Natural Family Planning (NFP) Research Study David Fine Karen Dluhosh Sarah Goldenkranz Center for Health Training Seattle, WA January, 2009

Study Aims/Goals Exploratory and descriptive study which aims to: Identify factors that affect the use of NFP 2. Assess predictors of contraceptive success among NFP users

Focus will be on the following areas: Social, cultural, and demographic indicators associated with NFP use; Individual and institutional barriers to use; Factors that may impact compliance with NFP practices; Indicators of self-efficacy among NFP users; and Rate and indicators of contraceptive success in this service population.

What is Natural Family Planning (NFP)? Contraceptive method / prevent unintended pregnancy Relies on identification of days in menstrual cycle when woman is most fertile and most likely to be come pregnant Teaches a woman to accurately monitor her cycle, identify her fertile period and either abstain from intercourse or use an alternative method of contraception

Definitions Natural Family Planning (NFP) Fertility Awareness Method (FAM) *FPAR definition: Broad term which includes “fertility awareness methods include rhythm/calendar, Standard DaysTM, Basal Body Temperature, Cervical Mucus, and Sympto-Thermal methods.” Fertility Awareness-Based (FAB) methods Cluster 1 - calendar based Cluster 2 - sympto-thermal based *Source: Family Planning Annual Report: 2007 National Summary, Table 7

Who are the users? Generally educated, young and single, or older and married Most prevalent in sub-Saharan Africa, Latin America, and the Caribbean NFP use in USA has decreased as more effective methods of contraception have become available

Reasons they use NFP Limited availability of other methods to prevent pregnancy (globally) Other reasons: cultural beliefs about self-discipline and self-restraint desire to use more natural methods of birth control fear of side effects and adverse health impacts of modern hormonal methods

Research Population of Interest Who: Title X providers (staff & clinicians) Clinic clients using NFP as their primary method of contraception Where: Title X-funded Family Planning clinics in Region X Focusing on Washington State in particular

Research Partners Washington State DOH Family Planning and Reproductive Health Planned Parenthood of the Great Northwest Research partners will: assist with selection of project field sites participate in staff needs assessments, staff and client interviews, staff focus groups & client interviews

Research Advisory Committee Provide input on all phases of the research Program-research linkages, NFP service financing issues, clinical staff needs, and NFP client service provision Membership will include: A state family planning grantee nurse consultant A medical director from PPGNW Title X grantee and delegate agency representatives Key stakeholders from participating clinics

Research Methods & Data Sources Quantitative Data Region X Title X needs assessment surveys Use: Describe agency and staff perspectives on NFP, program trends and variation in NFP service provision Source: Supplemental NFP questions added to annual web-based survey administered to clinic staff Clinic Visit Records, 2004-2008 Use: Characterize clients that use NFP and client contraceptive success Source: existing electronic records of clinic client visits, regional data base used for program monitoring, FPAR

Clinic Visit Records (CVRs)--Completed in each Region X Title X FP site for client visits qualifying as Title X events CVR domains Client demographics RH history Medical and lab service provision Counseling and education Provider types Contraceptive method, before/after visit Referrals

Focus groups and interviews with clinic staff Qualitative Data: Focus groups and interviews with clinic staff Use: Explore knowledge and training on NFP, experiences with clients, collect clinician-client stories Source: face-to-face and phone interviews, selected FP clinics in WA state NFP client interviews Use: Explore reasons for choosing NFP, methods used, training and information received, experiences at FP clinics, client expectations Source: face-to-face and phone interviews, selected FP WA state clinics

NFP Visits and Users Data from CVRs, 2004-2008 (through June ’08) 6,098 visits to FP clinics in Alaska, Idaho, Oregon and Washington where NFP was listed as BC method 5,061 female patients using NFP methods, before/after their clinic visit Aggregated by clinic and client ID An additional ~13,000 visits for these 5,061 patients, 2004-08, where NFP was not listed as BC method These records to be used to describe patterns of FP client BC method, services Assess number of pregnancies and intention status

NFP Visits Visit data, n = 6,098 NFP after visit 24% NFP before visit 29% NFP before/after visit 47%

NFP Visits—Contraceptive Methods % Before Visit NFP 76% Barrier 4% Hormonal Other 2% None 14% After Visit 71% 12% 1% No NFP at T1 and Yes NFP at T2=24% Yes NFP at T1 and No NFP at T2=37% N = 6,098

NFP Users Characteristic % State Alaska 4% Idaho 7% Oregon 60% Washington 29% Population Density (RUCA) Urban 75% Large Rural 12% Small Rural Isolated 6% N= 5,061

NFP Clients Characteristic % Age < 20 11% 20-24 27% 25-29 26% 30-34 16% 35-39 10% > 39 9% Race/Ethnicity White 82% Black 2% AI/AN 1% Hispanic Asian 4% NH/PI N= 5061

Characteristic % Number of Pregnancies 43% 1 21% 2 14% 3 10% 4 or more 43% 1 21% 2 14% 3 10% 4 or more 12% N= 5061

Next Steps—Regional CVR Data Update 2008 to annual data set Add other ~13,000 clinic visits where NFP was not the BC method Explore visit patterns Generate aggregate patient data set (n=~5,000) with all relevant data from the ~20,000 visits Pregnancy history (number/intention status), referrals, BC methods used

Other Next Steps Implement regional needs assessment with NFP items Finalize participating clinics Generate qualitative tools, client recruitment protocols, consent procedures Implement field qualitative study component