As a result of the 1994 International Conference on Population and Development (ICPD) in Cairo, reproductive health policy has expanded to include a more comprehensive view of health and development. No longer merely a response to concerns about the world's expanding population, reproductive health policy now addresses issues that reflect the needs of individuals, such as satisfying unmet need for contraception, promoting informed choice, involving men in reproductive health, securing contraceptive supplies and ensuring accessibility of services.
As policy issues have expanded in response to the ICPD, so too has the range of contraceptive methods offered by national programs. However, modifying family planning policy to include more methods does not necessarily translate into greater accessibility at the clinic level or into increased uptake by clients. The successful introduction of new methods also depends on a favorable policy environment. Therefore, all groups that are involved in policy formulation need to understand how the introduction of a new method addresses their concerns. This article examines how the Standard Days Method--a new family planning method based on fertility awareness that is currently being introduced into programs worldwide--addresses ICPD policy issues, while responding to the family planning needs of people around the world.
THE STANDARD DAYS METHOD
The Standard Days Method is based on the knowledge that the menstrual cycle is made up of a fertile phase preceded by and followed by infertile days. The concept behind the method is simple: Women with regular menstrual cycles lasting 26-32 days can prevent pregnancy by avoiding unprotected intercourse on days eight through 19. This 12-day fertile window takes into account the variability in the timing of ovulation and the viability of sperm in the woman's reproductive tract. A string of color-coded beads in the shape of a necklace (CycleBeads) helps users of the Standard Days Method to identify the fertile and infertile days of their cycle, as well as to monitor their cycle length. The failure rate of this method is less than five pregnancies per 100 woman-years during the first year of correct use.1
Given its ease of use and lack of side effects, the Standard Days Method may appeal to couples who are not currently using any method, those relying on a traditional method and those who are dissatisfied with their current or past method. Therefore, this new family planning method is an important addition to the method mix that could help many couples prevent unplanned pregnancy. Yet, for any new contraceptive method to have an impact, policymakers, program directors, service providers and the public must view it as a real alternative to existing methods, in terms of efficacy, safety, cost-effectiveness, acceptability and accessibility. The Standard Days Method represents such an alternative and offers a unique response to the ICPD.
ADDRESSING POLICY CONCERNS
Satisfying Unmet Need
A critical objective of the ICPD is reducing the level of unmet need--the proportion of fertile women who want to postpone or avoid pregnancy but are not using any form of family planning.2 Regardless of how unmet need is estimated, the family planning needs of countless women are not met for a variety of reasons, such as lack of access to services and methods, concern about side effects, partner and community disapproval, and lack of information.3
Table 1 draws on Demographic and Health Survey data to illustrate the need for family planning services in six developing countries: Ethiopia, Malawi, India, Haiti, Nicaragua and Peru.4 The proportion of women in union with an unmet need ranges from 10% in Peru to 40% in Haiti. In contrast, the proportion with a contraceptive need that is currently satisfied ranges from 8% in Ethiopia to 69% in Nicaragua. As family planning programs offer additional methods, contraceptive prevalence increases.5 Therefore, including the Standard Days Method in programs should help reduce the level of unmet need.
In many countries, the level of unmet need for means of spacing births is especially high among young women, many of whom may never have used a contraceptive before. Such women appear to find the Standard Days Method appealing: In trials conducted in El Salvador and India, up to one-half of women who adopted the method had never before practiced family planning, in large part because of concerns about side effects and a perceived threat to future fertility.6 In India, for example, one of the groups to which the Standard Days Method was offered consisted of recently married young women who wanted to space births but were unwilling to use any of the other, limited family planning options to which they had access.7
The Standard Days Method can also benefit some women who are not considered to have an unmet need, such as those who use traditional methods of family planning. The proportion of all use accounted for by such methods ranges from 4% in Nicaragua to 26% in Peru. Because programs tend not to offer traditional methods, users frequently do not know the criteria for effective use or what constitutes correct use, and do not have the support of a trained provider. Among women using periodic abstinence (one of the principal traditional methods), for example, only 35% of those in Nicaragua and 62% of those in Peru identified the middle of the menstrual cycle as the time when pregnancy is likely to occur. This finding suggests that a sizable proportion of women using traditional methods do not know when to practice effective abstinence or withdrawal.
If women currently using traditional methods opted for the Standard Days Method, which is scientifically based, many more would be able to space their births and avoid unplanned pregnancies. Although a switch to the Standard Days Method would not affect the level of unmet need, it would contribute to a reduction in the level of unwanted fertility. Similarly, switching from another modern method to the Standard Days Method would not affect the level of unmet need, but might keep it from rising by providing an acceptable alternative method and thus averting contraceptive discontinuation.
Promoting Informed Choice
The ICPD aims at reinforcing people's right to receive information about family planning options so that they can make responsible and appropriate decisions. Although policies supporting informed choice represent a step toward giving women information and options, they are effective only when appropriate services are in place and a full range of methods is available. Accordingly, the ICPD Programme of Action establishes informed choice and the availability of a full range of safe and effective methods as priorities for family planning programs.8 In the absence of these program elements, many women who want to avoid becoming pregnant will rely on ineffective methods or use no method at all.
Similarly, women who discontinue using an effective method, such as the pill or the injectable--for example, because of side effects--should have a range of alternative methods from which to choose. Including the Standard Days Method in programs upholds the right to informed choice by offering women and men an additional safe, effective family planning option. Though included in many program norms, natural methods are frequently not offered because of provider bias and insufficient knowledge.9 Because the Standard Days Method represents a type of method different from the hormonal and barrier methods that programs typically offer, it has the potential to reach a different segment of the population, including men.
Informed choice ensures that individuals have access to understandable information to guide their decision about family planning. Elements of informed choice counseling include method effectiveness, benefits and limitations, side effects and contraindications, how to use a method and how it affects fertility. Incorporating the Standard Days Method--or any other family planning method--into this information-based process will increase awareness of the method and allow women to determine, based on their own values and desires, which method they want to use.
Involving Men in Reproductive Health
The ICPD places the responsibility for family planning equally on men and women instead of solely on women, thereby emphasizing the importance of educating men as a means of achieving gender equity, especially with respect to family planning decisions and participation in method use. Implementing this goal, however, remains a challenge to many programs that struggle to find ways to increase male participation.
One of the defining attributes of the Standard Days Method is that men must be involved. Successful use of the method depends on the man's cooperation in avoiding unprotected sex on fertile days. Observers assume that identifying 12 days as fertile will curtail sexual activity, making men unwilling to participate in method use. Users of the Standard Days Method identify two principal strategies for dealing with fertile days. Many couples opt for condom use during the fertile period: More than 85% of acceptors in Delhi, India, and 65% of those at the Honduran International Planned Parenthood affiliate indicated that they would choose this strategy.10 An alternative strategy for couples is more frequent intercourse during infertile days. In the efficacy study conducted in Bolivia, Peru and the Philippines, in which participants were requested to abstain from sex on fertile days, couples using the Standard Days Method had intercourse, on average, 5.5 times per cycle; in comparison, studies have shown that users of coitus-dependent methods have sex 4.9 times per cycle.11 In Ecuador, new users of the Standard Days Method reported more frequent intercourse than did new users of the pill, the injectable or the IUD.12
Some men choose to take an active role in use of the Standard Days Method. Women in El Salvador, for example, reported that their partners help identify the fertile days in the menstrual cycle by moving the tracking band on the CycleBeads or marking the first day of the woman's menstrual period on a calendar.13 In rural India, where abstinence during fertile days is a common practice, many users reported that their husbands now ask if they can have sex, reflecting a change in men's attitudes.14 By using the Standard Days Method, men share the responsibility for family planning by joining in the decision-making process, communicating about a strategy to manage fertile days and following through with using the method.
Research indicates that men often care about women's health and want to be involved in family planning.15 However, many programs place little emphasis on men, and the most popular program-based contraceptive methods do not involve men. By its nature, the Standard Days Method encourages programs to view family planning as more than a woman's responsibility and to consider the role that men could play in the couple's family planning. Therefore, incorporation of the Standard Days Method into programs is likely to contribute to increased male involvement in a range of reproductive health decisions.
Securing Contraceptive Supplies
One of ICPD's concerns about the quality of family planning services is how programs can maintain a sufficient and continuous supply of contraceptive methods. For some programs, funding for supplies is already insufficient to meet the existing need, and this situation will only worsen as the demand for family planning grows. Experts estimate that the gap between needed and available funds could reach as much as $210 million by 2015 if funding remains at the 1999 level of $140 million.16 The gap could be narrowed by increasing reliance on the commercial sector and by reducing the proportion of clients who receive free contraceptive supplies. Nevertheless, stocks will still probably become depleted, and program needs are unlikely to be completely met.
Integration of the Standard Days Method into programs could help close the funding gap. The supplies required for the Standard Days Method are relatively inexpensive. Recent figures indicate that the U.S. Agency for International Development pays 6.6 cents per condom, 22 cents per cycle of pills, 97 cents per injection of Depo-Provera and $1.45 per IUD.17 In contrast, the one-time cost of a set of CycleBeads, which can be used for several years, is about $1.50.
Once a woman has learned to use the Standard Days Method, she can rely on it whenever supplies for other methods are unavailable. Hence, the method could be introduced as a stopgap measure for returning clients during times of stock depletion. In programs that are chronically out of stock, the Standard Days Method is both an alternative option and a solution to an ongoing problem that can undermine program efforts.
Ensuring Accessibility of Reproductive Health Services
Accessible services are a hallmark of high-quality reproductive health programs. To increase access, the ICPD Programme of Action recommends making family planning information, education, communication, counseling and services available through primary health care systems. This approach would make contraceptives available to clients who need them, and also offers a way of educating clients about new methods.
The successful introduction of a new method into a family planning program requires more than simply announcing its availability. Programmatic concerns must be addressed. The Standard Days Method can easily be incorporated into policy development, service delivery, supervision of providers and program evaluation. Experiences in Guatemala and Rwanda illustrate the feasibility of integrating the method into public sector primary health care programs. In Guatemala, the Standard Days Method was incorporated at the policy level, which is leading to its introduction into services, the management information system and the supervision system.18 In Rwanda, the method was initially introduced into a limited number of service delivery points, and is now being offered at an increasing number of centers. At the same time, the Standard Days Method is being incorporated into the revised national reproductive health program norms.19
The Standard Days Method has also been incorporated into programs that previously had not been involved in family planning and reproductive health. Kaanib, an agricultural cooperative in the Philippines, introduced the Standard Days Method to its members using trained couple and male providers.20 In addition, Project Concern International's water and sanitation program in El Salvador incorporated the Standard Days Method into its community development strategy.21 In both cases, providers were trained to ask clients about cycle length and discuss couple issues related to method use, such as dealing with the fertile period, reducing the risk of sexually transmitted infections, violence and alcohol abuse. Both organizations trained their staff to make referrals to the public sector for other contraceptive methods. The advantages of using these community-based organizations are that follow-up of clients can happen outside a structured clinic setting and hours, and that men are more readily involved. Primary health care systems and nonhealth organizations usually use different outreach and service delivery strategies to reach the public, but both have demonstrated their ability to increase access to the Standard Days Method.
The Standard Days Method contributes to reproductive health programs in a number of critical ways. By addressing concerns of policymakers, program managers and service providers, and by meeting the public's needs, the Standard Days Method responds in a unique way to the ICPD and to evolving global reproductive health concerns.
1. Arevalo M, Jennings V and Sinai I, Efficacy of a new method of family planning: the Standard Days Method, Contraception, 2002, 65(5): 333-338.
2. Johns Hopkins School of Public Health, Center for Communication Programs, Population Information Program, Meeting unmet need: new strategies, Population Reports, 1996, Series J, No. 43. Unmet Need: 1990-1994, DHS Comparative Studies, Calverton, MD, USA: Macro International, 1995, No. 16.
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4. Central Statistical Authority, Ethiopia, and Opinion Research Cor-poration (ORC) Macro, Ethiopia Demographic and Health Survey 2000, Addis Ababa, Ethiopia: Central Statistical Authority, and Calverton, MD, USA: ORC Macro, 2001, p. 91; National Statistical Office, Malawi, and ORC Macro, Malawi Demographic and Health Survey 2000, Zomba, Malawi: National Statistical Office, and Calverton, MD, USA: ORC Macro, 2001, p. 91; International Institute for Population Sciences, India, and ORC Macro, National Family Health Survey 1998-99, Mumbai, India: International Institute for Population Sciences, 2000, pp. 171-174; Cayemittes M et al., Enquête Mortalité, Morbidité et Utilisation des Services, Haïti 2000, Pétionville, Haiti: Institut Haïtien de l'Enfance, and Calverton, MD, USA: ORC Macro, 2001, p. 116; Instituto Nacional de Estadísticas y Censos, Nicaragua, Ministerio de Salud, and ORC Macro, Encuesta Nicaragüense de Demografía y Salud 2001, Calverton, MD, USA: Macro International, 2002, p. 147; and Instituto Nacional de Estadística e Informática, Peru, and Macro International, Encuesta Demográfica y de Salud Familiar 2000, Lima, Peru: Instituto Nacional de Estadística e Informática, 2001, p. 102.
5. Lapham RJ and Mauldin WP, Contraceptive prevalence: the influence of organized family planning programs, Studies in Family Planning, 1985, 16(3):117-137; Jain AK, Fertility reduction and the quality of family planning services, Studies in Family Planning, 1989, 20(1):1-16; and Ross J et al., Contraceptive choice in developing countries, International Family Planning Perspectives, 2002, 28(1):32-40.
6. Monroy M, Lundgren R and Montano G, Introducing the Standard Days Method of family planning into the water and sanitation program of PCI/Procosal El Salvador, final report, San Salvador, El Salvador: Project Concern International, 2003.
7. Dosajh U, Sood B and Lundgren R, Incorporating the Standard Days Method into CASP reproductive health and sustainability project, final report, � New Delhi, India: TNS MODE, 2003.
8. United Nations (UN), Report of the International Conference on Population and Development, Cairo, 5-13 September 1994, Cairo: UN, 1994, <http://www.un.org/popin/icpd/conference/offeng/poa.html>, accessed Sept. 15, 2003.
9. Pavon S, Velasquez C and Lundgren R, Informed choice in natural methods in family planning programs, final report, Tegucigalpa, Honduras: ASHONPLAFA and Secretaria de Salud, 2003.
10. Dosajh U, Sood B and Lundgren R, 2003, op. cit. (see reference 7); and Pavon S and Velasquez C, Introducing the Standard Days Method of family planning into existing multi-method and natural method family planning programs in Honduras, final report, Tegucigalpa, Honduras: ASHONPLAFA, 2003.
11. Arevalo M, Jennings V and Sinai I, 2002, op. cit. (see reference 1); and Stover J et al., Empirically based conversion factors for calculating couple-years of protection, Evaluation Review, 2000, 24(1):3-46.
12. Velasquez C and Gribble JN, Designing counseling to improve dual protection, poster presented at the annual meeting of the American Public Health Association, Philadelphia, PA, USA, Nov. 10-14, 2002.
13. Monroy M, Lundgren R and Montano G, 2003, op. cit. (see reference 6).
14. Johri L, Gupta YP and Lundgren R, Informed choice for birth spacing in India: incorporating the Standard Days Method, poster presented at the annual meeting of the American Public Health Association, Philadelphia, PA, USA, Nov. 10-14, 2002.
15. Ezeh AC, Seroussi M and Raggers H, Men's Fertility, Contraceptive Use, and Reproductive Preferences, DHS Comparative Studies, Calverton, MD, USA: Macro International, 1996, No. 18; and Robey B and Drennan M, Male participation in reproductive health, Network, 1998, 18(3):11-15.
16. Ross J and Bulatao R, Contraceptive projections and the donor gap, Rosslyn, VA, USA: John Snow Inc., 2001; and Sine J, How much is enough? estimating requirements for subsidized contraceptives: results from a ten-country analysis, Washington, DC: Commercial Market Strategies, 2002.
17. Gribble JN, Jennings V and Nikula M, Mind the gap: paying for family planning in developing countries, Washington, DC: Institute for Reproductive Health, 2003; and Ross J and Bulatao R, 2001, op. cit. (see reference 16).
18. Ministerio de Salud Publica y Asistencia Social, Guias nacionales para la salud reproductive, planificacion familiar, tomo 1, Ciudad Guatemala, Guatemala: Ministerio de Salud Publica y Asistencia Social, 2003.
19. Caroline Blair and Marie Mukabatsinda, Institute for Reproductive Health, Washington, DC, and Kigali, Rwanda, personal communications, May 14, 2003.
20. Sealza L, Rivera M and Blair C, Introducing the Standard Days Method of family planning into Kaanib: testing counseling strategies, final report, Cagayan de Oro City, Philippines: Research Institute for Mindanao Culture, 2003.
21. Monroy M, Lundgren R and Montano G, 2003, op. cit. (see reference 6).
James N. Gribble is senior technical research associate, the POLICY Project, Futures Group, Washington, DC. At the time this article was written, he was assistant professor and director of behavioral and operations research, Institute for Reproductive Health, Georgetown University, Washington, DC.
The author thanks Rebecka Lundgren, Victoria Jennings, Jeff Jordan, Mihira Karra and Minna Nikula for their comments during the preparation of this manuscript, which was funded by U.S. Agency for International Development grant HRN-A-00-97-00011-00 as part of the AWARENESS Project of the Institute of Reproductive Health, Georgetown University. Standard Days Method and CycleBeads are trademarks of Georgetown University.