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

1. Standard Days MethodA Simple Fertility Awareness-BasedApproach to Family Planning The Standard Days Method is a simple fertility awareness-based method of family planning. It was developed and tested by researchers at the Institute for Reproductive Health at Georgetown University with support from the U.S. Agency for International Development. USAID and the Institute saw the need for a method like the Standard Days Method because millions of women around the world have an unmet need for family planning. They are either using periodic abstinence without an understanding of their fertility, or they are using no method at all despite the fact that they don�t want to get pregnant. While this is a greater problem in some settings than others, and may stem from a variety of circumstances, it is a significant issue that needs to be addressed.The Standard Days Method meets the need for a natural method that can be integrated easily into public and private reproductive health programs. The Standard Days Method has 4 characteristics that make it appropriate for this purpose: It is simple � easy to teach, to learn, and to use It is very low cost It is effective � when used correctly, it significantly reduces the  probability of unplanned pregnancy. It is flexible, according to needs and preferences of users � it can  be used with a barrier method on the days of her menstrual cycle when the woman can become pregnant, or couples can abstain on these days.  It also can be used by couples who want to get pregnant.The Standard Days Method is a simple fertility awareness-based method of family planning. It was developed and tested by researchers at the Institute for Reproductive Health at Georgetown University with support from the U.S. Agency for International Development. USAID and the Institute saw the need for a method like the Standard Days Method because millions of women around the world have an unmet need for family planning. They are either using periodic abstinence without an understanding of their fertility, or they are using no method at all despite the fact that they don�t want to get pregnant. While this is a greater problem in some settings than others, and may stem from a variety of circumstances, it is a significant issue that needs to be addressed.The Standard Days Method meets the need for a natural method that can be integrated easily into public and private reproductive health programs. The Standard Days Method has 4 characteristics that make it appropriate for this purpose: It is simple � easy to teach, to learn, and to use It is very low cost It is effective � when used correctly, it significantly reduces the probability of unplanned pregnancy. It is flexible, according to needs and preferences of users � it can be used with a barrier method on the days of her menstrual cycle when the woman can become pregnant, or couples can abstain on these days. It also can be used by couples who want to get pregnant.

2. Learning Objectives 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 the method Describe how and why the programs include this method 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 the method Describe how and why the programs include this method

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 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 most 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 unprotected sex from day 8 through day 19 of each cycle. On all the other cycle days, they can have unprotected sex. To plan pregnancy, the Standard Days Method can help a couple identify the days to have sex. While this is not sufficient for all couples, it can be an important first step. 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 most 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 unprotected sex from day 8 through day 19 of each cycle. On all the other cycle days, they can have unprotected sex. To plan pregnancy, the Standard Days Method can help a couple identify the days to have sex. While this is not sufficient for all couples, it can be an important first step.

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 The Standard Days Method is used with CycleBeadsTM , 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 man�s support to use the method. It is very visual � he can literally see when the woman is on a fertile day. The Standard Days Method is used with CycleBeadsTM , 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 man�s support to use the method. It is very visual � he can literally see when the woman is on a fertile day.

5. What Is the Scientific Basis of the Standard Days Method? It is important for us to understand - as trainers, service providers, etc. - the scientific basis of the Standard Days Method. It has been carefully researched, and found to be more than 95% effective with correct use. In developing the method, researchers considered 2 probabilities: The probability of pregnancy from intercourse on cycle  days relative to ovulation The probability of the timing of ovulationIt is important for us to understand - as trainers, service providers, etc. - the scientific basis of the Standard Days Method. It has been carefully researched, and found to be more than 95% effective with correct use. In developing the method, researchers considered 2 probabilities: The probability of pregnancy from intercourse on cycle days relative to ovulation The probability of the timing of ovulation

6. Probability of Pregnancy from Intercourse on Days Relative to Ovulation With regard to the probability of pregnancy from intercourse on days relative to ovulation, ultrasound and hormonal studies have found that these are 6 days during the menstrual cycle when it is possible for a woman to become pregnant. Data on the probability of pregnancy on different days around ovulation indicates that: There is approximately a 4% probability of pregnancy from intercourse 5 days before ovulation. This increases to 15%, 4 days before ovulation. The highest probability of pregnancy � between 25 and 28% -- is on the 2 days before ovulation. On the day of ovulation, there is an 8-10% probability. Fertility then decreases � with a 0% probability of pregnancy by the day after ovulation. These probabilities are due to the limited viable life span of the sperm after ejaculation (not more than 5 days) and to the very limited viable life span of the egg following ovulation (less than 24 hours). Together these result in an actual fertile window of no more than 6 days during the woman�s cycle. On all the other days, the woman cannot become pregnant. Putting this in practical terms, if a woman has sex on Saturday and ovulates the following Wednesday, she has a 10 � 12% chance of getting pregnant that cycle. But if she has sex on Saturday and doesn�t ovulate until the following Friday, she has a basically zero % chance of pregnancy. But how do we know the moment ovulation occurs, and thus know the exact fertile window? With regard to the probability of pregnancy from intercourse on days relative to ovulation, ultrasound and hormonal studies have found that these are 6 days during the menstrual cycle when it is possible for a woman to become pregnant. Data on the probability of pregnancy on different days around ovulation indicates that: There is approximately a 4% probability of pregnancy from intercourse 5 days before ovulation. This increases to 15%, 4 days before ovulation. The highest probability of pregnancy � between 25 and 28% -- is on the 2 days before ovulation. On the day of ovulation, there is an 8-10% probability. Fertility then decreases � with a 0% probability of pregnancy by the day after ovulation. These probabilities are due to the limited viable life span of the sperm after ejaculation (not more than 5 days) and to the very limited viable life span of the egg following ovulation (less than 24 hours). Together these result in an actual fertile window of no more than 6 days during the woman�s cycle. On all the other days, the woman cannot become pregnant. Putting this in practical terms, if a woman has sex on Saturday and ovulates the following Wednesday, she has a 10 � 12% chance of getting pregnant that cycle. But if she has sex on Saturday and doesn�t ovulate until the following Friday, she has a basically zero % chance of pregnancy. But how do we know the moment ovulation occurs, and thus know the exact fertile window?

7. Probability of Ovulation Relative to Midpoint of the Cycle Again, consider probabilities. Data on when during the cycle ovulation occurs indicates that in the great majority of cycles, ovulation occurs very close to the middle of the cycle. In approximately 30% of cycles, ovulation occurs at the mid point (for example, on or very close to day 14 in a 28 day cycle, or day 15 in a 30 day cycle). In approximately 60% of cycles, ovulation occurs within 1 day before or after mid cycle. And in approximately 78% of cycles, ovulation occurs within 2 days before or after the midpoint. By 4 days before or after midpoint, 95% of ovulations have occurred. Again, consider probabilities. Data on when during the cycle ovulation occurs indicates that in the great majority of cycles, ovulation occurs very close to the middle of the cycle. In approximately 30% of cycles, ovulation occurs at the mid point (for example, on or very close to day 14 in a 28 day cycle, or day 15 in a 30 day cycle). In approximately 60% of cycles, ovulation occurs within 1 day before or after mid cycle. And in approximately 78% of cycles, ovulation occurs within 2 days before or after the midpoint. By 4 days before or after midpoint, 95% of ovulations have occurred.

8. With a combination of these probabilities � the probability of pregnancy on different cycle days related to ovulation, and the probability of the timing of ovulation -- it was possible to identify the days when pregnancy is VERY LIKELY and the days when it is MOST UNLIKELY. In menstrual cycles between 26 and 32 days long (which accounts for more than 80% of all cycles), the days pregnancy is very likely are days 8 through 19. On all the other days, pregnancy is very unlikely. Thus, researchers found that, in theory, the Standard Days Method was a very effective method of family planning. With a combination of these probabilities � the probability of pregnancy on different cycle days related to ovulation, and the probability of the timing of ovulation -- it was possible to identify the days when pregnancy is VERY LIKELY and the days when it is MOST UNLIKELY. In menstrual cycles between 26 and 32 days long (which accounts for more than 80% of all cycles), the days pregnancy is very likely are days 8 through 19. On all the other days, pregnancy is very unlikely. Thus, researchers found that, in theory, the Standard Days Method was a very effective method of family planning.

9. How Effective Is the Standard Days Method? So, that is how the Standard Days Method was developed. But theoretical information about probabilities is not enough. As with any method of family planning, it was necessary to conduct a prospective clinical trial to determine how effective the SDM would be in preventing pregnancy in women actually using the method.So, that is how the Standard Days Method was developed. But theoretical information about probabilities is not enough. As with any method of family planning, it was necessary to conduct a prospective clinical trial to determine how effective the SDM would be in preventing pregnancy in women actually using the method.

10. Efficacy Study of the SDM Multi-site prospective study Services provided through existing programs Clients followed monthly for 13 cycles So, researchers then examined the effectiveness through a clinical study. 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. So, researchers then examined the effectiveness through a clinical study. 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.

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 This is a summary of the findings from the clinical trial. They were published in the journal Contraception in 2002. Clearly, people are able to use the method correctly. When they do, the failure rate is less than 5. That is, fewer than 5 women out of 100 using the method for 1 year will get pregnant in the first year of use. When we look at typical use � that is, when we include the cycles when the method was used correctly and those when couples did have un protected sex on days 8 through 19 � we find a failure rate of 12. This is to be expected, because not using the method correctly means couples are having sex on the woman�s fertile days.This is a summary of the findings from the clinical trial. They were published in the journal Contraception in 2002. Clearly, people are able to use the method correctly. When they do, the failure rate is less than 5. That is, fewer than 5 women out of 100 using the method for 1 year will get pregnant in the first year of use. When we look at typical use � that is, when we include the cycles when the method was used correctly and those when couples did have un protected sex on days 8 through 19 � we find a failure rate of 12. This is to be expected, because not using the method correctly means couples are having sex on the woman�s fertile days.

12. Contraceptive Failure of User-Directed Methods 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. Those who use spermicides, a diaphragm, or condoms correctly, every time they have sex, 18, 6, and 2, respectively will become pregnant during the first year of use. OCs, used correctly, are more effective, with less than 1 woman getting pregnant with correct use. Clearly, the SDM is as or more effective with correct and typical use than other user-directed methods.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. Those who use spermicides, a diaphragm, or condoms correctly, every time they have sex, 18, 6, and 2, respectively will become pregnant during the first year of use. OCs, used correctly, are more effective, with less than 1 woman getting pregnant with correct use. Clearly, the SDM is as or more effective with correct and typical use than other user-directed methods.

13. Contraceptive Failure of Natural Methods It also is interesting to consider the effectiveness of the SDM compared to other methods that are based on fertility awareness. In terms of typical use, the SDM is more effective, probably because it is so much easier to understand and use. In terms of correct use, it appears that the SDM is slightly less effective. However, that may not be the case. Most of the efficacy studies that have been done on the other methods actually did not enter women into the study until they had completed 3 cycles of use. Women were entered in the SDM study beginning the very first cycle. Since most failures occur in the early cycles this gives us a biased comparison.It also is interesting to consider the effectiveness of the SDM compared to other methods that are based on fertility awareness. In terms of typical use, the SDM is more effective, probably because it is so much easier to understand and use. In terms of correct use, it appears that the SDM is slightly less effective. However, that may not be the case. Most of the efficacy studies that have been done on the other methods actually did not enter women into the study until they had completed 3 cycles of use. Women were entered in the SDM study beginning the very first cycle. Since most failures occur in the early cycles this gives us a biased comparison.

14. How Is the Standard Days Method Offered to Clients? Protocols also have been developed and tested for offering the SDM to clients, very similar to the protocols for other family planning methods.Protocols also have been developed and tested for offering the SDM to clients, very similar to the protocols for other family planning methods.

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 What does the service provider 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. Programs and  providers 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 her: that she has cycles  between 26 and 32 days, that she can avoid unprotected intercourse on days  8 through 19 of each cycle, and that she is not exposed to the risk of sexually  transmitted infections. Explain the method to her. Demonstrate how to use CycleBeads to know which cycle day she is on, to see  whether that is a day when she should avoid unprotected intercourse, and to  determine whether her cycles are between 26 and 32 days long. Have the client demonstrate how to use CycleBeads. Verify that she understands that she should avoid unprotected intercourse on  days 8- 19 of each cycle. Provide her with CycleBeads and any other materials to help her use the  method.What does the service provider 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. Programs and providers 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 her: that she has cycles between 26 and 32 days, that she can avoid unprotected intercourse on days 8 through 19 of each cycle, and that she is not exposed to the risk of sexually transmitted infections. Explain the method to her. Demonstrate how to use CycleBeads to know which cycle day she is on, to see whether that is a day when she should avoid unprotected intercourse, and to determine whether her cycles are between 26 and 32 days long. Have the client demonstrate how to use CycleBeads. Verify that she understands that she should avoid unprotected intercourse on days 8- 19 of each cycle. Provide her with CycleBeads and any other materials to help her use the method.

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 Note: Show the SDM Job Aids Packet and direct participants to their personal copy of these job aids during the discussion below. Essentially, there are 3 components of SDM counseling Screening � Help client determine if the SDM is appropriate for her. A calendar and screening checklist for the initial visit are job aids that providers can use during screening. Teaching � Provide information and instructions to use the SDM correctly. The CycleBeads Cue Card highlights the key information providers should discuss with clients. 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. Essentially, there are 3 components of SDM counseling Screening � Help client determine if the SDM is appropriate for her. A calendar and screening checklist for the initial visit are job aids that providers can use during screening. Teaching � Provide information and instructions to use the SDM correctly. The CycleBeads Cue Card highlights the key information providers should discuss with clients. Supporting � Explore and discuss couple issues and support correct method use.

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 Note: Brainstorm before showing these bullets 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. If a woman does not know the  approximate length of her menstrual cycles, this can be determined by a few simple questions. If she  has more than 1 cycle outside this range during a year, she should be encouraged to use another  method. She and her partner should be able to use the method together. 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. She should not be at risk of sexually transmitted infections. 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. Note: Brainstorm before showing these bullets 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. If a woman does not know the approximate length of her menstrual cycles, this can be determined by a few simple questions. If she has more than 1 cycle outside this range during a year, she should be encouraged to use another method. She and her partner should be able to use the method together. 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. She should not be at risk of sexually transmitted infections. 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.

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. 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 When their last period came When their next period will come Whether it usually comes when they expect it Simple questions to assess cycle length and regularity have been well tested. Women who typically have cycles between 26 and 32 days long and know the day their last period started can begin to use the SDM right away. Those who are not sure about the day of their last period can use the method when they start their next 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 When their last period came When their next period will come Whether it usually comes when they expect it Simple questions to assess cycle length and regularity have been well tested. Women who typically have cycles between 26 and 32 days long and know the day their last period started can begin to use the SDM right away. Those who are not sure about the day of their last period can use the method when they start their next period.

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? Some women keep track of their cycles and know when they started their most recent period. You can ask: When was the first day of your last period start? When do you expect your next period to start? If the date the woman started her last period and the date she expects her next period suggest that her cycle will be between 26 and 32 days long, she can start the SDM today, Regardless of where she is in her cycle. Give her CycleBeads and help her put the ring on the correct bead. If she had sex beyond day 7 of her cycle, advise her that there is a possibility she might be pregnant � however, she should use CycleBeads as directed. You may note that the package inset tells the woman to wait until her next period to start the SDM, even if she knows the date her last period started. This will be changed on subsequent printing of the insert. Some women keep track of their cycles and know when they started their most recent period. You can ask: When was the first day of your last period start? When do you expect your next period to start? If the date the woman started her last period and the date she expects her next period suggest that her cycle will be between 26 and 32 days long, she can start the SDM today, Regardless of where she is in her cycle. Give her CycleBeads and help her put the ring on the correct bead. If she had sex beyond day 7 of her cycle, advise her that there is a possibility she might be pregnant � however, she should use CycleBeads as directed. You may note that the package inset tells the woman to wait until her next period to start the SDM, even if she knows the date her last period started. This will be changed on subsequent printing of the insert.

20. Screening: Cycle Length(Start date of last period not known) But a woman doesn�t necessarily have to know exactly her cycle length to be able to use the SDM. Rather, she can answer these 3 simple questions: 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? Research has shown that most women have a fairly clear picture of their cycle length and regularity even if they lack precise information. This is sufficient for determining whether they are candidates for the SDM. If it is likely that her cycles are between 26 and 32 days long, even though she doesn�t know the exact date her last period started, she can begin using the SDM as soon as her next period starts.But a woman doesn�t necessarily have to know exactly her cycle length to be able to use the SDM. Rather, she can answer these 3 simple questions: 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? Research has shown that most women have a fairly clear picture of their cycle length and regularity even if they lack precise information. This is sufficient for determining whether they are candidates for the SDM. If it is likely that her cycles are between 26 and 32 days long, even though she doesn�t know the exact date her last period started, she can begin using the SDM as soon as her next period starts.

21. Criteria for Starting the SDM Now, to summarize, when can a woman start using the SDM: For women using no method, a barrier method, or a non-hormonal IUD � if they know the date they started their last period, they can begin using the method immediately. 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 are not sure of the date they started their last period, are using the pill, implant or patch, have had a miscarriage or abortion, or have used EC can start on the first day of their next period. Breastfeeding and other postpartum women and those who have been using the 3-month injectable need to wait until their cycles become regular again and their most recent two periods are about a month apart. If a woman is unable to start the SDM right away, she can use CycleBeads to track her cycle length while using a back-up method Now, to summarize, when can a woman start using the SDM: For women using no method, a barrier method, or a non-hormonal IUD � if they know the date they started their last period, they can begin using the method immediately. 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 are not sure of the date they started their last period, are using the pill, implant or patch, have had a miscarriage or abortion, or have used EC can start on the first day of their next period. Breastfeeding and other postpartum women and those who have been using the 3-month injectable need to wait until their cycles become regular again and their most recent two periods are about a month apart. If a woman is unable to start the SDM right away, she can use CycleBeads to track her cycle length while using a back-up method

22. Are her cycles between 26 and 32 days long? We�re getting ready to apply these screening criteria to 5 cases, each with a woman in a different situation. We know that most women who want to use the SDM can do so, and that they can start using it immediately or when their next period begins. From the provider�s standpoint, that is the easy part. Remember these basic criteria for method use. Now look at your case study handout. Note: Put participants in pairs to work together on an assigned case and report back to the group or go through each case with the whole group. We�re getting ready to apply these screening criteria to 5 cases, each with a woman in a different situation. We know that most women who want to use the SDM can do so, and that they can start using it immediately or when their next period begins. From the provider�s standpoint, that is the easy part. Remember these basic criteria for method use. Now look at your case study handout. Note: Put participants in pairs to work together on an assigned case and report back to the group or go through each case with the whole group.

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? When assessing a woman who is a current or recent user of a hormonal contraceptive, find out if her Cycles were 26 t0 32 days long before using the hormonal method This is because hormonal methods can alter a woman�s menstrual bleeding pattern. But research has shown that women who had regular cycles before using most common hormonal methods, can use the SDM right away, as soon as they have their period withdrawal bleed. So ask her: Before using this method or before pregnancy, did  your periods come when your expected them? Were they about a month apart? The non-hormonal IUD does not affect menstrual cycles, so women who have regular cycles while using this type of IUD can expect to have a similar experience when they stop using it. Similarly, for a woman using the levonorgesterol IUS, if her periods before using it were about a month apart, she can begin using the SDM as soon as she has a cycle within the 26 � 32 day range. EC should not affect the cycle, other than the cycle during which it is used. Thus a woman who has used EC can begin the SDM when she has her next period. Also, if she had an abortion on miscarriage, she can begin the SDM when her next period starts.When assessing a woman who is a current or recent user of a hormonal contraceptive, find out if her Cycles were 26 t0 32 days long before using the hormonal method This is because hormonal methods can alter a woman�s menstrual bleeding pattern. But research has shown that women who had regular cycles before using most common hormonal methods, can use the SDM right away, as soon as they have their period withdrawal bleed. So ask her: Before using this method or before pregnancy, did your periods come when your expected them? Were they about a month apart? The non-hormonal IUD does not affect menstrual cycles, so women who have regular cycles while using this type of IUD can expect to have a similar experience when they stop using it. Similarly, for a woman using the levonorgesterol IUS, if her periods before using it were about a month apart, she can begin using the SDM as soon as she has a cycle within the 26 � 32 day range. EC should not affect the cycle, other than the cycle during which it is used. Thus a woman who has used EC can begin the SDM when she has her next period. Also, if she had an abortion on miscarriage, she can begin the SDM when her next period starts.

24. Current/Recent Injection User For a woman who has recently used the three month contraceptive injection, there are additional screening criteria. She needs to wait: until she stopped using injection, (3 months have passed) and  periods are back to normal most recent cycle 26 to 32 days long This is because the injection can cause irregular bleeding or amenorrhea, and it may take her a while after stopping the injection before her cycles become regular. Here are some questions to ask the client to see if the SDM is right for her at this point. Once her periods are back to normal, she needs to wait until she has had 2 periods about a month apart before she starts using the SDM. While waiting for her cycles to become regular, she can use CycleBeads to keep track of her cycle length and use a back-up method of family planning until she has a 26 to 32 day cycle. For a woman who has recently used the three month contraceptive injection, there are additional screening criteria. She needs to wait: until she stopped using injection, (3 months have passed) and periods are back to normal most recent cycle 26 to 32 days long This is because the injection can cause irregular bleeding or amenorrhea, and it may take her a while after stopping the injection before her cycles become regular. Here are some questions to ask the client to see if the SDM is right for her at this point. Once her periods are back to normal, she needs to wait until she has had 2 periods about a month apart before she starts using the SDM. While waiting for her cycles to become regular, she can use CycleBeads to keep track of her cycle length and use a back-up method of family planning until she has a 26 to 32 day cycle.

25. Post-partum/Breastfeeding Woman For a breastfeeding or post-partum woman there are additional screening criteria. To start using the SDM she needs to wait: until she has had 4 consecutive periods (i.e. 3 cycles) most recent cycle 26 to 32 days long This is because women who are breastfeeding, and/or in the early postpartum months, are more likely to have irregular � usually very long � cycles, so they need to wait until they have had 4 periods, with the 2 most recent ones about a month apart. For a breastfeeding or post-partum woman there are additional screening criteria. To start using the SDM she needs to wait: until she has had 4 consecutive periods (i.e. 3 cycles) most recent cycle 26 to 32 days long This is because women who are breastfeeding, and/or in the early postpartum months, are more likely to have irregular � usually very long � cycles, so they need to wait until they have had 4 periods, with the 2 most recent ones about a month apart.

26. Criteria for Starting the SDM(Special Circumstances) Now, to summarize, when can a woman start using the SDM: For women using no method, a barrier method, or a non-hormonal IUD � if they know the date they started their last period, they can begin using the method immediately. 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 are not sure of the date they started their last period, are using the pill, implant or patch, have had a miscarriage or abortion, or have used EC can start on the first day of their next period. Breastfeeding and other postpartum women and those who have been using the 3-month injectable need to wait until their cycles become regular again and their most recent two periods are about a month apart. If a woman is unable to start the SDM right away, she can use CycleBeads to track her cycle length while using a back-up method Now, to summarize, when can a woman start using the SDM: For women using no method, a barrier method, or a non-hormonal IUD � if they know the date they started their last period, they can begin using the method immediately. 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 are not sure of the date they started their last period, are using the pill, implant or patch, have had a miscarriage or abortion, or have used EC can start on the first day of their next period. Breastfeeding and other postpartum women and those who have been using the 3-month injectable need to wait until their cycles become regular again and their most recent two periods are about a month apart. If a woman is unable to start the SDM right away, she can use CycleBeads to track her cycle length while using a back-up method

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. Note: 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. After about 5 minutes, stop the activity and ask how they felt. Did the provider explain clearly? Did the client understand? Are there any doubts? Clarifications needed? Note: 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. After about 5 minutes, stop the activity and ask how they felt. Did the provider explain clearly? Did the client understand? Are there any doubts? Clarifications needed?

29. Can they avoid unprotected sex days 8 -19? Screening to See if the SDM is Appropriate for the Couple Another screening criterion, �Can the couple avoid unprotected sex on the woman�s fertile days?� Some couples prefer to abstain during the fertile days. Others use condoms or develop other ways to express intimacy. Another screening criterion, �Can the couple avoid unprotected sex on the woman�s fertile days?� Some couples prefer to abstain during the fertile days. Others use condoms or develop other ways to express intimacy.

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. The woman�s partner plays a critical role in using the SDM. Clearly, it is a �couple method�. Research has shown that when men understand the method, the couple is much more likely to be satisfied with it and use it correctly. So special efforts should be made to involve men. CycleBeads help men and women talk about how to manage the fertile days. And, even if they don�t discuss it, CycleBeads are a visual aid � the man can see when to use a condom or abstain.The woman�s partner plays a critical role in using the SDM. Clearly, it is a �couple method�. Research has shown that when men understand the method, the couple is much more likely to be satisfied with it and use it correctly. So special efforts should be made to involve men. CycleBeads help men and women talk about how to manage the fertile days. And, even if they don�t discuss it, CycleBeads are a visual aid � the man can see when to use a condom or abstain.

31. Involving Men: Community Outreach Posters, flyers, radio and television Community networks Male providers/outreach workers Materials brought home by their partners Although counseling men is ideal, and attempts should be made to do so, other strategies to raise men�s awareness of the method have been shown to be effective. These include providing general information to men through the media and in the community, and helping women talk with their partners.Although counseling men is ideal, and attempts should be made to do so, other strategies to raise men�s awareness of the method have been shown to be effective. These include providing general information to men through the media and in the community, and helping women talk with their partners.

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! Encourage women to talk with their husbands or partners 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 partner? How will you communicate about your fertile days? How might you and your partner handle the fertile days? Have you and your partner used condoms? How do you and he feel about using them? Perhaps the most important thing is to be sure that she leaves with a plan for talking with her partner and for handling her fertile days.Encourage women to talk with their husbands or partners 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 partner? How will you communicate about your fertile days? How might you and your partner handle the fertile days? Have you and your partner used condoms? How do you and he feel about using them? Perhaps the most important thing is to be sure that she leaves with a plan for talking with her partner and for handling her fertile days.

33. Note: Ask participants to turn to the person next to them. The one who was the provider before is now the client, and vice versa. Ask the provider to engage the client in a discussion about how she and her partner will handle the fertile days. After about 5 minutes stop the activity and ask how they felt. 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? Anything else? Other issuesNote: Ask participants to turn to the person next to them. The one who was the provider before is now the client, and vice versa. Ask the provider to engage the client in a discussion about how she and her partner will handle the fertile days. After about 5 minutes stop the activity and ask how they felt. 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? Anything else? Other issues

34. Experience with the SDM Why offer the SDM? Who chooses the SDM? Why? How do couples manage fertile days? Now that we understand how to offer the SDM to clients, let�s look at the experience other programs have had with the method. Why do they offer the SDM? Who chooses to use this method � and why? And what about the fertile days? Are couples really able to mange them?Now that we understand how to offer the SDM to clients, let�s look at the experience other programs have had with the method. Why do they offer the SDM? Who chooses to use this method � and why? And what about the fertile days? Are couples really able to mange them?

35. Why Offer the SDM? Increases choice Expands coverage Addresses an unmet need Empowers women Involves men Offers a low-cost method Any time we consider adding a new method to our program, we need to think seriously about what we expect to gain by offering this particular method. In the case of the SDM, it is very likely that providers don�t have any experience with it or even with any similar methods, so they may be very skeptical. Current clients may be adequately served by existing methods, and most clients � and potential clients � don�t know about the method. What are some reasons why we might want to offer the SDM? (Note: Ask audience/trainees this question before clicking on answers. Be prepared to address issues of provider bias.)Any time we consider adding a new method to our program, we need to think seriously about what we expect to gain by offering this particular method. In the case of the SDM, it is very likely that providers don�t have any experience with it or even with any similar methods, so they may be very skeptical. Current clients may be adequately served by existing methods, and most clients � and potential clients � don�t know about the method. What are some reasons why we might want to offer the SDM? (Note: Ask audience/trainees this question before clicking on answers. Be prepared to address issues of provider bias.)

36. SDM User Profile Note: Add slide with country data if available Some interesting differences between the U.S. and other countries in terms of previous contraceptive use. The countries included here are Ecuador, El Salvador, Honduras, Benin, India, and the Philippines. Whereas about half of women in other countries had never used any method and about 1/3 had ever used condoms, pills, and injections, in the U.S., all women had contraceptive experience. 87% had used condoms and 96% hormonal methods. It appears that in the U.S., some women who have used other methods may be looking for a different kind of method.Note: Add slide with country data if available Some interesting differences between the U.S. and other countries in terms of previous contraceptive use. The countries included here are Ecuador, El Salvador, Honduras, Benin, India, and the Philippines. Whereas about half of women in other countries had never used any method and about 1/3 had ever used condoms, pills, and injections, in the U.S., all women had contraceptive experience. 87% had used condoms and 96% hormonal methods. It appears that in the U.S., some women who have used other methods may be looking for a different kind of method.

37. Reasons for Choosing the SDM Note: Add slide with country data if available In studies conducted in several countries, - six countries plus the U.S. - we find that the overwhelming reason why women choose the SDM is that it doesn�t affect their health and has no side effects. We know that most contraceptives do not have negative health effects for the vast majority of women. Indeed, there is good evidence that some methods actually have health benefits. And we know that most side effects are transitory and manageable. Nonetheless, these are many women who want something natural.Note: Add slide with country data if available In studies conducted in several countries, - six countries plus the U.S. - we find that the overwhelming reason why women choose the SDM is that it doesn�t affect their health and has no side effects. We know that most contraceptives do not have negative health effects for the vast majority of women. Indeed, there is good evidence that some methods actually have health benefits. And we know that most side effects are transitory and manageable. Nonetheless, these are many women who want something natural.

38. How Couples Manage the Fertile Days Couples in different settings and with different experiences and backgrounds will use different approaches to managing their fertile days. While there are a range of options, the 2 most frequently reported are abstaining from sex or using a condom. Many couples abstain sometimes and use a condom other times. Here we can see what couples report in 4 quite different settings.Couples in different settings and with different experiences and backgrounds will use different approaches to managing their fertile days. While there are a range of options, the 2 most frequently reported are abstaining from sex or using a condom. Many couples abstain sometimes and use a condom other times. Here we can see what couples report in 4 quite different settings.

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. Any time we consider adding a new method to our program, we need to think seriously about what we expect to gain by offering this particular method. In the case of the SDM, it is very likely that providers don�t have any experience with it or even with any similar methods, so they may be very skeptical. Current clients may be adequately served by existing methods, and most clients � and potential clients � don�t know about the method. What are some reasons why we might want to offer the SDM? (Note: Ask audience/trainees this question before clicking on answers. Be prepared to address issues of provider bias.)Any time we consider adding a new method to our program, we need to think seriously about what we expect to gain by offering this particular method. In the case of the SDM, it is very likely that providers don�t have any experience with it or even with any similar methods, so they may be very skeptical. Current clients may be adequately served by existing methods, and most clients � and potential clients � don�t know about the method. What are some reasons why we might want to offer the SDM? (Note: Ask audience/trainees this question before clicking on answers. Be prepared to address issues of provider bias.)

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 The results of the SDM efficacy study were published in Contraception in June, 2002. Since then, there has been a growing interest in the method in many, very different, countries. These are some of the countries where it is available � through public, private, and non-profit family planning providers. In some of these countries it is widely available � in others it�s available in very limited settings. But demand and use are growing. In the U.S., several state health departments, Planned Parenthood groups, and private practitioners are offering it, and it is available at an increasing number of retail settings � pharmacies, natural food stores, etc. And it is available over the internet at www.cyclebeads.com. Around the world, a number of different service delivery strategies are being implemented.The results of the SDM efficacy study were published in Contraception in June, 2002. Since then, there has been a growing interest in the method in many, very different, countries. These are some of the countries where it is available � through public, private, and non-profit family planning providers. In some of these countries it is widely available � in others it�s available in very limited settings. But demand and use are growing. In the U.S., several state health departments, Planned Parenthood groups, and private practitioners are offering it, and it is available at an increasing number of retail settings � pharmacies, natural food stores, etc. And it is available over the internet at www.cyclebeads.com. Around the world, a number of different service delivery strategies are being implemented.

42. Introducing the SDM Service Delivery Resources Training Procurement/Reimbursement MIS and supervision Information and Education Introducing any new method into a program is not an easy task. There may be resistance by providers who feel more comfortable with current methods, or providers may be overly enthusiastic, wanting to offer the method to everyone. Programs need to consider how they�re going to offer the method � who will provide it, where, and to whom. And they need resources � manuals, brochures, contraceptives, trained providers, CycleBeads, etc. For the Standard Days Method, what do you think will be the attitudes of providers in your program? Note: Brainstorm, discuss Let�s look at reactions of some providers to other methods. Introducing any new method into a program is not an easy task. There may be resistance by providers who feel more comfortable with current methods, or providers may be overly enthusiastic, wanting to offer the method to everyone. Programs need to consider how they�re going to offer the method � who will provide it, where, and to whom. And they need resources � manuals, brochures, contraceptives, trained providers, CycleBeads, etc. For the Standard Days Method, what do you think will be the attitudes of providers in your program? Note: Brainstorm, discuss Let�s look at reactions of some providers to other methods.

43. State of the Art Guidelines Other resources include: WHO Eligibility Criteria for Contraceptive Use Contraceptive Technology, 2004 edition IPPF Medical Bulletin, Oct. 2003 Other resources include: WHO Eligibility Criteria for Contraceptive Use Contraceptive Technology, 2004 edition IPPF Medical Bulletin, Oct. 2003

44. Resources for SDM Implementation There are many resources available to support SDM training and service delivery. These include: - online SDM training for providers - provider job aids - reference guide for counseling clients - informational SDM video - counselor training video - provider training manual - pamphlets, brochures, etc. There are many resources available to support SDM training and service delivery. These include: - online SDM training for providers - provider job aids - reference guide for counseling clients - informational SDM video - counselor training video - provider training manual - pamphlets, brochures, etc.

45. In closing, the SDM is a new �fertility awareness-based� method that is easy to use, easy to teach others to use, and shown to be effective through a clinical trial. It offers one more family planning option for women and couples. In closing, the SDM is a new �fertility awareness-based� method that is easy to use, easy to teach others to use, and shown to be effective through a clinical trial. It offers one more family planning option for women and couples.