4/21/2017 Follow along! You will see slides in different colors throughout the presentation. Yellow: learning Blue: questions to reflect on Green: group.

4/21/2017 Follow along! You will see slides in different colors throughout the presentation. Yellow: learning Blue: questions to reflect on Green: group activities and/or opportunities to practice

Natural Methods of Family Planning
4/21/2017 Natural Methods of Family Planning Natural methods of family planning help individuals achieve their reproductive goals to either prevent or achieve a pregnancy by: Tracking the menstrual cycle days and avoiding or having intercourse during the fertile window; or Observing and tracking a woman’s signs of fertility and avoiding or having intercourse on her fertile days

Modern Natural Methods
4/21/2017 Modern Natural Methods Natural methods such as the Billings Ovulation Method and the Sympto-thermal Method have been available for many years. In the last decade, two simple effective natural methods—Standard Days Method®, TwoDay Method®--were developed and tested by Georgetown University’s Institute for Reproductive Health.

Why SDM and TwoDay Method?
4/21/2017 Why SDM and TwoDay Method? I appreciate the simplicity of the [SDM and TwoDay method]. They are easier to train to teach in Spanish and it is not a big time commitment for the teachers. – NFP Doctor, Atlanta It’s important to be able to reach the community. – NFP Coordinator, Boston

Standard Days Method® of Family Planning
4/21/2017 Standard Days Method® of Family Planning Suggested script: The Standard Days Method® , or SDM as commonly called for short, is a fertility awareness-based (FAB) method of family planning. Fertility Awareness is the knowledge of the days in a woman’s menstrual cycle when she is likely to become pregnant (fertile days). The SDM identifies days 8 through 19 as the fertile days of the cycle for most women—those who have menstrual cycles between 26 and 32 days long. To prevent pregnancy couples don’t have intercourse during those days. CycleBeads® is a tool that helps women keep track of their fertility when using the SDM.

Learning Objectives SDM Overview Offering SDM to clients Practice
4/21/2017 Learning Objectives SDM Overview Describe the characteristics of the SDM Summarize SDM scientific basis and efficacy Offering SDM to clients Explain how SDM works with CycleBeads® Apply SDM eligibility criteria Determine when clients can start the SDM Practice Practice counseling clients in the SDM Suggested script: By the end of this training, you will be able to: Explain how the Standard Days Method and CycleBeads work Summarize the scientific basis and efficacy of the method Explain how to provide the method

SDM Overview Characteristics Scientific basis Research and development
4/21/2017 SDM Overview Characteristics Scientific basis Research and development Effectiveness CycleBeads (tool to track cycle days)

SDM Characteristics Identifies days 8 to19 of the cycle as fertile.
4/21/2017 SDM Characteristics Identifies days 8 to19 of the cycle as fertile. Is appropriate for women with menstrual cycles between 26 and 32 days long (women who have their periods about once a month fit within this range) Helps a couple avoid pregnancy by knowing which days they should not have sex Helps a couple plan a pregnancy by knowing which days they should have sex Does not protect against STIs/HIV Suggested script: The Standard Days Method identifies days 8 – 19 of the menstrual cycle as the fertile days, when there is a significant probability of pregnancy. On all the other days of the cycle, pregnancy is unlikely. The method works best for women who have cycles between 26 and 32 days long. Therefore, to use the Standard Days Method to prevent pregnancy, couples avoid sex from day 8 through day 19 of each cycle. On all the other cycle days, they can have sex. To plan pregnancy, the Standard Days Method can help a couple identify the days to have intercourse. While the fertile phase identified by SDM is not narrow enough to identify more precisely the peak days of fertility, it is a first step for couples to identify if when to time intercourse. ADDITIONAL INFORMATION: The method is based on a formula that accounts for natural variations in the length of the menstrual cycle and the occurrence of ovulation within the cycle (26 to 32 days). With correct use during the first year, there is a 5% pregnancy rate. With typical use, the pregnancy rate during the first year of use increases to 12%. A set of color-coded set beads, called CycleBeads®, help users track their menstrual cycle and the days they are likely to become pregnant. References: Arevalo M, Jennings V, Sinai I. Efficacy of a new method of family planning: the Standard Days Method. Contraception. 2002;65: Hatcher RA, Trussell JA, Stewart F, Cates W, Stewart GK, Guest F, Kowal D, eds. Contraceptive Technology. 18th rev. ed. New York; 2004.

Determining the Fertile Window
4/21/2017 Ovulation 5 days (sperm life) 12 to 24 hours (ovum life) Suggested script: You may be wondering how cycle days 8 through 19 were selected as the fertile window for the Standard Days Method. Researchers applied various formulae to over 7500 cycles in an existing data set from the World Health Organization, and looked at two sets of probabilities: the probability of pregnancy on different days around ovulation (from up to 5 days before ovulation…until 24 hours after ovulation taking into consideration the viability of sperm and ovum during this time), and the probability of ovulation on different days of the cycle (usually occurring close to the middle of the cycle, give or take a day or two.) As a result, they determined that for cycles between 26 to 32 days, a fertile window of cycle days 8 through 19 (shown here in green in the lower graph) provided maximum coverage for efficacy while minimizing the number of days for avoiding intercourse. Day 8 Day 19

4/21/2017 CycleBeads SDM is used with CycleBeads®, a color-coded string of beads to help a woman: Track her cycle days Know when she is fertile Monitor her cycle length Suggested script: The Standard Days Method is used with CycleBeads®, a color-coded string of beads to help a woman Track her cycle days Know when she is fertile Monitor her cycle length Many people also find that CycleBeads are an important factor in gaining the husband’s support to use the method. It is very visual – he can literally see when the woman is on a fertile day. It also has served to facilitate communication of the couple regarding how to handle the fertile phase.

4/21/2017 How CycleBeads Work On WHITE bead days you can get pregnant. Do not have intercourse to prevent a pregnancy. On the day you start your period, move the ring to the RED bead. Every morning move the ring to the next bead. Move the ring even on days when you’re having your monthly bleeding Also, mark this date on your calendar Keep moving the ring one bead every day. When you start your next period, move the ring directly to the red bead and begin again. On BROWN bead days you can have intercourse. If you have not started your period by the day after you put the ring on the last brown bread, contact your NFP teacher. If you start your period before you put the ring on the darker brown bead, contact your NFP teacher. 1 2 Play video, insert video clip or do a demonstration of how CycleBeads work using the explanation below. If you use this slide, note that it is animated. What are CycleBeads? CycleBeads represent the menstrual cycle There are 32 beads, each representing a day of the cycle The red bead represents the first day of menstruation – which also is the first day of the cycle The brown beads represent when pregnancy is very unlikely The white beads represent fertile days when a woman can get pregnant A moveable rubber ring is used to mark each day The cylinder, with an arrow, indicates the direction in which the ring should be moved The darker brown bead helps you know if your period came on time. How to use CycleBeads To use CycleBeads you put this ring (indicate ring) on the red bead the day you get your period. Then each day after that you move the ring forward, one bead per day, in the direction of the arrow. Move the ring even on days when you’re having your menstrual bleeding (or monthly bleeding). When the ring is on the red bead or a brown bead, you are on a day when it is very unlikely to get pregnant if you have sex. When the ring is on a white bead, you are on a day when pregnancy is very likely. To prevent pregnancy do not have sex on these white-bead days. Most women will get their periods somewhere in this area (indicate days between dark brown bead and last bead) and when they do they simply move the ring forward to the red bead and start the process over. Because this method works best for women with cycles between 26 and 32 days long, there is a darker bead to let you know if you have a shorter cycle (indicate darker bead). If you get your period before reaching this dark brown bead, your cycle is shorter than 26 days and this may not be as effective for you. There are also 32 beads here so if you don’t get your period by the day after the ring is put on the last bead, your cycles may be longer than 32 days and again, this method may not be as effective for you. The medical recommendation is that if you have a cycle outside this range more than once in a given year that you use a different family planning method. To help you know if you have moved the ring daily, always mark the first day of your period on a calendar. That way, if you ever forget if you have moved the ring, you can check your calendar to see when your period came. Starting with the first bead, count how many days have passed since your period started and place the ring on the bead for today. The instructions that accompany the beads in the packaging includes a section that describes this information. Point to it when explaining these to the client. She can review them at home with her husband. If you want to plan a pregnancy these are the days to have intercourse

How Effective Is the Standard Days Method? Reflection
4/21/2017 How Effective Is the Standard Days Method? Reflection How effective do you think SDM is in helping a couple avoid pregnancy? What do you think may be some benefits of a natural method like SDM? What are some potential constraints or challenges of SDM? Ask participants about what they’ve heard of the Standard Days Method. Ask what they think the pregnancy rate of the method is and any concerns they may have. Often teachers have concern about the efficacy of natural methods of family planning and it is important to address those concerns with evidence on the method. To be prepared to discuss information and evidence, the facilitator can rely on: SDM Fact Sheet SDM Field Notes which describes in simple terms the underlying science for the method and its development and testing process. WHO Medical Eligibility Criteria

Efficacy Study of the SDM
4/21/2017 Efficacy Study of the SDM Multi-site prospective study Services provided in existing programs Clients were followed monthly for 13 cycles Couples used the method correctly in 97% of cycles 478 women in the study, 43 got pregnant With correct use, the pregnancy rate is 4.8 With typical use the pregnancy rate is 12.0 Suggested script: An international multi-center study was conducted. The Standard Days Method was provided to clients of public and private sector family planning programs. Health personnel were trained to offer the Standard Days Method to their clients. Clients who were interested in using the method were screened according to specific criteria. They were taught how to use the method. They were followed every month for a little over one year, to collect data about their menstrual regularity, their use of the method, their satisfaction with the method, whether they had gotten pregnant, etc. Results of the efficacy trial were published in the journal Contraception. References: Arevalo M, Jennings V, Sinai I. Efficacy of a new method of family planning: the Standard Days Method. Contraception. 2002;65: Arevalo M et al., Contraception, 2002;65:

Key Research Findings Women of all educational levels can learn SDM.
4/21/2017 Key Research Findings Women of all educational levels can learn SDM. Involving men increases method satisfaction and continuation. SDM can be offered in a 20 min. counseling session. Provider attitudes toward SDM improve with training and experience. SDM can be taught in clinic and community settings. From over 10 years of clinical and operations research as well as pilot introduction studies involving SDM integration into programs, IRH has a collection of published research findings that show the viability of including the method in programs from the perspective of users and counselors. From the user perspective…. SDM appeals to a broad range of women throughout the world, including women of all educational levels. Research shows that a wide range of women can learn to use SDM, independent of their educational level. Involving men in SDM use increases method satisfaction and continuation for the couple. In fact, results from 14 pilot studies worldwide show that both men and women report high level of satisfaction with the method. From the program/counselor perspective: SDM can be offered in a 20 minute counseling session. Provider attitudes towards SDM can improve with training and experience. SDM can be appropriately taught in both clinic and community settings.

Failure Rates of User-Directed Methods
4/21/2017 Failure Rates of User-Directed Methods *Percentage of women who became pregnant 1st year of use Correct Use Typical Use OCs .3 8 Condom 2 15 **TwoDay Method 4 13 ***Standard Days Method 5 12 Diaphragm 6 16 Spermicides 18 29 No Method 85 Symptothermal Method 2-5 18-22 Billings Ovulation Method 3-5 20-22 It is important to put this information about efficacy in the context of other user-directed methods. Of 100 women using no method of family planning for 1 year, 85 will become pregnant. During typical use, those who use spermicides, a diaphragm, or condoms correctly, every time they have sex, 29, 16 and 15, respectively will become pregnant during the first year of use. OCs are more effective, with 8 women getting pregnant with correct use. Two well-established natural methods, Symptothermal and Ovulation are effective with perfect use but have very high failure rates with typical use, 18 and 20 respectively. Clearly, the SDM is as or more effective with correct and typical use than other user-directed methods. *Adapted from Contraceptive Technology, 18th edition, 2004 **Source: Arévalo et al. Fertility & Sterility, October 2004 ***Source: Arévalo et al. Contraception, 2002

Natural Family Planning – Method Comparison
4/21/2017 Natural Family Planning – Method Comparison Billings Creighton Model/ Fertility Care monitor Marquette Sympto-Thermal Standard Days TwoDay Archdiocese of Boston Cross-Check Method Fertility signs monitored Secretions Cervical secretions hormonal monitoring basal body temperature (optional) basal body temperature cervix position no fertility signs monitored hormonal monitoring (optional) Effectiveness (Correct & Total Use) CU 97% TU 78 – 80% TU 84% CU 98% TU 89% CU 98-90% TU % CU 95% TU 88% TU 87% TU 90%

Natural Family Planning Methods Comparison
4/21/2017 Natural Family Planning Methods Comparison Billings Creighton Marquette Sympto-Thermal Standard Days TwoDay Lactational Amenorrhea Method Secretions  – Temp Cervix Supplies Chart & stamps Chart Thermometer Hormonal Fertility Monitor Thermometer Chart CycleBeads Client Card Infertile (Median) 10 10-12 12 6 months PP Pregnancy Rate (Correct & Total Use) 3 – 5 20 – 22 .5 – 1.3 3.7 – 6.7 .6 – 2 10 – 12.5 2 – 5 18 – 22 5 3.5 13.7 2 # Client Teacher Sessions & length of session 4 sessions in 6 months 60 minutes 9 sessions in one year 60 – 90 minutes 3 sessions in six months 4 sessions in six months 90 – 120 minutes 1 Session 20 minutes 1 Session 20 – 30 minutes 1 Session 15 minutes

References for the Natural Family Planning Comparison Table
4/21/2017 References for the Natural Family Planning Comparison Table Arévalo M., et al. (2002). Efficacy of a new method of family planning: the Standard Days Method. Contraception, 65, Arévalo M., et al. (2004, October). Efficacy of the new TwoDay Method of family planning. Fertility & Sterility, 82(4), Billings Ovulation Method. Retrieved May 14, 2008 from Creighton Model FertilityCare™ System. Retrieved May 14, 2008 from Fehring, R., et al. (2008). Retrospective efficacy of the Marquette Method of natural family planning. American Journal of Maternal Child Nursing. In press. Fehring, R., et al. (2007). Efficacy of cervical mucus observations plus electronic hormonal fertility monitoring as a method of natural family planning. Journal of Obstetric, Gynecologic and Neonatal Nursing, 36(2), Hatcher, R., et al. Contraceptive Technology. Ardent Media: New York Hilgers, T., et al. (1998, June). Creighton Model NaPro education technology for avoiding pregnancy. Journal of Reproductive Medicine 43(6), Marquette Model of Natural Family Planning. Retrieved May 14, 2008 from Sympto-Thermal Method. Retrieved May 14, 2008 from World Health Organization. (1981). A prospective multicentre trial of the ovulation method of natural family planning II. The effective phase. Fertility and Sterility, 36(5)

4/21/2017 QUESTIONS?

SDM Attributes Reflection
4/21/2017 SDM Attributes Reflection Who might be interested in using SDM? Someone who has never used a FP method Couples who want to follow the Church’s teaching Couples who don’t desire hormonal methods or devices Adolescent women Breastfeeding women with regular menses Ask participants for reasons why women might prefer or avoid this method. Then, click the mouse to reveal the next example.

Reasons for Choosing the SDM
4/21/2017 Reasons for Choosing the SDM Six Countries1 U.S.2 Doesn’t affect health 70% 80% No side effects 20% 30% Economical 5% Easy to learn/use 10% 45% Suggested script: In studies conducted in several countries, - six countries plus the U.S. – it was found that the overwhelming reason why women choose the SDM is that it doesn’t affect their health and has no side effects. 1 Interviews with users in 6 countries; 2 Survey of internet purchasers

Offering SDM to Clients
4/21/2017 Offering SDM to Clients Protocols have been developed and tested for offering the SDM to clients.

What is Involved in SDM Teaching?
4/21/2017 What is Involved in SDM Teaching? Screening – Help the woman determine if her cycles are of the right length. Teaching – Provide information and instructions on how to use the SDM correctly. Supporting – Explore and discuss couple issues and support correct method use. Note: Show the SDM Job Aids Packet and direct participants to their personal copy of these job aids during the discussion below. The following components will be covered in more detail later in this module and opportunities to apply the job aids also are provided. Essentially, there are 3 components of SDM counseling Screening – Help client determine if the SDM is appropriate for her. A checklist for the initial visit are job aids that providers can use during screening. Teaching – Provide information and instructions on how to use the SDM correctly. The CycleBeads Cue Card highlights the key information providers should discuss with clients. The instructional insert that accompanies CycleBeads also is helpful to point the client the key information to read when using the method at home. Supporting – Explore and discuss couple issues and support correct method use. What does the NFP teacher do to offer the Standard Days Method to a potential user? Determine that the client is interested in using the method. This suggests that clients have to be aware that the method exists. NFP programs should make every effort to inform their clients and the communities they serve about all methods of family planning. When a new method is offered, a special effort is needed to let people know about it. Ascertain whether the method is appropriate for the couple: that she has cycles between 26 and 32 days and that the couple is ready to abstain from sexual intercourse on days 8 through 19 of each cycle. Demonstrate how to use CycleBeads to know which cycle day she is on, to see whether that is a day when the couple should abstain from sexual intercourse, and to determine whether her cycles are between 26 and 32 days long. Have the clients demonstrate how to use CycleBeads. Verify that they understand that they must not have sex on days 8 to 19 of each cycle. Provide them with CycleBeads and any other materials to help her use the method.

Screening Who Can Use the SDM?
4/21/2017 Screening Who Can Use the SDM? Women with cycles 26 to 32 days long. (Women who have their periods monthly fit within this range). Couples who can avoid sex on days 8 to19 of the woman’s cycle. Note: Brainstorm before showing these bullets. 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. 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 husband should be able to avoid having sex on days 8 to 19 of her cycle. The collaboration of the husband 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 not have intercourse. 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. The SDM does not protect against STIs, or HIV/AIDS

Screening to See if the SDM is Appropriate for the Woman
4/21/2017 Screening to See if the SDM is Appropriate for the Woman When screening, determine if the woman’s cycle between 26 and 32 days long: Ask simple questions to assess cycle length and regularity: Does your period come about once a month? Does it usually come when you expect it? To determine if she can start SDM immediately, or if she has to wait for her next cycle, ask: 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? To determine if she can start SDM immediately, or if she needs to wait for her next cycle, ask: When was the first day of your last period?

When to start using the SDM
4/21/2017 When to start using the SDM Woman knows date of her last period Start immediately Woman does not know date of her last period Start on first day of next period 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 not have sex until she’s able to start using the method.

Who Should Not Initiate the SDM: Special Circumstances
4/21/2017 Who Should Not Initiate the SDM: Special Circumstances Two 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, IUS Wait 90 days after last injection Start after 3 most recent periods are about a month apart Breastfeeding and postpartum women must wait until their cycles become regular again and have had at least four periods with their most recent two periods about a month apart. If a woman is unable to start the SDM right away, she can use CycleBeads to track her cycle length. Women who have recently used the 3-month injection, the pill, implant, patch or IUS must wait until they’ve had 3 periods that are about a month apart (2 cycles between 26 and 32-day range)

Helping the couple manage fertile days
4/21/2017 Can they avoid having sex on days 8 through 19 of the cycle? NFP teachers can make efforts to help the couple determine their level of readiness to handle abstinence for several days in a row. Can the couple avoid having sex on the woman’s fertile days 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: abstaining during fertile days Following wife’s instructions Keeping track of fertile days Purchasing CycleBeads

Using SDM with spouse support Reflection
4/21/2017 Using SDM with spouse support Reflection 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 the couple’s relationship? What are ways you can inquire about possible domestic violence or alcohol/drug use that can affect correct SDM use? How comfortable do you feel engaging couples in discussing about how they will handle fertile days? TAKE TIME TO LET PARTICPANTS REFLECT ON THESE QUESTIONS. ASK FOR VOLUNTEERS TO SHARE EXAMPLES. 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: • “As you consider using a natural method, it is important to know a bit more about your relationship as husband and wife”. • “Lately, violence has become common in daily life, so we have begun to ask all our clients about any abuse they might be experiencing at home.” • “How would you feel about abstaining from sexual intercourse during 12 days in a row”? • “What are ways in which you can handle abstinence during those days?” Note: 1. Introduce provider cue card 2. Conduct activity giving participants an opportunity to: Practice explaining to clients how to use the SDM and CycleBeads, Identify possible difficulties, Assist each other in overcoming them. 3. Ask participants to turn to the person next to them. One plays the role of the provider, the other is the client. The provider shows the client how to use CycleBeads and engages the client in a discussion about how she and her partner will handle the fertile days. After five minutes they can switch roles. 4. Process the activity with the whole group. After about 5 minutes, stop the activity and ask how they felt. Did the provider explain clearly? Did the client understand? Did they use any of the job aids to explain the method (Cue Card or CycleBeads insert) Are there any doubts? Clarifications needed? When discussing method use with the partner, what questions did the provider ask? How did he/she feel asking them? How did the client respond? How did she feel talking about this?

QUESTIONS? http://foryourmarriage.org/
4/21/2017 QUESTIONS? This website provides resources that follow the Catholic teachings about marriage as a lifelong partnership of mutual and exclusive fidelity between a man and a woman ordered by its very nature to the good of the spouses and the procreation and education of children. The initiative includes videos, resource booklets, and an interactive website. An initiative of the U.S. Conference of Catholic Bishops

Apply SDM Eligibility Criteria
4/21/2017 Apply SDM Eligibility Criteria Decide which women meet the criteria to use SDM and when to start using the method. Read each case study Answer questions Review and discuss answers as a group Now let’s look at some case studies, some real-life situations that you might encounter. Note to facilitator: Refer to the set of case studies to determine SDM eligibility and select the context appropriate cases to insert in the presentation. [A suggested process: Read each of the first three case studies. Pause after each case study for answers from participants. Discuss each case study and provide correct answer to each before proceeding to the next case study. Following the reading of the third case study, instruct participants to turn to the person beside them. In pairs, they discuss the third case study. After pairs have discussed, reconvene the group to discuss the last case study together. Clearly state the answer to the case study.]

Group Activity SDM Eligibility Criteria – Cycle Regularity
4/21/2017 Case 1 - Lori Date last menstrual period: April 8 Date of visit to clinic: April 14 Lori 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 the Standard Days Method? If suitable, when could she start using it? What are some recommendations to offer this client? Yes. Instructions for facilitator: Ask a volunteer to read the case: Case 1 - Lori 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. Ask participants to work in pairs with the person next to them and answer the following questions: Can she use the Standard Days Method? Yes If suitable, when could she start using it? Immediately What are some recommendations to offer this client? Monitor cycle length over time, discuss with partner. Place ring on correct bead Immediately. Monitor cycle length over time, discuss with husband. Place ring on correct bead.

Date last menstrual period: Does not remember; beginning of month
Group Activity SDM Eligibility Criteria – Cycle Regularity 4/21/2017 Case 2 - Maggie Date last menstrual period: Does not remember; beginning of month Date of visit to clinic: May 20 The couple is 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 any other method, and they have been married only a few months. Can she use the Standard Days Method? If suitable, when could she start using it? What are some recommendations to offer this client? Yes. Instructions for facilitator: Ask a volunteer to read the case: Case 2 - Maggie Date last menstrual period: Does not remember; beginning of month Date of visit to clinic: May 20 Your client and her husband are interested in the 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 about a month apart, around the same time each month. She has not been using a method and has been married only a few months. Ask participants to work in pairs with the person next to them and answer the following questions: Can she use the Standard Days Method? Yes If suitable, when could she start using it? Wait until next period starts. What are some recommendations to offer this client? Abstain until she starts SDM. Discuss method use with husband. Once she starts SDM, monitor cycle length over time. Inform her she may already be pregnant if she had sex this month. Return if her period does not start when expected. Wait until next period starts Abstain until she starts SDM. Discuss method use and how they’ll manager. If they had sex this month, she may already be pregnant.

Date last menstrual period: May 12 Date of visit to clinic: May 28
Group Activity SDM Eligibility Criteria – Cycle Regularity 4/21/2017 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 the Standard Days Method? If suitable, when could she start using it? What are some recommendations to offer this client? Yes. Instructions for facilitator: Ask a volunteer to read the case: 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. Ask participants to work in pairs with the person next to them and answer the following questions: Can she use the Standard Days Method? Yes If suitable, when could she start using it? Immediately What are some recommendations to offer this client? Monitor cycle length over time, discuss with husband. Place ring on bead. If she had sex this month, she may already be pregnant. IF YOU HAVE QUESTIONS AT THIS TIME, PLEASE REFER TO THE FREQUENTLY ASKED QUESTIONS IN YOUR PACKET. Immediately. Discuss with husband method use. If she had sex this month, she may already be pregnant.

Teaching How to use the SDM
4/21/2017 Teaching How to use the SDM Teach client how to use SDM with CycleBeads Confirm client knows how to use the method and when to return to the teacher After screening for cycle length and possible special circumstances, the next step is to explain the client how to use the method and how CycleBeads work. Asking clients to explain back is a good way to determine whether the instructions are clear and clarify them as needed. Remind clients that the instructions for use also are included in the insert that accompanies the beads. A cue card to use during the teaching is available to help the teacher remember the key points to cover.

Monitoring Cycle Length
4/21/2017 Monitoring Cycle Length It is important for women to monitor their periods regularity over time. Periods must always come between darker brown bead and last bead. If period comes early (before darker brown bead) or late (does not start the day after the last bead) more than once in a year, switch to another method. Note to facilitator: Both the video animation of how CycleBeads work and the script for a demonstration mention how a woman can continue to monitor that her periods come on time. However, emphasis on this aspect is critical to ensure the method is appropriate for her in the future. While a woman’s cycle may be within the correct range to use the Standard Days Method, it is possible that over time her cycles may change. Thus, she needs to continue to know that her periods should always come between the dark brown bead and the last brown bead (show that section of the necklace). To the extent possible avoid language about “needing to have cycles within 26 to 32-day range”. Rather, show on the necklace when she must get her periods to know they’re coming on time and be able to have this method work for her. Explain that: • If you start your period before you put the ring on the DARK BROWN bead, it means it has come too soon to use the method. • If you have not started your period by the day after you put the ring on the last BROWN bead, it means your period is too late to use this method. • Contact your provider if you have more than on cycle out of range. Package Instructions

Practice Teaching How CycleBeads Work
4/21/2017 Practice Teaching How CycleBeads Work Note: Ask participants to turn to the person next to them and take turns explaining each other how to use CycleBeads relying on the instructional insert or the provider Cue Card. ***If you don’t have a set of CycleBeads, there is a paper image provided for you to use in your folders*** CycleBeads CycleBeads represent the menstrual cycle There are 32 beads, each representing a day of the cycle The red bead represents the first day of menstruation – which also is the first day of the cycle The brown beads represent when pregnancy is very unlikely The white beads represent fertile days A moveable rubber ring marks each day of the woman’s cycle The cylinder, with an arrow, indicates the direction in which the ring should be moved To use CycleBeads you put this ring (indicate ring) on the red bead the day you get your period. Also mark that day on your calendar. Then each day after that you move the ring forward, one bead per day, in the direction of the arrow. Move the ring even on days when you have your monthly bleeding. When the ring is on the red bead or a brown bead, you are on a day when it is very unlikely to get pregnant if you have sex. When the ring is on a white bead, you are on a day when pregnancy is very likely. To prevent pregnancy, don’t have sex on those days. Most women will get their periods somewhere in this area (indicate days between dark brown bead and last bead) and when they do they simply move the ring forward to the red bead and start the process over. Because this method works best for women with cycles between 26 and 32 days long, there is a darker bead to let you know if you have a shorter cycle (indicate darker bead). If you get your period before reaching this dark brown bead, your cycle is shorter than 26 days and this may not be as effective for you. There are also 32 beads here so if you don’t get your period by the day after the ring is put on the last bead, your cycles may be longer than 32 days and again, this method may not be as effective for you. The medical recommendation is that if you have a cycle outside this range more than once in a given year that you use a different family planning method. But, most women do get their periods in this range (indicate) and when you do, you simply move that ring forward to the red bead and start the process over. If you ever forget whether you moved the ring, check your in your calendar when your period started and starting with the red bead count the days that have passed since the first day of menstrual bleeding. Place the ring in the bead corresponding to today.

Using the SDM Reflection
4/21/2017 Using the SDM Reflection How can you help the woman remember to move the ring every day? Why is it important that she moves the ring daily? How will the women be sure her cycles are within the right range for the method to work for her? Note to facilitator: Ask participants to share any strategies that they have developed or their clients have used to establish a daily routine in order to remember to move the ring on her CycleBeads and thus know if: (1) she’s on fertile or infertile day; and (2) if her cycles continue to be on the 26 to 32-day range required for the SDM. Possible strategies may be to move the ring at the same time every day, moving the ring at the time she wakes-up or as she gets ready for her first daily activity or, pairing moving the ring with another daily activity such as washing up before bed.

Supporting Couple’s use of SDM
4/21/2017 Supporting Couple’s use of SDM During method teaching: Set the stage Encourage couples to discuss SDM use Identify possible challenges to abstinence and solutions Role play talking with each other If not present, invite husband to meet with NFP teacher Recommend resources within the diocese BE SURE SHE/COUPLE LEAVES WITH A PLAN! Engage participants in a discussion about how can they encourage clients to involve their partners in using the SDM and discussing how to manage the fertile days. This discussion can be done with all participants or in small groups.

Supporting Couple’s use of SDM (cont’d)
4/21/2017 Supporting Couple’s use of SDM (cont’d) During teaching, encourage the couple to discuss SDM use. Questions to help couples focus their discussion: Have you talked about using a natural method? How will you communicate about the fertile days? How might the two of you handle the fertile days? Have you used abstinence regularly? What are ways to avoid intercourse on days when you are fertile? What are possible challenges to avoiding sex on fertile days? How can they be overcome? Would you like to know of resources that can help you handle this aspect of your relationship? Encourage women to talk with their husbands about SDM use and what kind of problems might come up during the fertile days. Brainstorm with her what problems she and her husband might have using the method, and how she might solve them. Do a role play to provide her the opportunity to practice talking with her husband. If necessary, offer to meet with her husband. The provider can help women plan how to manage the fertile days by asking questions such as: Have you talked about this method with your spouse? How will you communicate about your fertile days? How might you and your spouse handle the fertile days? Perhaps the most important thing is to be sure that she leaves with a plan for talking with her husband and for handling her fertile days.

Supporting the couple Reflection
4/21/2017 Supporting the couple Reflection How can you help the couple identify possible challenges to using the SDM? What are possible ways the couple can handle the fertile days? Are these options feasible and appropriate in your setting? What are ways in which you think male spouses users can participate in SDM use in this setting? Note to facilitator: Ask participants to share ideas on possible approaches for helping women engage their husbands in a conversation about using the SDM and managing the fertile days. Refer to the handout Introduction to Sexuality and Couple Communication for tips on helping clients manage fertile days. Emphasize the need for the woman to discuss method use with her partner as soon as possible and determine how they will handle the fertile days. A key objective of SDM counseling is to have the client leave with a plan on how she and her spouse will manage the fertile days.

When to Return Return to your NFP teacher:
4/21/2017 Return to your NFP teacher: If your period starts before placing ring on the darker brown bead (short cycle) or if your period did not start after moving ring to the last brown bead (long cycle) If you/your spouse are having difficulty handling the fertile days If your period has not returned and you think you might be pregnant If you would like to stop using the method Note to Facilitator: Before disclosing the bullets, ask participants for examples of when would they advise clients to return.

4/21/2017 QUESTIONS?

Key Counseling Topics for SDM Users
4/21/2017 Efficacy (which depends on the woman’s ability to track her cycle days and the couple’s ability to avoid having sex on fertile days.) How SDM works Remembering to move the ring daily and continue monitoring cycle length/regularity Importance of couple’s discussing how to avoid sex during the 12 white bead days. Informing SDM does not protect from STIs/HIV When to return After a client decides to use the SDM, and the NFP determines that she meets the method criteria, the NFP and the clients should discuss in greater detail how to use this method and address any additional questions or misconceptions that the client may have. Specifically, they should discuss: how effective the SDM is, how efficacy is affected by a woman’s ability to follow the requirements of tracking her cycle with CycleBeads to know if she’s on a fertile or infertile day and with her husband not having sex, how the SDM works to prevent pregnancy, strategies for managing the fertile phase and when to return to her teacher. The teacher should encourage the client her CycleBeads and remind her that what you have explained also is described in the instructional insert in the package. She can review the insert with her spouse to start using the method correctly. The client and teacher should also discuss the fact that SDM does not protect against STIs/HIV. Finally, the provider should discuss when to return – which was described in more detail on an earlier slide.

Teaching SDM to Clients Practice, Observe, Offer Feedback
4/21/2017 In group training, organize participants in groups of three and ask them to take turns counseling a client on the SDM. Participants rotate the role of client, counselor and observer. Using the observation checklist, the observer will mark each item covered during the demonstration. In individual learning, the course participant will identify actual clients or someone to explain how the method works as part of the practicum component of the course. Refer to Handout “Standard Days Method – Case Study” for the role play case and the observation checklist.

Small Group Discussion Questions
4/21/2017 Small Group Discussion Questions What was going on between the teacher and couple? What did the teacher do that was effective in this situation? What might the teacher consider doing differently if this situation were to happen again? How did the teacher attend to the items on the self-evaluation checklist? In group training, after the participants have conducted a mock role play session, use this slide or a prepared flip chart to display these discussion questions and encourage the small group members to talk about what happened during the role-play from the perspective of the provider (self-assessment), the client (personal satisfaction with the interaction), and the observer (objective assessment using the Counseling Observation Checklist).

Follow-up for Client No fixed schedule.
4/21/2017 Follow-up for Client No fixed schedule. Encourage method users to contact teacher with questions or if she has out-of-range cycles: If the woman has 2 cycles outside of the 26 to 32-day range in a 12-month period, suggest another method. Support couple’s use of the method. If spouse is not present, offer to include him in any subsequent visits. If a follow-up visit takes place: Confirm client’s cycle continue within 26 to 32-day range Assess method satisfaction and couple’s ability to manage fertile days. Reinforce correct method use (keep track of cycles and avoid sex on fertile days). Follow-up visits do not have to occur on a fixed schedule and a follow-up visit should be scheduled if the client or teacher think it would help the couple better handle the method. However, scheduled follow-up visits are not necessary, but clients should be advised to return to the clinic anytime they have questions or concerns. During follow-up visits, the teacher should ask if the client is satisfied with the method and re-assess if her cycles continue to be within the required 26 to 32-day range. A simple way of determining this with the client is asking if her periods are coming between the darker brown bead and the last brown bead, as noted in the instructional insert. Also ask how she is managing the fertile time and whether she and her husband are having any challenges avoiding sex during that time. Finally, verify understanding of method requirements and use.

SDM Resources www.naturalfp.com Reference Materials & Tools
4/21/2017 SDM Resources Reference Materials & Tools Links to scientific articles Technical briefs IEC materials Job aids Training Materials Trainers’ Manual Participant Handbook Online Training As program and providers begin offering the method, needs for resources to support training, service delivery, etc. may arise. There are many resources available to support SDM training and service delivery, all of which are available for download in the Resources section of the IRH website ( Additionally, IRH recently developed a SDM K4Health Toolkit, and this is another place where program guidelines and service delivery tools can be found. Examples of resources include: - online SDM training for providers - Technical briefs - provider training manual and job aids - reference guide for counseling clients - IEC pamphlets, brochures, etc. Nature’s Warehouse: 1(800)

Learning Objectives Revisited
4/21/2017 Learning Objectives Revisited SDM Overview Describe the characteristics of SDM Summarize SDM Scientific Basis and efficacy Offering SDM to clients Explain how SDM works with CycleBeads® Apply the SDM eligibility criteria Determine when clients can start SDM Practice Practice counseling in SDM

4/21/2017 Follow along! You will see slides in different colors throughout the presentation. Yellow: learning Blue: questions to reflect on Green: group.

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4/21/2017 Follow along! You will see slides in different colors throughout the presentation. Yellow: learning Blue: questions to reflect on Green: group.

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Presentation on theme: "4/21/2017 Follow along! You will see slides in different colors throughout the presentation. Yellow: learning Blue: questions to reflect on Green: group."— Presentation transcript:

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