Bringing New People to Family Planning: The Broader Impact of the Fertility Awareness Approach

1. Is introducing the SDM to services worth the cost and effort?
2. What else is necessary (besides getting staff trained) to start services that eventually will be sustainable? 
3. Is there enough demand for the SDM to justify the initial efforts?
4. Will new SDM clients just be switching over from other methods? Or will the SDM bring new users to the programs?

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1. Is the SDM effective enough to be offered through mainstream FP programs? Although pregnancy rates for the SDM (5% with correct use, 12% overall) are comparable to or better than those of other user-controlled methods (such as condoms or spermicides), many providers and even managers are not aware of this and are still reluctant to offer the SDM as part of regular services, out of fear that many clients will become pregnant. 
2. Are providers usually knowledgeable of which methods are more effective?
3. How do providers discuss efficacy of methods with their clients?
4. How can program managers address provider concerns about FAM methods?
5. How can program managers ensure that providers have accurate and full information about the efficacy of methods, including FAM?

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1. In your programs, is the SDM provided by community health workers or do they mainly refer women to clinics? 
2. If community health workers provide the SDM, how does their training differ from that provided to clinical personnel? 
3. What about supervising them after training? 
4. How does the quality of SDM services provided by community health workers compare to that provided by auxiliary nurses and other types of providers?

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1. We know that correct use of the SDM depends on both the man and the woman. However, in most settings it is not feasible to counsel men. 
2. What have you done in your programs to address this issue?
3. Do you think that the fact that the SDM is a couple method is an advantage or a disadvantage?
4. Ironically, family planning providers are often uncomfortable discussing sex. How have your programs helped providers to openly address the topic of how they will manage the fertile days?

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1. ) Screening, to assess if the TDM is appropriate for her.
   - Establishing whether for her it is acceptable to touch her genitals or otherwise check for secretions.
   - Determining that her partner is likely to cooperate with her in using the method, avoiding unprotected sex on her fertile days.
   
2. ) Explaining which days are her fertile days:
   She should consider herself fertile, and thus avoid unprotected sex:
   - ALL days she notices ANY secretions (of any type, characteristics, color and in any amount) in her genitals; AND
   - The day AFTER she noticed any secretions.
   
3. ) Helping her find the best way to check herself for the presence of secretions.
   - Determining whether she has paid attention to her secretions in the past.
   - Describing what the pattern of secretions will be throughout her cycle.
   - Telling her and discussing what secretions may look like, feel like to the touch, or feel like on her genitals.
   - Suggesting different ways to check herself, including touching her external genitals, examining her underwear or toilet paper, or just by sensation.

Counseling on the TDM takes almost 20 minutes. Over 92% of women who received this initial counseling were able to use the method correctly (determine when they had secretions, in a pattern similar to what is normal in healthy women, thus suggesting they had correctly identified their fertile days; and avoid unprotected sex on days with secretions and the day after).

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The TwoDay Method is a fairly new fertility awareness-based method that has been shown to be as effective as the SDM. Also developed by the Institute for Reproductive Health, it offers women who want a fertility awareness-based method another option to consider. However, information about the TDM has not been widely disseminated and many programs and women may not know about it, how it works, and who might benefit from using it.

The TDM uses cervical secretions as the indicator of fertility and has been found to be more than 96% effective when used correctly. Women are taught to monitor daily the presence of secretions to know when they might be fertile and the days when pregnancy is most likely. A woman is told that she should consider herself fertile if she notices any secretions today OR yesterday. 

Advantages of the TDM include that it does not require regular menstrual cycles as a criteria, and it is easy to teach and to use.

Please check the forum library for scientific articles addressing the scientific basis and efficacy of the TDM.

- Is this a method that would be potentially of interest to your program?
- Are there benefits to your program of offering the method?
- Is there a specific target group for this method?

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The Institute has developed both provider and client materials for offering the TDM that are available through the Forum Library. We will continue to refine these materials as further research on the introduction of the TDM is conducted. For example, we just recently completed a study in Peru which tested a “quick-start” approach to providing the Two Day Method. The study showed that users could receive counseling and begin using the method at any time during their cycle rather than waiting for the beginning of their cycle, which had been the protocol used in the efficacy trials. This change in the protocol will make it easier for programs to offer the method as they will no longer need to wait until the woman is menstruating.

The Institute plans to continue to refine TDM protocols and provider and client materials based on field studies of TDM services.

- How can we offer the TDM in our programs?
- What plans are there for making the TDM more widely available?

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As the end of these two weeks approaches, we would like to address Fertility Awareness-Based Methods (FAM) in general. Are there any questions that as participants, you would like to see answered?

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1. Initially, many providers are skeptical of the SDM. However, after several months of providing the SDM, most providers become very convinced that the SDM is feasible to offer, an effective option and a valuable addition to the services they provide.
2. Training CHWs is a feasible and effective strategy for expanding access to family planning..
3. It is important to involve men, but this should not become a barrier to SDM use.
4. A comprehensive information system that captures information from initial order to arrival at the service delivery post would really help donors, national-level decision-makers, and program staff keep track of CycleBeads and other commodities.