Method 5 12
    26. 27. Standard Days Method <ul><li>Is appropriate for women with menstrual cycles 26 to 32 days long. </li></ul><ul><li>Is used with CycleBeads, a string of color-coded beads to help a woman track her cycle days to: </li></ul><ul><ul><li>- Know when she is fertile </li></ul></ul><ul><ul><li>- Monitor her cycle length </li></ul></ul><ul><li>Couples use condoms or avoid sex on fertile days to prevent pregnancy. </li></ul>
    27. 28. CycleBeads®
    28. 29. Is the SDM a Modern Method? <ul><li>It is based on recent findings of research in reproductive biology </li></ul><ul><li>It was developed following the scientific model and using modern research tools, including computer modeling </li></ul><ul><li>It was clinically tested following universally accepted research methodology </li></ul><ul><li>It is included in State of the Art (SOTA) guidelines </li></ul>
    29. 30. Guidance Documents <ul><ul><li>IPPF Medical Bulletin – 2000, 2003 </li></ul></ul><ul><ul><li>IRH Reference Guide – 2002 </li></ul></ul><ul><ul><li>WHO Medical Eligibility Criteria – 2002, 2004 </li></ul></ul><ul><ul><li>WHO Selected Practice Recommendations – 2004 </li></ul></ul><ul><ul><li>Contraceptive Technology – 2004, 2007 </li></ul></ul><ul><ul><li>USAID Global Health Technical Briefs – 2004 </li></ul></ul><ul><ul><li>Pocket Guide to Managing Contraception – 2004 </li></ul></ul><ul><ul><li>Pop Report (New Contraceptive Methods) – 2005 </li></ul></ul><ul><ul><li>WHO FP Decision-Making Tool - 2005 </li></ul></ul><ul><ul><li>WHO Global Handbook for Family Planning – 2006 </li></ul></ul><ul><ul><li>Pop Council Balanced Counseling Strategy – 20066 </li></ul></ul><ul><ul><li>Ministries of Health norms and policies 2003 -2008 </li></ul></ul>
    30. 31. The Road to Scaling-up SDM
    31. 32. What Have We Learned About Offering the Standard Days Method to Clients?
    32. 33. SDM User Profile 1 Interviews with users in 6 countries 2 Survey of internet purchasers Six Countries 1 U.S. 2 Mean Age 29 27 Mean Parity 2.8 .4 Previous use of: Nothing/ineffective method Condom (inconsistent) Pills/injection IUD 52% 38% 33% 10% 0% 87% 96% 2%
    33. 34. Reasons for Choosing the SDM 1 Interviews with users in 6 countries 2 Survey of internet purchasers Six Countries 1 U.S. 2 Doesn’t affect health 70% 80% No side effects 20% 30% Economical 30% 5% Easy to learn/use 10% 45%
    34. 35. How Couples Manage the Fertile Days Project reports and U.S. Survey Abstain Condom U.S. 15% 85% Rural India 70% 30% Urban India 13% 87% Philippines 70% 30%
    35. 36. SDM Continuation (Among women who completed one year of use and entered the long-term follow-up study) <ul><li>Efficacy Trial </li></ul><ul><li>67% were still using the SDM two years later. </li></ul><ul><li>OR Study </li></ul><ul><li>% continuing 1 year after study: </li></ul><ul><li>Ecuador 60% </li></ul><ul><li>India (rural) 77% </li></ul><ul><li>India (urban) 75% </li></ul><ul><li>Benin 60% </li></ul>
    36. 37. Involving Men <ul><ul><li>Posters, flyers, radio and television </li></ul></ul><ul><ul><li>Community networks </li></ul></ul><ul><ul><li>Male providers/ outreach workers </li></ul></ul><ul><ul><li>Materials brought home by their wives </li></ul></ul>Counseling men is ideal, but men can also be taught about the method through community outreach:
    37. 38. Who can offer the SDM? <ul><li>Physicians, nurses, auxiliary nurses and community volunteers </li></ul><ul><li>Public and private sector reproductive health programs </li></ul><ul><li>Social marketing programs through pharmacies and retailers </li></ul>
    38. 39. SDM client counseling takes 10 to 20 mins. and involves the following: <ul><li>Screening – Help client determine if the SDM is appropriate for the woman. </li></ul><ul><li>Teaching – Provide information and instructions to use the SDM correctly. </li></ul><ul><li>Supporting – Explore and discuss couple issues and support correct method use. </li></ul>
    39. 40. Comparison of Community and Clinic Provider Competency: (12 months after training) <ul><li>Source: Results of Supervision Guide in El Salvador, Honduras & India </li></ul>Community (n=76) Clinic (n=46) Screening 83% 92% Teaching 96% 95% Couple Aspects 92% 91% Total 94% 93%
    40. 41. <ul><li>Can be taught in about 20 minutes, even in low-literacy settings </li></ul><ul><li>Continuation and correct use improved with 2 nd visit but not necessary </li></ul>
    41. 42. Comparison of SDM, Sterilization, and Pill Counseling at GoJ Clinics Source: Simulated clients, endline (n=59) SDM (n=59) Pill (n=59) Sterilization (n=59) Interpersonal relations 78% 78% 83% Information exchange 64% 58% 44% Session length 17 min. 13 min. 15 min.
    42. 43. Willingness to Pay U. S. $15 - $30 Ecuador $5 - $7 El Salvador $1.40 - $2.20 India $1 - $2.50
    43. 44. Demand Generation <ul><li>The feasibility of long-term provision of the SDM depends on the ability of organizations to stimulate demand for the SDM </li></ul>
    44. 45. IEC Interventions <ul><li>Health providers (clinic or community-based) were primary source of information. </li></ul><ul><li>Media (flyers, posters, radio, TV) primary source in urban Benin. </li></ul><ul><li>Family and community outreach played larger role in rural areas </li></ul>Source: OR study reports, 6 countries
    45. 46. Why Offer the SDM as Part of a Family Planning Program? <ul><li>Increases choice </li></ul><ul><li>Expands coverage </li></ul><ul><li>Addresses an unmet need </li></ul><ul><li>Empowers women </li></ul><ul><li>Involves men </li></ul><ul><li>Offers a low-cost method </li></ul>
    46. 47. Offering SDM attracts New FP Users <ul><li>More then ½ of women who choose SDM have never used family planning </li></ul><ul><li>Most have not used a family planning method in the past 3 months </li></ul><ul><li>Appeals to wide variety of women- age, education, religion, education, rural/urban </li></ul>
    47. 48. “ If we offer this method, services for other methods will be affected, clients will start switching to the SDM” SDM integration has NO negative effect on family planning use and method mix. For example, in the state of Jharkhand, India, 87% of new SDM users are new to family planning
    48. 49. What method were clients using two months before adopting the SDM? Government Statistics collected during SDM Impact Study
    49. 50. SDM contributes to CPR without reducing the demand of other methods Community survey rural areas E Salvador. Project Concern International 2002. CPR in study area before and 18 months after SDM introduction Pre Post SDM Total prevalence 45% 58% Permanent Methods (T.L. and Vasectomy) 16% 19% Birth Spacing Methods 28% 39% SDM 0% 4%
    50. 51. CPR in study area before and 18 months after SDM introduction - Urban slums, India) Source: Community survey, TNS MODE, 2004 Pre SDM Post SDM Total Prevalence 49% 58% Tubal Ligation 20% 24% DMPA < 1% 1% Condom 15% 17% IUD 5% 5% SDM 0% 1%
    51. 52. SDM is a low cost option for family planning programs <ul><li>One set of CycleBeads costs approx. R.70 </li></ul><ul><li>One set of CycleBeads achieves 2 CYP, equivalent to 240 condoms, 30 pill packets, 8 Depo Injections </li></ul><ul><li>No re-supply or special s torage </li></ul>
    52. 53. Logistics and Procurement <ul><li>[email_address] </li></ul><ul><li>[email_address] </li></ul>
    53. 54. Global Programmatic Experience
    54. 55. SDM Offered Worldwide <ul><ul><li>Albania </li></ul></ul><ul><ul><li>Angola </li></ul></ul><ul><ul><li>Armenia </li></ul></ul><ul><ul><li>Azerbaijan </li></ul></ul><ul><ul><li>Bangladesh </li></ul></ul><ul><ul><li>Benin </li></ul></ul><ul><ul><li>Bolivia </li></ul></ul><ul><ul><li>Burkina Faso </li></ul></ul><ul><ul><li>DR Congo </li></ul></ul><ul><ul><li>Ecuador </li></ul></ul><ul><ul><li>El Salvador </li></ul></ul><ul><ul><li>Ethiopia </li></ul></ul><ul><ul><li>Ghana </li></ul></ul><ul><ul><li>Guatemala </li></ul></ul><ul><ul><li>Haiti </li></ul></ul><ul><ul><li>Honduras </li></ul></ul><ul><ul><li>India </li></ul></ul><ul><ul><li>Kenya </li></ul></ul>Malawi Mauritius Mozambique Nicaragua Nigeria Pakistan Peru Philippines Romania Rwanda Senegal Tajikistan Tanzania Timor Este Turkey Uganda Ukraine United States Zambia
    55. 56. SDM Scale-Up Example: Madagascar <ul><li>Led by Ministry of Health and Social Protection </li></ul><ul><li>Strong political commitment to FP </li></ul><ul><li>National norms </li></ul><ul><li>Public sector/ MOH </li></ul><ul><li>Social marketing through CBD agents and private health centers </li></ul><ul><li>FBO interest </li></ul><ul><li>Coverage: 1/3 of country </li></ul>
    56. 57. Social Marketing in Ecuador, Benin, and DR Congo <ul><li>Both clinic and pharmacy users demonstrated high levels of correct use: clinic (87%) and pharmacy (93%) </li></ul><ul><li>Mass media campaign critical to increase sales </li></ul><ul><li>DRC: Also community mobilizers </li></ul>
    57. 58. After integration, emphasis on sustainable training approaches: Peru <ul><li>SDM coverage in 1/3 of country </li></ul><ul><li>In-country training capacity through distance learning </li></ul><ul><li>Nursing Association offering self study course to 14,000 registered nurses </li></ul><ul><li>Online training through University of San Martin </li></ul><ul><li>Accreditation by the Peruvian College of Nurse Midwives and Council of Accredited Nursing School </li></ul>
    58. 59. CycleBeads in the U.S. <ul><li>Offered state health departments, Planned Parenthood groups, and private practitioners </li></ul><ul><li>Retail sales in natural food stores and Internet sales </li></ul><ul><li>Accredited classroom and online training </li></ul><ul><li>SDM introduction study funded by U.S. Department of Health and Human Services </li></ul>
    59. 60. Highlights: Asia/Near East <ul><li>Philippines : The 2004 DHS reports that 10% of married women had heard of the SDM, and 0.3% are reported as having used it. 120 local governments (municipal, regional or provincial) are covering the costs of the CycleBeads and/or trainings. </li></ul><ul><li>India : SDM and LAMrecognized by Government of India as a method for expanding choice and is scaling it up in Jharkhand. CycleBeads manufactured by HLL a Government of India enterprise </li></ul><ul><li>Pakistan: SDM and LAM were recently integrated into the national standards </li></ul>
    60. 61. Implementing the SDM through partnerships <ul><li>ADRA </li></ul><ul><li>BBC Education Trust </li></ul><ul><li>CARE </li></ul><ul><li>CEDPA </li></ul><ul><li>Chemonics </li></ul><ul><li>CRS </li></ul><ul><li>EngenderHealth </li></ul><ul><li>FHI </li></ul><ul><li>Futures Group </li></ul><ul><li>Global Health Council </li></ul><ul><li>Population Council </li></ul><ul><li>Project Concern </li></ul><ul><li>Project Hope </li></ul><ul><li>PSI </li></ul><ul><li>Save the Children </li></ul><ul><li>UNFPA </li></ul><ul><li>URC </li></ul><ul><li>USAID </li></ul><ul><li>WHO </li></ul><ul><li>INTRAHealth </li></ul><ul><li>IPPF </li></ul><ul><li>JHPIEGO </li></ul><ul><li>JHU/CCP </li></ul><ul><li>JSI </li></ul><ul><li>MercyCorps </li></ul><ul><li>MSH </li></ul><ul><li>Pathfinder </li></ul><ul><li>Plan International </li></ul>
    61. 62. Research to Practice <ul><li>Evidence is generated and shared to key stakeholders </li></ul><ul><li>Key stakeholders become convinced and share information </li></ul><ul><li>“ Pockets” of people accept it and begin to use it </li></ul><ul><li>News of their experience spreads </li></ul><ul><li>It becomes widespread and commonly accepted by programs, providers, and end users </li></ul><ul><li>It’s feasible and it works </li></ul>
    62. 63. <ul><li>Q: How do you ensure that integration is successful? </li></ul><ul><li>A: It is not just training! </li></ul>
    63. 64. Lesson learned: Need multi-level efforts to ensure sustainability of the SDM as part of FP programs <ul><li>Norms & procedures </li></ul><ul><li>Pre & in-service curricula </li></ul><ul><li>Supervision </li></ul><ul><li>HIS </li></ul><ul><li>Procurement & distribution </li></ul><ul><li>Budget lines </li></ul><ul><li>Provider training </li></ul><ul><li>Availability of CycleBeads </li></ul><ul><li>Supportive supervision </li></ul>
    64. 65. Discussion <ul><li>How can FAM contribute to your program goals to reposition and expand access to family planning </li></ul>
    65. 66. Integrating the SDM and LAM in the method mix <ul><li>Policies and guidelines </li></ul><ul><li>Training and Supervision </li></ul><ul><li>Procurement/Logistics/MIS (for SDM) </li></ul><ul><li>Information and Education </li></ul><ul><li>Service Delivery </li></ul>
    66. 67. Facilitating Factors <ul><li>Effective </li></ul><ul><li>Evidence-based </li></ul><ul><li>Feasible for programs </li></ul><ul><li>Easy to teach, learn, use </li></ul><ul><li>Offered by wide range of providers </li></ul><ul><li>Supporting guidelines & tools </li></ul>
    67. 68. Guidance to Programs <ul><li>Select target areas and population groups </li></ul><ul><li>Build support for the SDM and LAM </li></ul><ul><li>Engage partners strategically </li></ul><ul><li>Address provider barriers to services </li></ul><ul><li>Tailor training to provider needs </li></ul><ul><li>Create community awareness </li></ul><ul><li>Incorporate the SDM and LAM into reporting systems </li></ul><ul><li>Ensure the availability of CycleBeads </li></ul>
    68. 69. Resources for SDM Integration <ul><li>Reference Materials </li></ul><ul><li>Links to scientific articles </li></ul><ul><li>Technical Briefs </li></ul><ul><li>SDM Service Protocol </li></ul><ul><li>Sample Norms </li></ul><ul><li>Training Materials </li></ul><ul><li>Trainers’ Manual </li></ul><ul><li>Participant Handbook </li></ul><ul><li>Training Video </li></ul><ul><li>Online Training </li></ul>www.irh.org
    69. 70. <ul><li>For more information: </li></ul><ul><li>Go to www.irh.com </li></ul><ul><li>Register for on-line training </li></ul><ul><li>Answer “frequently-asked questions” </li></ul><ul><li>Down-load published papers, materials </li></ul><ul><li>Link to related sites </li></ul>

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