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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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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
  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.”