1. Standard Days Method (SDM)
Session II:
Who Can and Cannot
Use SDM

2. Medical Eligibility
What are medical eligibility criteria? Define the conditions related to temporary methods of family planning. Define the conditions related to fertility awareness methods
Instructions for facilitator:
The purpose of this activity is to give participants an opportunity to share what they know about medical eligibility criteria, or MEC, so that the facilitator can determine whether the participants have the requisite foundation or whether they need additional background information before proceeding.
Ask several participants to share one thing that they know about the eligibility criteria established by the World Health Organization (WHO) or how the criteria are reflected in their national FP/RH guidelines.
Ask participants to define WHO categories 1, 2, 3, and 4 (or the categories in the national FP/RH guidelines).
Ask if they are aware that fertility awareness methods use different categories than the categories for temporary methods of family planning.
Based on the participants’ responses, make a decision about how to proceed:
If the participants seem very aware of the MEC criteria and understand how conditions are categorized, provide a quick overview (or invite an informed participant to provide an overview).
If the participants have not yet been introduced to the WHO MEC, take the time to explain more about the WHO MEC. Refer to the Family Planning Training Resource Package, WHO’s Family Planning Guidance Documents and Job Aids. The module can be found on the website where this module is located: Return to this presentation and proceed to the next slide.

3. Conditions Relating to Fertility Awareness Methods
Age: post menarche or perimenopause
Taking drugs that affect cycle regularity*
C= Caution
Vaginal discharge
Diseases that elevate body temperature
A= Accept
Conditions
WHO Category
Breastfeeding< 6 weeks postpartum
Breastfeeding > 6 weeks postpartum
Postpartum not breastfeeding
Postabortion
D=Delay
Explain that all women can use SDM No medical conditions prevent the use of SDM but some conditions can make it harder to use SDM effectively. See next slide.
*Delay until drug’s effect has been determined, then use caution
Source: Family Planning A Global Handbook for Providers 2011

4. Who Should Delay or Use Caution in Beginning SDM
Circumstances that can affect cycle length and regularity are recent pregnancy or recent use of a hormonal method of contraception
Postpartum/breastfeeding
Wait for 4 consecutive periods
Start after 2 most recent periods are about a month apart
3-month Injection, pill, patch, implant, IUD
Wait 90 days after last injection
Start after 3 most recent periods are about a month apart
Emergency Contraceptive Pills, miscarriage or abortion
If cycles before pregnancy were 26 to 32 days long
Start on first day of next period
*Note to Facilitator: This slide may not be pertinent to CHWs as the service protocol for this level calls for referral to the facility in the circumstances detailed in the slide.
In the following situations use caution with SDM:
Menstrual cycles have just started or have become less frequent or stopped due to older age: Menstrual cycle irregularities are common in young women in the first several years after their first monthly bleeding and in older women who are approaching menopause. Identifying the fertile time may be difficult.
In the following situations delay starting calendar-based methods: Recently gave birth or is breastfeeding: Delay until she has had at least 3 menstrual cycles and her cycles are regular again. For several months after regular cycles have returned, use with caution. Recently had an abortion or miscarriage: Delay until the start of her next monthly bleeding.
In the following situations delay or use caution with SDM: Taking any mood-altering drugs such as anti-anxiety therapies (except benzodiazepines), antidepressants (selective serotonin reuptake inhibitors [SSRIs], tricyclic, or tetracyclic), long-term use of certain antibiotics, or long-term use of any nonsteroidal antiinflammatory drug (such as aspirin, ibuprofen, or paracetamol). These drugs may delay ovulation.
Women who are infected with HIV, have AIDS, or are on antiretroviral (ARV) therapy can safely use SDM Urge these women to use condoms while practicing SDM. Used consistently and correctly, condoms help prevent transmission of HIV and other STIs. Condoms also provide extra contraceptive protection for women on ARV therapy.

5. When is SDM Most Successful?
SDM is most successful at preventing pregnancy when:
Women have regular menstrual cycles (26 to 32 days long)
Couples are motivated to avoid intercourse or use condoms during fertile days
<Ask participants who they think can use the SDM?>
The World Health Organization, in its publication “Medical Eligibility for Contraceptive Use”, states that the SDM, like other fertility awareness-based methods, poses no adverse risk to women who choose to use it. In general, this method can be provided without concern for health effects to people who choose It. There are no medical conditions that become worse because of SDM. But the SDM is intended for women who meet certain criteria: What are they?
The majority of her cycles should be between 26 and 32 days. Women who get their periods about once a month fall within this range.
She and her partner should be able to avoid unprotected sex, i.e. use condoms or not have sex, on days 8 to 19 of her cycle. The collaboration of the man is extremely important for the successful use of the method. He needs to understand and accept that on days 8-19 of each cycle, they will need to use a condom or not have intercourse. If the man (or the woman) cannot avoid unprotected intercourse during the fertile days, they should be encouraged to use another method.
If either member of the couple is exposed to the risk of sexually transmitted infections, the Standard Days Method, as well as most other methods of family planning, will not protect against these infections. Condoms are the only method that provides protection from these infections.
**SDM does not protect against STIs or HIV/AIDS. Use condoms (for men and women) every time you have sex, to help protect yourself from these diseases.

6. Screening to See if SDM is Appropriate for the Woman
Is her cycle between 26 and 32 days long?
Ask simple questions to assess cycle length and regularity:
Does your her period come about once a month?
Does it usually come when you expect it?
When was the first day of your last period?
While the SDM will work for most women- that is, most women have most cycles between 26 and 32 days long, it is important to assess whether the method is appropriate for the individual woman.
Studies in several countries have found that most women have a general idea of whether it usually comes when they expect it
Simple questions to assess cycle length and regularity have been tested and found to be effective indicators of whether the woman’s cycle is within the 26 to 32-day range. A woman who has her period about once a month regularly falls within this range. Simple questions can help a provider establish if the client periods are in this range:
Does your period come about once a month?
Does it usually come when you expect it?
When was the first day of your last period?

7. Is SDM Appropriate for the Couple?
Can they use condoms or avoid sex on days 8 through19 of the cycle?
Explain that another screening criterion, “Can the couple avoid unprotected sex on the woman’s fertile days?” is related to the woman and her partner’s ability to discuss protection during fertile days to prevent pregnancy. Some couples prefer to abstain during the fertile days while others use condoms or develop other ways to express intimacy.
Results from efficacy trials and introduction studies show that men participate in SDM use in a number of ways:
Using a condom or abstaining during fertile days
Following wife’s instructions
Keeping track of fertile days

8. Using SDM with Partner’s Support
It is important to:
Approach clients to inquire about the couple’s relationship in a careful and sensitive way.
Engage your client in talking about sexuality and her couple relationship?
Inquire about possible domestic violence or alcohol/drug use that can affect correct SDM use?
Discuss condom use
during the fertile days.
Before asking a woman directly about sexuality, it is important to start with a brief introduction to the subject. Some ways of doing this are presented below:
• “Before talking about possible contraceptive methods, it is important to know a bit more about your relationship with your partner”
• “Lately, violence has become common in the daily life many women, so we have begun to ask all our clients about any abuse they might be experiencing at home.”
Review the handout “Introduction to Sexuality and Couple Communication.” It offers suggestions of open-ended, direct and indirect questions providers can use or adapt to their context when screening clients for the behavioral criterion on avoiding unprotected sex during the fertile days.
Ask participants:
<What are some examples of ways in which you would approach clients to inquire about the couple’s relationship?>
<In your setting, are there issues that might emerge if you engage your client in talking about sexuality and her couple relationship?>
<What are ways you can inquire about possible domestic violence or alcohol/drug use that can affect correct SDM use?>
<Would you recommend clients use condoms during the fertile days? How comfortable do you feel discussing/demonstrating condom use?>

9. When to Start SDM User: Start:
User knows the first day of her last period.
Start today
User does not remember the first day of her last period
Start the first day of the next period
Postpartum or breastfeeding.
Wait until you have had 4 periods since baby was born. Start after last two periods have been about a month apart
3-month injection user.
Wait until 90-day protection ends, and last three periods have been
about a month apart
Hormonal method user (the pill, 1-month injection, or implant)
After discontinuing method, start SDM if her last three periods have been about a month apart
Had a miscarriage or abortion in the past month OR used emergency contraception.
Start on the first day of her next period
* Note to Facilitator: this slide is not pertinent to CHWs who should be instructed to have, women who meet the method criteria, begin using the method on the first day of their next period.
Ask participants: <When can women who meet the method criteria start using the method?>
Women who know when their last period started can use the SDM right away. They simply count on the calendar to see which day of their cycle they are on and put the ring on the corresponding bead. Women who do not remember that date can begin the SDM when their next period starts. While she waits for her period to start, she should use condoms or another back-up method.

10. Case Study 1 SDM Eligibility Criteria – Cycle Regularity
Case 1 - Fatima
Date last menstrual period: April 8
Date of visit to clinic: April 14
Your client has regular periods that come each month, when she expects them. She and her husband are both interested in a natural method. She is not breastfeeding and has never used a hormonal method of family planning.
Can she use Standard Days Method? Yes
If suitable, when could she start using it?
What are some recommendations to offer this client?
Immediately.
Case Studies
Explain to participants that they will be looking at some case studies, some real-life situations that they might encounter. They will decide which women meet the criteria to use the SDM and when to start using the method.
Ask a participant to read each of the first three case studies on slides 10, 11 and 12. After reading each case study, instruct participants to turn to the person beside them. In pairs, they are to discuss each case study. After pairs have discussed each case study, reconvene the group to discuss the case study. Before proceeding to each case study, clearly state the answer to the current case study. Click on each of the questions written in red on the slide to reveal the answer.
[Note: Case Studies for SDM Criteria/Answer Key and additional guidance can be found in the Facilitator’s Guide for this module.
Monitor cycle length over time, discuss with partner. Place ring on correct bead.

11. Date last menstrual period: Does not remember; beginning of month
Case Study 2 SDM Eligibility Criteria – Cycle Regularity
Case 2 - Sarah
Date last menstrual period: Does not remember; beginning of month
Date of visit to clinic: May 20
Your client and her partner are interested in SDM because it is natural and there are no side effects. She does not know the exact date of her last period but her periods come around the same time each month. She has not been using a method and has been married only a few months.
Can she use Standard Days Method?
If suitable, when could she start using it?
What are some recommendations to offer this client?
Yes.
Wait until next period starts
Ask a volunteer to read the case:
Ask participants to work in pairs with the person next to them and answer the questions on the slide. After participants have reconvened in a group to discuss the case study, Click on each of the questions written in red on the slide to reveal the answer.
Use condoms or abstain until she starts SDM. Discuss with partner method use. If she had sex this month, she may already be pregnant.

12. Date last menstrual period: May 12 Date of visit to clinic: May 28
Case Study 3 SDM Eligibility Criteria – Cycle Regularity
Case 3 - Emma
Date last menstrual period: May 12
Date of visit to clinic: May 28
Emma breastfeeds her 15-month old son. She started getting her periods regularly about eight months ago. Her husband travels often, at least twice a month and for several days at a time. Sometimes they abstain and other times they use withdrawal. They both have decided to use a natural method.
Can she use Standard Days Method?
If suitable, when could she start using it?
What are some recommendations to offer this client?
Yes.
Immediately.
Ask a volunteer to read the case:
Ask participants to work in pairs with the person next to them and answer the questions on the slide. After participants have reconvened in a group to discuss the case study, Click on each of the questions written in red on the slide to reveal the answer.
Discuss with partner method use. If she had sex this month, she may already be pregnant..