Natural Family Planning Project Paul G. Whittaker, Linda Hock-Long, Rebecca Merkh Family Planning Council Philadelphia, PA Funded by US DHHS, Office of Population Affairs

Background Family Planning Council Title X grantee, SE Pennsylvania 26 agencies, 75 clinics 145,289 patients in 2007 49% Black, 32% White, 11% Hispanic FPAR reports 0.16% (range 0-1.8%) use ‘natural methods’ 2006 Title X FPAR: < 1% of Title X consumers nationwide use fertility awareness methods

Background Findings from our OPA-funded study ‘Couples and Contraceptive Practice’ suggested: Many young adults believe condoms reduce pleasure and intimacy It is common for women to avoid or discontinue hormonal methods due to access barriers or problems with regimens and side effects

Background Use of withdrawal was common among our young adults (as an alternative to using barrier or hormonal methods) More than a third of both men and women used withdrawal as their primary method of pregnancy prevention for more than one month

Background Participant quotes: She said, “I can't be on the pill… I'm scared because I already got the pill before and look what it did to me.” So we started trying out the pull out method. She was not on the pill… It’s not something she wants to put into her body. We tried to use condoms… That didn’t really work. So I switched to a combination of withdrawal and rhythm.

Background Use of empirically-based Natural Family Planning (NFP) was not common among our young adults One of 95 participants used an empirically-based NFP: I feel comfortable with it now, because I’m used to it, and I still haven’t gotten pregnant - learning about tracking your ovulation, and the fertility awareness method was educational. It helped me feel a little more secure … knowing when to worry and when not to worry. Withdrawal users may potentially be interested in using empirically-based NFP

Consumers – Other Studies Potential advantages of NFP: Fertility unaffected Lack of side effects Leads to better understanding of reproductive physiology Improved partner communication Potential disadvantages of NFP: Perception of high failure rates Requires understanding of reproductive physiology Needs sustained motivation, partner cooperation Monitoring fertile period and using alternatives therein

Consumers - Other Studies NFP methods most appropriate for women: Willing and motivated to monitor fertile signs Who accept potential for unintended pregnancy With cultural beliefs for not using other contraception With regular cycles

Providers – Other Studies Assumed that providers don’t recommend NFP because they: Overestimate complexity of use and failure rates Underestimate ability of consumers to use NFP Perceive difficulty in offering & supporting NFP use Believe increased NFP may lead to decreased use of other more reliable methods

Project Aim 1 Assess female Title X consumers’ knowledge, attitudes & beliefs regarding NFP, plus experiences, barriers & facilitators to NFP use. Consumer Surveys (N=384) Consumer Qualitative Interviews (N=20-60)

Conceptual Model Theory of Planned Behavior (TPB). Intention to use NFP determined by: Attitudes (advantages/disadvantages) Subjective norms (support/oppose) Perceived behavioral control (easy/hard) Background influences (age, education etc.)

Consumer Eligibility Criteria Females 18-35 years of age English-speaking Established clinic patients (Survey only) Have used NFP for a minimum of 3 consecutive months in the past year (Interview only)

Consumer Recruitment Consumer Survey Consumer Qualitative Interviews Participants will be recruited from Title X clinics Consumer Qualitative Interviews Participants will be recruited from Title X clinics and elsewhere in the community (e.g. midwifery & doula practices, NFP training programs)

Consumer Surveys Will be administered at Title X clinics via ACASI Domains will include: Socio-demographics Fertility history & perceived pregnancy risk Pregnancy intentions & contraceptive use Fertility knowledge Awareness, knowledge, attitudes & experiences re: NFP Provider interactions re: NFP

Consumer - Survey Assessment Are consumers aware of NFP options? Do they have enough reproductive health knowledge to implement and correctly use NFP? Do they use NFP? Why do they opt to use NFP? What are the perceived barriers to NFP use? What are socio-demographics of those who use NFP? Do they discuss the use of NFP with family planning providers? Do they think providers approve or disapprove of NFP?

Consumer Interviews Qualitative interviews will approximate a natural conversation; participants will be encouraged to share their experiences in their own words Probes will be used as needed to elicit further information, seek clarification or shift topics Interviews will be conducted until saturation is reached (no new themes emerge from the data)

Consumer Interviews Domains will include: Childbearing desires & pregnancy intentions Contraceptive beliefs, attitudes & history Individual, social & environmental factors influencing uptake & use of NFP Perceived advantages & disadvantages of NFP use Perceived barriers & facilitators to NFP use Perceived efficacy in using NFP

Consumer Interviews Data : Atlas.ti will be used to manage and analyze interview data Themes identified using framework analysis – a priori concepts from conceptual model plus grounded theory

Consumer - Interview Assessment Do pregnancy intentions, past contraceptive experiences, relationship status, partner attitudes, and socio-demographics influence decisions to use NFP? Do women find NFP to easy/hard to use? What types of barriers do NFP users encounter? How do they overcome these barriers? What are the perceived advantages/disadvantages of NFP use? How do advantages outweigh disadvantages? Do women feel supported by their male partners and providers in their use of NFP?

Project Aims 2 & 3 2) Assess Title X provider knowledge, attitudes & beliefs regarding NFP, plus barriers/facilitators to NFP service delivery. Initial Provider Focus Groups (N=2) Provider Surveys (N=225) 3) Identify potential strategies to reduce barriers to consumer use of NFP uptake. Follow Up Provider Focus Groups (N=2)

Title X Provider Eligibility Criteria Family planning clinicians & counselors providing direct care services Have been employed at their respective agency for more than 3 months

Initial Provider Focus Groups 6-12 participants per Focus Group (FG) Will include individual free list exercises and group discussion FG discussion will explore provider attitudes, beliefs & practices related to NFP

Provider Surveys Will be completed by ~3 providers at each of 75 clinics Paper and web-based versions will be available Domains will include: Socio-demographics Knowledge, attitudes, beliefs & practice experiences re: NFP Perceived level of consumer experience with NFP Perceived consumer interest in & eligibility for NFP

Providers – Our Assessment Do providers routinely assess consumer correct use of NFP? Does contraceptive counseling include a review of NFP methods and provide guidance? What is the congruence between provider estimates of consumers’ NFP use and actual level of use? What are provider level barriers/facilitators related to the provision of NFP counseling services? Do providers have the requisite knowledge and perceived skills to deliver NFP counseling services? Do providers view NFP as effective and appropriate contraceptive options for their consumers?

Provider Follow Up FGs 6-12 participants per FG Discussion will be organized around findings in following areas: Use of NFP by their consumers Gaps in consumer knowledge of NFP Providers own attitudes, knowledge and skills in delivering counseling on NFP

Conclusion This research will help us: Identify facilitators & barriers to: Consumer uptake and successful use of NFP Delivery of NFP-related services Identify individual, social and/or environmental level (consumer & provider) strategies to maximize facilitators and overcome barriers to NFP uptake.