1. Standard Days Method A Simple Fertility Awareness-Based Approach to Family Planning

2. Learning Objectives At the end of the workshop, participants will be able to:  Describe how the SDM works  Summarize the scientific basis and efficacy of the method  Identify the method eligibility criteria  Explain how to use the SDM with CycleBeads  Identify key issues in SDM service delivery

3. Standard Days Method  Identifies days 8-19 of the cycle as fertile  Is appropriate for women with menstrual cycles between 26 and 32 days long  Helps a couple avoid unplanned pregnancy by knowing which days they should not have unprotected sex  Helps a couple plan pregnancy by knowing which days they should have sex

4. CycleBeads The 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

5. What Is the Scientific Basis of the Standard Days Method?

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

7. Probability of Ovulation Relative to Midpoint of the Cycle Source: IRH analysis of WHO 1981 data % 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

8. Day 8Day 19 Determining the Fertile Window

9. How Effective Is the Standard Days Method?

10. Efficacy Study of the SDM Multi-site prospective study Services provided through existing programs Clients followed monthly for 13 cycles

11. 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

12. Contraceptive Failure of User-Directed Methods Correct UseTypical Use No Method 85 Spermicides 1829 Diaphragm 616 Condom 215 OC.38 Standard Days Method 512 Adapted from Contraceptive Technology, 18 th edition, 2004 % of women who became pregnant during 1 st year of use

13. Contraceptive Failure of Natural Methods Correct UseTypical Use Symptothermal Method 2 – 518 - 22 Billings Ovulation Method 3 – 520 - 22 Standard Days Method 512 Sources: Guida M., et al. Gynecological Endocrinology 1997.: Arévalo M., et al. Contraception May 2002 World Health Organization, Fertility and Sterility, 1981 Trussell, et al., Family Planning Perspectives, 1990 % of women who became pregnant during 1 st year of use

14. How Is the Standard Days Method Offered to Clients?

15. Offering the SDM  Determine client interest in the SDM  Screen for cycle length, ability to avoid unprotected intercourse on fertile days and STI risk  Explain SDM  Demonstrate CycleBeads  Have client demonstrate  Verify understanding/acceptance  Provide CycleBeads, other materials

16. What is Involved in SDM Counseling?  Screening – Help client determine if the SDM is appropriate for her. Calendar and Screening Checklist  Teaching – Provide information and instructions to use the SDM correctly. Cycle Beads Cue Card  Supporting – Explore and discuss couple issues and support correct method use. Screening Checklist

17. Screening Who Can Use the SDM?  Women with cycles 26 to 32 days long  Couples who can avoid unprotected sex on days 8-19 Couples not at risk of STIs

18. Screening to See if the SDM is Appropriate for the Woman  Is her cycle between 26 and 32 days long? Most women have a general idea of:  When their last period started  When their next period will start  Whether it usually comes when they expect it  Simple questions to assess cycle length and regularity.  Women who know when their last period started can use the SDM right away.  Women who do not know can begin the SDM when their next period starts.

19. Screening: Cycle Length (Start date of last period known)  What day did your last period start?  When do you expect your next period to start? Begin SDM today 26 – 32 days? yes no Offer other method

20. Screening: Cycle Length (Start date of last period not known)  Do your periods come about when you expect them?  Do your periods come about a month apart?  Does your period often come later or earlier than you expect it? Begin SDM when period starts 26 – 32 days? yes no Offer other method

21. Criteria for Starting the SDM Date of the last period known Start immediately Date of last period unknown Start on first day of next period

22.  Are her cycles between 26 and 32 days long? Screening to See if the SDM is Appropriate for the Woman

23. Screening: Special Circumstances Oral contraceptive, Patch, Implant, IUD/IUS, EC, Abortion or Miscarriage  Before using this method or before pregnancy, did your periods come when you expected them?  Were they about a month apart? Begin SDM when period starts 26 – 32 days? yes no Offer other method

24. Current/Recent Injection User Needs to wait:  until she stopped using injection (3 months since last injection) and periods are back to normal  most recent cycle was 26 to 32 days long Ask the client:  When did you have your last injection?  When were you supposed to get your next injection?  How many periods have you had since your last injection?  Do your periods come when you expect them?  Were your last two periods about a month apart?

25. Post-partum/Breastfeeding Woman Needs to wait:  until she has had 4 consecutive periods (i.e. 3 cycles)  most recent cycle 26 to 32 days long Ask the client:  Has your period returned?  How many periods have you had since your baby was born?  Are your periods regular? or, Do they come when you expect them?  Were your last two periods about a month apart?

26. Criteria for Starting the SDM (Special Circumstances) Postpartum/breastfeeding Wait until for 4 periods Start after 2 most recent are about a month apart 3-month Injection Wait 90 days after last injection Start after 2 most recent periods are about a month apart OC, patch, implant, EC, IUS, miscarriage or abortion Cycles before using method or pregnancy were 26 to 32 days long Start on first day of next period

27. Teaching How to use the SDM Teach client how to use the SDM with CycleBeads Confirm client knows how to use the method and when to return to the provider

28. CycleBeads ™

29.  Can they avoid unprotected sex days 8 -19? Screening to See if the SDM is Appropriate for the Couple

30. SDM: a Couple Method  If men understand the method, couples are more likely to use it correctly.  Special efforts should be made to involve men.  CycleBeads is a visual communication tool that men appreciate.

31. Involving Men: Community Outreach  Posters, flyers, radio and television  Community networks  Male providers/outreach workers  Materials brought home by their partners Counseling men is ideal, but men can also be taught about the method through:

32. Involving Men: During Counseling Encourage women to discuss SDM use with their partner:  Identify potential problems and solutions  Role play talking with her partner  Offer to talk with her partner Ask the client:  Have you talked about this method with your partner?  How will you communicate about the fertile days?  How might you and your partner handle the fertile days?  Have you and your partner ever used condoms?  How do you and he feel about using them? BE SURE SHE LEAVES WITH A PLAN!

34. Experience with the SDM  Why offer the SDM?  Who chooses the SDM? Why?  How do couples manage fertile days?

35. Why Offer the SDM?  Increases choice  Expands coverage  Addresses an unmet need  Empowers women  Involves men  Offers a low-cost method

36. SDM User Profile 1 Interviews with users in 6 countries 2 Survey of internet purchasers Six Countries 1 U.S. 2 Mean Age 2927 Mean Parity 2.8.4 Previous use of: Nothing/ineffective method Condom (inconsistent) Pills/injection IUD 52% 38% 33% 10% 0% 87% 96% 2%

37. Reasons for Choosing the SDM Six Countries 1 U.S. 2 Doesn’t affect health 70%80% No side effects20%30% Economical30%5% Easy to learn/use10%45% 1 Interviews with users in 6 countries 2 Survey of internet purchasers

38. 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

39. 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.

40. Lessons Learned (cont.) Women can learn to use the SDM in 15- 20 minutes. Offering the SDM helps programs reach new clients. Many couples use condoms on fertile days The SDM is cost effective.

41. SDM Services Worldwide Angola Azerbaijan Bangladesh Benin Bolivia Burkina Faso DR Congo Ecuador El Salvador Ethiopia Ghana Guatemala Honduras India Mauritius Nicaragua Peru Philippines Romania Rwanda Tajikistan Turkey United States Zambia Zanzibar

42. Introducing the SDM  Service Delivery  Resources  Training  Procurement/Reimbursement  MIS and supervision  Information and Education

43. State of the Art Guidelines

44. Resources for SDM Implementation Reference Materials  Links to scientific articles  Technical Briefs  SDM Service Protocol  SDM Service Delivery Guidelines Training Materials  Trainers’ Manual  Participant Handbook  Training Video  Online Training www.irh.org

45. Standard Days Method For more information contact: Institute for Reproductive Health Georgetown University irhinfo@georgetown.edu or visit: www.irh.org