Overview of the Standard Days Method, why integrating it into all FP services is important, and common misconceptions.

1. Bringing New People to Family Planning: The
Broader Impact of Fertility Awareness Methods
1

2. FAM INTRODUCTION
Slides 4 to 18
© 2004 Eileen Dietrich, Courtesy of Photoshare
2

3. 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.
3

4. 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
4

5. 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. 5

6. Use of family planning remains low in
many countries
Percent of married women using
contraception
40
30
Modern Methods
20
Traditional or folk
10 methods
0
Benin DR Congo Zambia India - UP
Source: PRB 2005 World Population Data Sheet and ORC Macro DHS

7. Family Planning Use Worldwide
(Women in Union)
43%
8%
8% Natural
No methods 42%
methods
49%
50% Modern methods
Levels and Trends of Contraceptive Use as Assessed in 1998. United Nations, Report
ESA/P/WP.155 New York, 1999

8. Percentage of Married Women
Using Contraception
Source: PRB 2005 World Population Data Sheet and ORC Macro DHS 8

9. Percentage of Married Women
Using Periodic Abstinence
Source: ORC Macro. 2006. MEASURE DHS STATcompiler 9

10. Context for FAM
FAM in the context of:
• Healthy Timing and
Spacing of
Pregnancies (HTSP)
• Informed choice in
family planning
10

11. 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. 11

12. 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
12
12

13. 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.
13

14. 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

15. 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

16. Comparing effectiveness of FP methods
Source: Family
Planning: A Global
Handbook for Providers
2007, WHO

17. STANDARD DAYS METHOD®
OVERVIEW
Slides 49 to 66
17

18. 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
18

19. 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
19

20. 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
20

21. Determining the Fertile Window
Ovulation
5 days (sperm life) 12 to 24 hours
(ovum life)
Day 8 Day 19
21

22. 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. 22

23. 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. 23

24. The Road to Scaling-up SDM
Impact
OR Studies Studies
2003- 2005 2005 -
Pilot 2007
Introductions
Method FP programs
Efficacy
2000-2004
2002
Method
Concept 1999
24

25. What Have We Learned About Offering
SDM to Clients?
25

26. 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 96%
33%
IUD 2%
10%
1 Interviews with users in 6 countries 26
2 Survey of internet purchasers

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
27
of internet purchasers

28. 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.
28
Source: Project reports and U.S. Survey

29. 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 29

30. 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
30

31. 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 31

32. 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.
32

33. SDM COUNSELING
Slides 67 to 82
33

34. How is the SDM offered to Clients?
• Screening
• Teaching
• Support couple’s use
• When to return
34

35. 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
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. 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. 37

38. 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
38

39. 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:
39

40. 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 Insert
40

41. 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 41

42. 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
42

43. 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.
43

44. 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 44

45. Review
Slides 83 to 93
45

46. Why Offer SDM
 Increases choice
 Expands coverage
 Addresses unmet need
 Empowers women
 Involves men
 Offers low-cost method
46

47. 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
47

48. 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/sdm48

49. 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”
49

50. 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
50

51. 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 51

52. 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 52

53. 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
interested in using SDM.”
53