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Family planning when “green” is queen: Exploring the potential for fertility awareness-based methods (FAM) in U.S. Title X...
<ul><li>I have no relationships to disclose. </li></ul>Presenter’s statement
<ul><li>Half of pregnancies in U.S. each year are  unintended </li></ul><ul><li>7% of women 15-44 are at risk of unwanted ...
<ul><li>To test provision of SDM in Title X programs through regional training centers </li></ul><ul><ul><li>Identify fact...
Standard Days Method (SDM) <ul><li>Identifies days 8-19 of the cycle as fertile </li></ul><ul><li>Is appropriate for women...
Partners
<ul><li>Reproductive health status </li></ul><ul><li>Users’ perspectives </li></ul><ul><li>Religious/cultural norms </li><...
WHO Strategic Approach: 3 phases
Methods
<ul><li>Potential clients’ knowledge, needs, and interest in FAM </li></ul><ul><li>Provider knowledge, attitudes, and prac...
<ul><li>Site assessment: review of clinic structure, client flow, materials used, service statistics from previous year </...
Results
<ul><li>In 2008: 2 FAM users out of 13,501 female FP users </li></ul><ul><li>No manager anticipated problems integrating S...
<ul><li>24 staff interviewed </li></ul><ul><ul><li>8 clinicians </li></ul></ul><ul><ul><li>3 nurses </li></ul></ul><ul><ul...
<ul><li>Interest in offering FAM to expand options </li></ul><ul><li>Enhanced ability to meet needs of clients seeking a n...
<ul><li>Uncertainty about patient demand </li></ul><ul><li>Cultural and partner issues; “machismo;” inability of some clie...
<ul><li>7 focus group discussions </li></ul><ul><li>4 in English, 3 in Spanish </li></ul><ul><li>n=45 </li></ul><ul><li>Me...
<ul><li>Dislike of hormonal methods due to side effects </li></ul><ul><li>Lack of confidence in methods such as the pill d...
<ul><li>“ Oh yes, we need something new. I am tired of the pill.” </li></ul><ul><li>“ [I’d like something with] no side ef...
<ul><li>“ I always wanted to do the calendar thing, but never knew how.” </li></ul><ul><li>“ I like this method because I ...
Moving to phase 2…
<ul><li>There is need for more non-hormonal options and  interest in the SDM among potential clients </li></ul><ul><li>Pro...
<ul><li>Providers trained to offer method </li></ul><ul><li>CycleBeads available </li></ul><ul><li>Materials produced </li...
<ul><li>Decision to offer new method should be based on needs perceived by stakeholders </li></ul><ul><li>Strategy should ...
<ul><li>Gribble, JN., Lundgren, R., Velasquez, C., Anastasi, E., Being Strategic about Contraceptive Introduction: the Exp...
For more information: www.irh.org
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Family planning when “green” is queen: Exploring the potential for fertility awareness-based methods (FAM) in U.S. Title X clinics

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This presentation was given at the American Public Health Association in 2009 by the Institute for Reproductive Health at Georgetown University.

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Family planning when “green” is queen: Exploring the potential for fertility awareness-based methods (FAM) in U.S. Title X clinics

  1. 1. Family planning when “green” is queen: Exploring the potential for fertility awareness-based methods (FAM) in U.S. Title X clinics Katherine Lavoie, Myriam Hernandez-Jennings, Renee Marshall, Beatriz Reyes, Renee LaForce, Rebecka Lundgren APHA 2009
  2. 2. <ul><li>I have no relationships to disclose. </li></ul>Presenter’s statement
  3. 3. <ul><li>Half of pregnancies in U.S. each year are unintended </li></ul><ul><li>7% of women 15-44 are at risk of unwanted pregnancy but not using contraceptives </li></ul><ul><li>Fertility awareness-based methods (FAM) are safe, effective and included in Title X’s mandate, yet underutilized </li></ul><ul><ul><li>Rhythm/calendar, Standard Days Method,® Basal Body Temperature, Cervical Mucus, Symptothermal Methods </li></ul></ul><ul><ul><li>Less than 1% of Title X family planning clients use FAM </li></ul></ul>Background
  4. 4. <ul><li>To test provision of SDM in Title X programs through regional training centers </li></ul><ul><ul><li>Identify factors which constrain and facilitate FAM availability and use </li></ul></ul><ul><ul><li>Develop and test a process to introduce the SDM within a framework of expanded choice </li></ul></ul><ul><ul><li>Assess acceptance, correct use, and satisfaction </li></ul></ul>Study purpose
  5. 5. Standard Days Method (SDM) <ul><li>Identifies days 8-19 of the cycle as fertile </li></ul><ul><li>Is appropriate for women with menstrual cycles between 26 and 32 days long </li></ul><ul><li>Helps a couple avoid unplanned pregnancy by knowing which days to avoid unprotected sex </li></ul><ul><li>Is used with CycleBeads </li></ul>
  6. 6. Partners
  7. 7. <ul><li>Reproductive health status </li></ul><ul><li>Users’ perspectives </li></ul><ul><li>Religious/cultural norms </li></ul>WHO Strategic Approach: Considerations for contraceptive introduction <ul><li>Method-mix </li></ul><ul><li>Method characteristics </li></ul><ul><li>Costs </li></ul><ul><li>Policies & management </li></ul><ul><li>Availability and access </li></ul><ul><li>Quality of care </li></ul>
  8. 8. WHO Strategic Approach: 3 phases
  9. 9. Methods
  10. 10. <ul><li>Potential clients’ knowledge, needs, and interest in FAM </li></ul><ul><li>Provider knowledge, attitudes, and practices regarding FAM </li></ul><ul><li>Service delivery systems and outreach activities </li></ul><ul><li>Opportunities and challenges to adding SDM to method mix </li></ul>Phase 1: Needs assessment
  11. 11. <ul><li>Site assessment: review of clinic structure, client flow, materials used, service statistics from previous year </li></ul><ul><li>Provider interviews </li></ul><ul><li>Focus groups with potential clients </li></ul>Participatory Approach
  12. 12. Results
  13. 13. <ul><li>In 2008: 2 FAM users out of 13,501 female FP users </li></ul><ul><li>No manager anticipated problems integrating SDM </li></ul><ul><li>CycleBeads procurement may be an issue in the future </li></ul>Site assessment
  14. 14. <ul><li>24 staff interviewed </li></ul><ul><ul><li>8 clinicians </li></ul></ul><ul><ul><li>3 nurses </li></ul></ul><ul><ul><li>13 counselors/educators </li></ul></ul><ul><li>FAM counseling provided by clinicians upon request </li></ul><ul><li>Counselors/educators not trained to offer FAM </li></ul>Provider interviews
  15. 15. <ul><li>Interest in offering FAM to expand options </li></ul><ul><li>Enhanced ability to meet needs of clients seeking a natural or non-hormonal method </li></ul><ul><li>Characteristics of method - easy to use, cost effective, and promotes body awareness </li></ul>Provider perspective: Facilitating factors for SDM integration
  16. 16. <ul><li>Uncertainty about patient demand </li></ul><ul><li>Cultural and partner issues; “machismo;” inability of some clients to negotiate sex and/or condoms </li></ul><ul><li>Lack of fertility awareness among clients </li></ul><ul><li>Clients might forget to move the ring on CycleBeads every day </li></ul><ul><li>Lack of confidence in the method among staff and/or clients </li></ul>Provider perspective: Potential constraints
  17. 17. <ul><li>7 focus group discussions </li></ul><ul><li>4 in English, 3 in Spanish </li></ul><ul><li>n=45 </li></ul><ul><li>Mean age=31 </li></ul><ul><li>FP use=65% </li></ul><ul><li>Criteria: </li></ul><ul><ul><li>In a relationship </li></ul></ul><ul><ul><li>Wanted to avoid pregnancy </li></ul></ul><ul><ul><li>Not using FP or not satisfied with current method </li></ul></ul>Community based-focus groups
  18. 18. <ul><li>Dislike of hormonal methods due to side effects </li></ul><ul><li>Lack of confidence in methods such as the pill due to past method failure </li></ul><ul><li>Difficulty remembering to take a pill every day </li></ul><ul><li>Dislike of condoms, particularly among male partners </li></ul><ul><li>Procrastination and/or lack of motivation to go to the clinic </li></ul>Focus group perspectives: Reasons for lack of family planning use
  19. 19. <ul><li>“ Oh yes, we need something new. I am tired of the pill.” </li></ul><ul><li>“ [I’d like something with] no side effects, weight gain, mood changes, or irregular bleeding.” </li></ul><ul><li>“ Another option is good. People can try it.” </li></ul><ul><li>“ I don’t like the idea of something in me all the time and that I can’t take out. </li></ul><ul><li>“ I think it would be great for males to have to take on some of the responsibility as well.” </li></ul>Focus group perspectives: Demand for a new method
  20. 20. <ul><li>“ I always wanted to do the calendar thing, but never knew how.” </li></ul><ul><li>“ I like this method because I cannot use hormones.” </li></ul><ul><li>“ You can involve men. This is something visual.” </li></ul><ul><li>“ My husband will be very happy that he does not have to pull out.” </li></ul><ul><li>“ My sister might like it – she’s a vegetarian and rides her bike.” </li></ul><ul><li>“ I am not quite convinced yet. I may need more time. I am afraid to get pregnant.” </li></ul>Focus group participants liked SDM
  21. 21. Moving to phase 2…
  22. 22. <ul><li>There is need for more non-hormonal options and interest in the SDM among potential clients </li></ul><ul><li>Providers are open to offering it to expand choice </li></ul><ul><li>Considerations for training: method effectiveness, how to support correct use, cultural factors/ machismo </li></ul><ul><li>There are no barriers to method integration from a systems perspective </li></ul><ul><li>Procurement likely to be a challenge in future as method is not on insurance formularies </li></ul>Implications of needs assessment
  23. 23. <ul><li>Providers trained to offer method </li></ul><ul><li>CycleBeads available </li></ul><ul><li>Materials produced </li></ul><ul><li>Outreach ongoing </li></ul><ul><li>Client follow-ups ongoing </li></ul><ul><li>Next step: simulated client visits </li></ul>Recent activities
  24. 24. <ul><li>Decision to offer new method should be based on needs perceived by stakeholders </li></ul><ul><li>Strategy should be developed through a participatory, transparent process that focuses on client needs and quality services </li></ul><ul><li>Can increase the likelihood of sustainable, replicable services within Title X program </li></ul>Conclusion
  25. 25. <ul><li>Gribble, JN., Lundgren, R., Velasquez, C., Anastasi, E., Being Strategic about Contraceptive Introduction: the Experience of the Standard Days Method. Contraception 2008; 77: 147-154. </li></ul><ul><li>Making decisions about contraceptive introduction : a guide for conducting assessments to broaden contraceptive choice and improve quality of care. 2002. WHO: Geneva. Available at http://www.who.int/reproductivehealth/publications/family_planning/RHR_02_11/en/index.html </li></ul><ul><li>Simmons, R., Hall, P., Diaz, J., et al. The Strategic Approach to Contraceptive Introduction. Studies in Family Planning 1997; 28(2): 79-94. </li></ul><ul><li>Simmons R, Fajans P, and R Ghiron. 2007. Scaling up health service delivery from pilot innovations to policies and programmes. World Health Organization, ExpandNet: Switzerland. </li></ul><ul><li>Guttmacher Institute – Facts in brief. Available at www.guttmacher.org. </li></ul>References
  26. 26. For more information: www.irh.org

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