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

1. Bringing New People to Family Planning: The
Broader 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 years
after 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 CycleBeads
Method Eligibility  Women with cycles between 26 and 32
Criteria (who can use days long
the method)  Couples who can avoid unprotected sex on days 8 to19
Exceptions (who Women in postpartum or breastfeeding must have had at least 4 periods
cannot 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-years
How 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 study
Findings • 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. CycleBeads
The SDM is used with CycleBeads®, a
color-coded string of beads to help a
woman:
• 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 85
Source: 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.2
Mean Age 29 27
Mean Parity 2.8 .4
Previous 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.2
Doesn’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%
relations
Information 64% 58% 44%
exchange
Session length 17 min. 13 min. 15 min.
Source: Simulated clients, endline Jharkhand, India 26

27. Reasons for Choosing the SDM
Six Countries1 U.S.2
Doesn’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 Attributes
Who 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. Screening
Who 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 and
LEAVES 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 Toolkit
Reference 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 to
decide 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 hard
for illiterate women to
use SDM.”
Fact: SDM appeals to women
from a range of socio-
economic backgrounds
Fact: Low literacy or
illiterate women can learn Myth: "More educated
how to use SDM correctly women would not be
56
interested in using SDM.”