1. Institute for Reproductive Health Georgetown University

2. The Standard Days Method ® and CycleBeads ® A Simple Fertility Awareness-based Approach to Family Planning

3. Presentation Outline » What is the SDM? » What is the scientific basis of the SDM? » How does the SDM work? » How are programs introducing the SDM? » Why introduce the SDM?

4. What is the Standard Days Method? » Expands family planning options » Helps programs meet demand for a simple natural method. »Is a method that: involves both partners doesn’t require costly imported commodities offers opportunities for improved communication

5. How does the SDM work? » Helps a couple avoid unplanned pregnancy by knowing which days they should not have unprotected intercourse. » Identifies days 8-19 of the cycle as fertile » Is appropriate for women with menstrual cycles 26-32 days long. »Uses a color-coded string of beads– CycleBeads ® – to help women keep track of their cycle days and know when they are fertile.

6. CycleBeads ®

7. Levels and Trends of Contraceptive Use as Assessed in 2002. United Nations, Report ST/ESA/SER.A/239 New York, 2006

8. Who can use the SDM? » Women who usually have cycles between 26 and 32 days long. » Couples who can avoid unprotected sex during the woman’s fertile days.

10. The Standard Days Method does not protect against sexually transmitted infections (STIs) or HIV/AIDS.

11. Scientific Basis of the Standard Days Method

12. The Standard Days Method is based on » The probability of pregnancy relative to ovulation. » Timing of ovulation. Viable sperm – up to 5 days Viable egg – up to 24 hours Menstrual Cycle mid-point ± 3 days

13. Determining the Fertile Window Day 8Day 19

14. Probability of Pregnancy from Intercourse on Days Relative to Ovulation Pregnancy Rate Ovulation Source: Wilcox et al. 1998

15. Probability of Ovulation Relative to Midpoint of the Cycle % of cycles Peak day used as proxy of ovulation 4.3 8 12.1 18.4 30.1 11.9 5.6 2.4 0.9 > < 0 5 10 15 20 25 30 35 -4-3-2Midpt Days 1234

16. Effectiveness of the Standard Days Method

17. SDM Efficacy Study Results » Couples used the method correctly in 97% of cycles » Of the 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

18. Contraceptive Failure of User-Directed Methods Correct UseTypical Use No Method85 Spermicides1829 Diaphragm616 Condom215 OC.38 Standard Days Method512 % of women who became pregnant during 1 st year of use Source: Adapted from Contraceptive Technology, 19 th edition, 2007

19. Contraceptive Failure of Natural Methods Correct UseTypical Use Symptothermal Method2-518-22 Billings Ovulation Method3-520-22 Standard Days Method512 % of women who became pregnant during 1 st year of use Sources: Guida M., et al. Gynecological Endocrinology 1997; Arévalo, M., et al. Contraception May 2004; World Health Organization, Fertility and Sterility, 1981 Trussell, et al., Family Planning Perspectives, 1990

20. How is the SDM different from the Rhythm Method? » SDM uses a fixed formula for the fertile phase » SDM clients uses the same fertile window for all cycles » SDM has been tested in a well-designed trial » Rhythm requires information about the previous 6 cycles » Rhythm users must make complex monthly calculations » Rhythm has never been tested in a well- designed trial

21. Who uses the SDM?

22. SDM User Profile Six Countries 1 U.S. 2 Mean Age2927 Mean Party2.8.4 Previous Use of: Nothing/ineffective method Condom Pills/injection IUD 52% 38% 33% 10% 0% 87% 96% 2% 1 Interviews with users in 6 countries 2 Survey of internet purchasers

23. Reasons for Choosing the SDM Six Countries 1 U.S. 2 Doesn’t affect health70%80% No side effects20%30% Economical30%5% Easy to learn/use10%45% 1 Interviews with users in 6 countries 2 Survey of internet purchasers

24. How Couples Manage the Fertile Days AbstainCondom Rural India70%30% Urban India13%87% Philippines70%30% U.S.15%85% Project reports and U.S. Survey

25. 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.

26. Lessons Learned (continued) » Offering the SDM helps programs reach new clients. More than ½ of women who choose SDM have never used family planning. Most have not used a family planning method in the last 3 months. » SDM contributes to CPR without reducing the use of other methods. » SDM is cost effective

27. Service Provision Screening Teaching Supporting the Couple

28. Screening: Cycle Length » Do your periods come about a month apart? » Do you usually have your period every month? » Does you period usually come about when you expect it? » Have you recently been pregnant or used another method of family planning? » When did you start your last period?

29. Screening: Managing the Fertile Days » Will you be able to talk with your partner about this method? » How do you think your partner will feel about it? » Do you think you and your partner can avoid unprotected sex for 12 consecutive days? » What will you do to avoid unprotected sex on fertile days?

30. Criteria for Starting the SDM (special circumstances) Postpartum/ breastfeeding Wait until 4 periods have come. Start after 2 most recent are about a month apart. 3-month injectionWait 90 days after last injection. Start after 3 consecutive periods are about a month apart. OC, patch, ring or 1 month injection, implant, hormonal IUS Stop the hormonal method. Start CycleBeads after 3 consecutive periods are about a month apart. Miscarriage or abortion, EC Start CycleBeads on the first day of her next period (if cycles were about a month apart before miscarriage or abortion, or using EC).

31. Counseling » Teaching the method and checking the client’s understanding. » Helping the client use the method correctly with her partner.

32. Follow-Up » Schedule follow-up visits according to existing protocols (often initial visit and one follow up visit). » Encourage client to contact provider with questions or out-of-range cycles. » If client has 2 cycles outside the 26 to 32 day range in a 12-month period, suggest another method. » Offer to include partner in subsequent visits.

33. Support Materials » For clients: Necklaces Instruction card and calendar » For Providers: Counseling guide Laminated calendar » For Programs: Provider training manual Client register Monitoring checklist Promotional Materials

34. Why Offer the SDM as Part of a Family Planning Program? » Increases choice » Expands coverage » Addresses an unmet need » Empowers women » Involves men » Offers a low-cost method

35. SDM Offered World Wide Albania Angola Armenia Azerbaijan Bangladesh Benin Bolivia Burkina Faso DR Congo Ecuador El Salvador Ethiopia Ghana Guatemala Haiti Honduras India Kenya Malawi Mauritius Mozambique Nicaragua Nigeria Pakistan Peru Philippines Romania Rwanda Senegal Tajikistan Tanzania Timor Este Turkey Uganda Ukraine United States Zambia

36. Institute for Reproductive Health Georgetown University