RH Awareness 10

enable
Chapter 10 Family Planning and the RHA Approach
Close supportive relationships are the key to a healthy life.

DEAN HORNISH, M.D.
Table of Contents Chapter 10

Reproductive Health Awareness: A Wellness, Self-Care Approach Family Planning and the RHA Approach
Chapter 10 Family Planning and the RHA Approach Introducing Chapter Ten ........................................................................................................10-5 Training Schedule for the Sample RHA Training............................................................10-13 Objectives.........................................................................................................................10-14 Sample Lesson Plan for Session 10..................................................................................10-15 Important Terms ...............................................................................................................10-16 Activities and Handouts for the Lesson Plan .......................................................................10-19 Dual Protection and Sexual Expression ...........................................................................10-20 Body Awareness and Self-Care Practices for Family Planning Method Users ...............10-26 HomeworkFamily Planning Services and Supplies in Our Area .................................10-34 Alternate Activities and Handouts .......................................................................................10-36 Risk of Pregnancy and Gender Issues ..............................................................................10-37 Basic Facts about Family Planning Methods ...................................................................10-41 What are Fertility Awareness Methods? ..........................................................................10-53 Standard Days Method and CycleBeads ..........................................................................10-59 Steps in Male Condom Instruction...................................................................................10-65 Resources .............................................................................................................................10-76
Related Activities in other Chapters Reproductive System Puzzle Pieces...................................................................................3-19 Menstrual Cycle Flash Cards .............................................................................................3-42 How Long Is Her Menstrual Cycle ....................................................................................3-59 Sexual Response Cycle ......................................................................................................5-24 Its Hard to Talk about This ...........................................................................................6-19 Partner Negotiation Role-Play............................................................................................6-27 Talking about Sensitive Issues ...........................................................................................7-27 Improving Counseling with Interpersonal Communication Skills.....................................7-48 Effective Communication in Response to Pressure ...........................................................8-51 10-2
Reproductive Health Awareness
Stages of Change Model...................................................................................................11-22 Approaches to Counseling and Education that Support Healthy Behavior Change in Clients ......................................................................................................................11-39 RHA and Community Advocacy .....................................................................................12-17
Family Planning and the RHA Approach
10-3
Key Questions How do gender issues affect unintended

pregnancy and the use of family planning methods?
Which methods of family planning provide dual

protection against both pregnancy and STIs, including HIV/AIDS?
How do these methods affect a persons

expression of his or her sexuality? The need or desire to talk about sexual issues?
When using a method of family planning, what

should a person know about body awareness and self-care practices?
ntroducing Chapter Ten
By using family planning, people can have the number of children they would like, and plan when they would like to have them. There are many safe and effective methods of family planning. These include male and female condoms, spermicides, the diaphragm and cervical cap, oral contraceptives, injections, implants, intrauterine devices (IUDs), male and female sterilization, fertility awareness-based methods, and abstinence. Male and female condoms are methods that provide dual protection against both pregnancy and STIs including HIV/AIDS. Abstinence also provides dual protection, as does avoiding penetrative sex. People who are sexually active may decide to use one method of family planning for a while and then switch to a different method, depending on their experience and life circumstances.
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Benefits of Family Planning

Regardless of the method used, family planning can help women, men and even their children live healthier and more fulfilling lives. Family planning can help women and men
Delay the birth of their first child until they are emotionally and financially ready to
have a child
Have the number of children they can care for and afford to clothe, feed, and educate Use their time and resources to do things besides child rearing such as going to
school, getting a job, or preparing the home
Express their sexuality without fear of pregnancy Protect themselves from HIV/AIDS and other STIs (if using condoms correctly or
abstaining from penetrative sex) Family planning can also help women
Keep healthy after childbirth by having time to recuperate from one pregnancy before
becoming pregnant with another child
Avoid potential health risks of pregnancy Space children at least 3 years apart for optimal health and survival of themselves and
their children When parents plan their families, their children are often able to
Breastfeed for 2 years or more, before another child is conceived who also will need
to nurse
Enjoy more opportunities for getting enough food, clothing, education, and loving
attention from parents
Grow up with more opportunities for good health and family resources
10-6
Family planning has many benefits Many factors influence a persons ability to select and successfully use a method of family planning. These include knowledge about the methods, the availability and quality of services, cost, access to supplies, side effects experienced, partner support, cultural beliefs, past experiences, and personal concerns.
Integrating the RHA Approach

The ability of individuals and couples to plan their families is also strongly influenced by issues of gender, body awareness, and self-care, sexuality and interpersonal communicationthe four pillars of Reproductive Health Awareness (RHA).
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R R R E E EP PPR R R O O O D D D U U U C C C T T TI IV IV V E E E A
Death Birth
Birth tati on
ing
Infa
na l La c
nc
Fertility Awareness
Family Planning
Pr eg na nc y C on c ep tion
artum cy Post-p nan reg re fe P l Ca Sa a at en r P
Pre con
cep tion
ile
Ag
e Adol
sc
en
AWARENESS AWARENESS
Body Awareness and Self-Care
Childhood
Go od N Tes ticu utrit lar ion Se Pregn ancy lf-e xa Loss m Breastfeeding
Ma ter
e e Exercis otenc Imp e Male us pa no y M e rtilit fe In
H H H T T T L L L A A A E E E H H H
g rin ito on on M nizati h t u m w rty ro Im G Pube
TIs I/S RT S /AID HIV
Gender
With a RHA approach to family planning, providers incorporate these issues into their typical family planning education, counseling, and service delivery. Providers also address RHA issues directly with clients (along with other important family planning topics). They do this in ways that can facilitate and support successful method use. Consider the list of questions below when planning to integrate a RHA approach into family planning education and services. Body Awareness and Self-Care
Do women, men, and adolescents know

How the male and female reproductive systems work? How to observe and care for their reproductive health? Which signs alert them to a possible reproductive health problem? When and where to seek resources and services?
Do family planning clients understand and appreciate how their chosen method of
family planning works (in their bodies) to prevent pregnancy? Do they understand how it prevents (or not) HIV/AIDS and other STIs?
r Fe
Sexuality
Interpersonal Communication
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Do clients develop self-observation and self-referral skills necessary for effective

family planning method use, especially for those methods with common side effects and/or warning signs of a possible health problem? Gender
How are power dynamics expressed within the couples relationship? Who has decision-making power regarding whether to have sex, use of a family
planning method, and protection against HIV/AIDS and other STIs?
Who decides which method to use, how and when to use it, and whether resources are
available for a visit to the provider?
How does gender influence partner communication about effective method use? Does the organization or service delivery system support and advocate for gender
equity when providing family planning education and services?
Are couples welcome? Are there relevant services for men?

Sexuality
Do clients discuss how certain methods of family planning may impact their
expression of sexuality and the spontaneity of lovemaking?
Do clients discuss how freedom from the fear of pregnancy may improve spontaneity
and pleasure of lovemaking?
Does a sexually active adolescent actually consider herself or himself to be sexually

active?
Do older clients learn how aging may affect their sexual response cycle? Do older clients know about and discuss the risk of getting HIV/AIDS and other STIs
within the context of their sexual relationships?
Are providers trained to offer practical help with sexuality issues?

Interpersonal Communication
What influences partner communication about family planning? Is it difficult for intimate sexual partners to discuss whether to have sex at a particular
time? What enhances communication?
What makes it hard for intimate partners to talk about family planning, method use,
and protection against HIV/AIDS and other STIs? How do people overcome barriers to communication?
How does a provider help clients and community members develop and practice the
communication skills they need to improve family planning method use? (See chapter 7 and the resource list at the end of this chapter for more information on this topic.)
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The Family Planning Client

A family planning client should be able to make an informed choice about which method appears to be best suited for her or him. To do this the person needs basic information about all the methods of family planning. They need to know what methods are available, how they work, how to use them, and possible side effects or complications. They also need to know how effective the method is in preventing pregnancy and reducing the risk of STIs, other factors that may influence the effective use of the method (including perceived advantages and disadvantages), and when to return for family planning services or supplies.
Family planning method selection: Making an informed choice With this information clients can then make an informed choice about which method they would like to use at this point in their lives. During this process, family planning providers can be instrumental in assessing the clients educational needs, discussing key information about available methods of family planning, and supporting clients as they make their own informed choice about what is best for them. Skilled providers of family planning are also instrumental in making sure that clients leave with a method that is well-suited for them and their specific health care needs. There are many family planning resources that describe how to provide basic information about all methods of family planning and ensure that clients make an informed choice. There are also many materials that cover issues regarding important aspects of quality family planning service delivery. Since comprehensive family planning training and education is beyond the scope of this manual, see the resource list at the end of this chapter for more information.
10-10 Reproductive Health Awareness
Basic Family Planning Information and the RHA Approach

In order to incorporate the RHA approach into family planning as presented in this chapter, providers need to already have the basic knowledge, attitudes and skills necessary to provide family planning information, counseling, and services. The activities in this chapter are based on the assumption that participants have already received basic family planning training, and are learning to incorporate RHA concepts. For providers who already have a basic foundation in family planning, you can incorporate the RHA approach as presented in this chapter, addressing relevant issues regarding body awareness and self-care, gender, sexuality, and interpersonal communication. However, if you are training a group of providers with little previous experience in family planning, you will also need to include basic family planning information and skill development along with the points suggested for the integration of the RHA approach. A family planning training with basic information and the RHA approach may include topics like the following
Benefits of family planning from a gender and cultural perspective Reproductive rights and informed consent Male and female reproductive systems Sexuality and family planning Specifics about all family planning methods (including body awareness and self-care
information)
Family planning and protection against HIV/AIDS and other STIs Partner communication, negotiation, and family planning Client education and counseling Service delivery procedures Return visits and referrals Field practice In This Chapter
This chapter focuses on how to integrate the RHA approach into existing family planning education and training. It provides activities for raising awareness around gender issues, body awareness and self-care, sexuality, and interpersonal communication as these topics relate to family planning. The core activities in the sample lesson plan for this chapter address
Family planning methods that provide protection against both unintended pregnancy
and STIs, including HIV/AIDS
How these methods may impact sexual expression, gender relationships, and
communication about sex
10-11
Body awareness and self-care practices important for users of all family planning
methods The alternate activities at the end of this chapter include a review of all methods of family planning, and specific information about fertility awareness methods and condoms. Since this chapter does not provide a model for designing comprehensive family planning training, you may need to complement the activities presented here with additional topics. See chapter 13 for ideas about designing training to meet the specific needs of your group.
Reproductive Health Awareness: A Wellness, Self-Care Approach Training Schedule for the Sample RHA Training
Schedule Day One (Chapter 1) Introduction Pretest Reproductive Health Awareness: An Overview Session (Chapter 2) Gender: Implications for Health Session (Chapter 3) Body Awareness and Self-Care: Focus on Fertility Session (Chapter 4) Body Awareness and Self-Care Practices Session 4 3 BREAK (Chapter 8) RHA through the Life Cycle: Birth through Adolescence 8 Assign Any Homework (Chapter 12) RHA and the Community: A Focus on Safe Motherhood 12 (Chapter 14) Evaluation Posttest Presentation of Certificates 16 2 LUNCH (Chapter 7) Interpersonal Communication: Skills for Providers 7 (Chapter 11) Creating Change: Achieving Healthy Behaviors 11 (Chapter 13) Implementing the RHA Approach, continued 15 1* BREAK (Chapter 6) Interpersonal Communication: Talking with My Partner 6 (Chapter 10) Family Planning and the RHA Approach 10 (Chapter 13) Implementing the RHA Approach, continued 14 Day Two (Chapter 5) Sexuality: Healthy Expression Throughout Life Day Three (Chapter 9) RHA Through the Life Cycle: Fertile and Aging Adults Day Four (Chapter 13) Implementing the RHA Approach Review Any Homework Assignments
13
* Bold numbers refer to the number of each 90-minute session for this sample training.
10-13
bjectives
By the end of this session, participants will be able to
Name two methods of family planning that protect against both pregnancy and STIs,
including HIV/AIDS
Identify gender issues that may influence effective use of male and female condoms Describe how the use of male and female condoms might affect a persons expression
of his or her sexuality
List at least one self-observation message and one self-referral message clients should
know in order to use a family planning method
Describe how to discuss body awareness and self-care messages with family planning
clients
Tell where to receive family planning information, supplies, and services in the local
community
Family Planning and the RHA Approach Sample Lesson Plan for Session 10
Time Content Methodology Materials
Sample Lesson Plan
Evaluation
Participants list methods that provide dual protection and describe how these methods may affect sexual expression and gender relationships. They list ways to improve couple communication about dual protection.
30 to 60 Dual Protection and minutes Sexual Expression Dual protection Sexual expression Gender issues Communication and self-care practices
Participants identify family - Large pieces of planning methods that blank paper, provide dual protection colorful marking against both pregnancy and pens, and tape STIs. Using the whip methodology they describe - Male and female condoms how these methods might affect the expression of a - Handouts How persons sexuality. They to Use Male brainstorm ways to deal Condoms, How with gender issues and to Use Female improve couple Condoms and communication. The ABCs of Prevention of STIs/HIV Each small group of participants is given a different family planning method. They list what clients should know about self-observation and selfreferral when using this method and describe how to discuss this information with clients. A representative of each small group reports to the large group.
55 to 90 Body Awareness and minutes Self-Care Practices for Family Planning Self-observation Self-referral Client education
- Samples of family Given a family planning methods planning method, participants will list - Pamphlets and at least one selfinformational observation and sheets about the self-referral methods message clients should know to use - Handout Family this method. They Planning will also describe Methods: Body how to discuss selfAwareness and care practices with Self-Care family planning Practices clients. After a few days, participants present their findings, accurately describing available family planning services and supplies.
5 Homework Family For homework, participants - Notebook and pen minutes Planning Services and discover where to get more or pencil Supplies in Our Area information, supplies and services for family Visit local pharmacies, planning as well as the cost stores, clinics and other to community members. health service delivery centers.
10-15
Important Terms
Abstinence
Some people define abstinence as refraining from vaginal or anal intercourse. Others have a more broad definition that may range from not having any genital contact with another person to avoiding all sexual behavior all together, including masturbation. Primary abstinence refers to someone who has not had a sexual experience with another person. Secondary abstinence refers to a person who is sexually experienced but chooses not to engage in sexual activities during some time of their lives (Hatcher, et al., 1998). Placing the clients needs and satisfaction as the highest priority. This means the provider treats clients well, shows respect, and ensures privacy and confidentiality. The provider also pays close attention to the verbal and nonverbal messages of each client, actively engages the client in the interaction, personalizes the approach to meet the clients individual needs, and uses memory aids to help the client remember key messages (Murphy, et al., 1999). All encounters both verbal and nonverbal between clients and service providers. This includes interactions with counselors, educators, receptionists, and clinicians. It also includes interactions with those who dispense medications, schedule appointments, and request payment for services. Protection from pregnancy and STIs/HIV either through the use of a condom or the use of a condom plus another family planning method. Abstinence also provides dual protection, as does avoiding penetrative sex (Spieler, 2000). Avoiding penetrative sex for dual protection means avoiding vaginal sex to prevent pregnancy protection, and avoiding vaginal, anal, and oral sex to protect against STIs including HIV/AIDS. How well a family planning method works to prevent pregnancy. For the typical user, some methods are more effective than others. However, when family planning methods are used correctly and consistently they are usually very effective. The freedom and ability to decide whether to have children, how many to have and when to have them. The different ways to limit or space births are called family planning methods.
Client-Centered Approach
Client-Provider Interaction
Dual Protection
Effectiveness
Family Planning
Family Planning Methods
The many family planning methods to choose from include N Fertility awareness methodsStandard Days Method* (SDM), Basal Body Temperature Method, Cervical Secretion Methods, Symptothermal Methods, Calendar/Rhythm, Lactational Amenorrhea Method (LAM), withdrawal, and abstinence (the decision not to have sex) Barrier methodsmale and female condoms, diaphragms, and cervical caps Spermicides (which kill sperm without harming people)contraceptive foam, cream, jelly, film, or vaginal foaming tablets Hormonal methodsthe combined pill, minipill, implants, the injection and some IUDs Devices placed in the uterusIntrauterine devices, also called IUDs Permanent methodsmale and female sterilization
N N N N N
People who plan their families may use a particular method for some time, and then switch to a different method later on. In some areas only a few methods are available.
Informed Choice
When a client has the information about methods and servicesincluding risks and benefitsthat enables the person to make a fully informed decision about whether to obtain or decline treatment or services; which family planning method, treatment or service to select; and whether to seek and follow up on a referral. The process of ensuring informed choice for family planning involves considering a wide range of factors that could affect the persons method choice. (Family Health International, 2002) Like informed choice but a more formal, legal process in which the individual is first fully informed and then gives consent, usually in writing, to receive a method or service or participate in a research study. (Family Health International, 2002) How a family planning method works to prevent pregnancy. In addition to helping individuals space or limit the number of children they have, family planning methods have many other benefits. For example, condoms reduce the likelihood of getting a sexually transmitted infection (STI). Birth control pills can reduce a womans chance of getting cancer of the uterus and cancer of the ovaries. Some pills can also reduce acne. Fertility awareness methods help couples do more than just prevent pregnancy. They can use the information to learn more about their bodies, be better prepared to follow self-care and self-referral practices, and actually plan a pregnancy in the future.
Informed Consent Mechanism of Action Noncontraceptive Benefits
* Standard Days Method is a trademark of Georgetown University. Family Planning and the RHA Approach
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Precautions
People with certain medical conditions may be advised not to use a particular method of family planning. Or they may need to be followed closely by a trained provider, when using their method. These precautions are also called contraindications. Trained providers will review a clients medical history to determine whether the person has a health problem that may affect her family planning options. The ability of individuals and couples who are fully informed to choose: 1) to have childrenincluding a healthy pregnancy, safe delivery and good postpartum care; and 2) to limit or space the number of children they have in a safe and comfortable way. These choices should remain with the individual and couple, without pressure from family or providers. Minor changes that may occur when using certain family planning methods. Some people experience these changes while others do not. For example, some women using the pill may experience breast tenderness or light spotting of blood. Often side effects go away after a few months. Although side effects are not life threatening, they can be bothersome to some people. On very rare occasions, the use of some family planning methods may make a health problem worse. Trained providers tell clients if they should look for signs of a possible health problem associated with the use of their selected method, and when to return to a provider to be checked. Body awareness, self-observation, and self-referral are important for all people, including those who use family planning methods.
Reproductive Options
Side Effects
Warning Signs
Activities and Handouts for the Lesson Plan
Dual Protection and Sexual Expression Body Awareness and Self-Care Practices for Family Planning Method Users HomeworkFamily Planning Services and Supplies in Our Area
10-19
A
Time
ctivity Dual Protection and Sexual Expression

By the end of the activity, participants will be able to
Objective
Name two family planning methods that protect against both pregnancy and
sexually transmitted infections, including HIV/AIDS
Identify gender issues that may influence the effective use of male and female
condoms
Describe how the use of condoms may affect a persons expression of his or
her sexuality
List ways to improve couple communication about dual protection

45 to 60 minutes Participants should be knowledgeable of all family planning methods, especially male and female condoms, before conducting this activity. (If not, see the alternate activities in this chapter for ways to review family planning methods, including how to use male condoms.) For this activity you will need male and female condoms, large pieces of paper, colorful marking pens, and tape. If appropriate, distribute the handouts How to Use Male Condoms, How to Use Female Condoms, and The ABCs of Prevention of STIs/HIV
Preparation
Directions
1. Invite participants to list all methods of family planning. Record responses on a large piece of paper. Add any methods that were not included. 2. From the list ask participants to identify the methods that provide dual protection against pregnancy and STIs, including HIV/AIDS. Circle female and male condoms. 3. Mention that abstinence and nonpenetrative sex are other ways to protect against both pregnancy and sexually transmitted infections. (Mutual monogamy among uninfected partners also protects against sexually transmitted infections, although it does not protect against pregnancy.) This activity, however, will focus on male and female condoms. 4. If needed, ask one participant to review how to use the male condom and another participant to review how to use the female condom. Provide a sample male and female condom for the demonstration. Correct any misinformation.
5. Ask participants to arrange their chairs in one large circle. Then, ask them to think about how the use of male condoms might affect a persons expression of their sexuality. 6. Tell participants you will go around the circle asking each person to quickly share a word or a phrase that describes the first thing that comes to his or her mind when thinking about how the use of a male condom might affect a persons sexual expression. (Possible answers include: interrupts love making, embarrassing, helps an erection last longer, messy, uncomfortable, lubricant with condoms can make sex more pleasurable for some women, etc.) If a participant wishes to pass he or she may. 7. Using the same technique, ask participants to think about how the use of the female condom might affect a persons expression of his or her sexuality. Go around the circle again, asking participants to quickly share a word or a phrase that describes the first thing that comes to their mind when they think about how the female condom might effect a persons sexual expression. 8. Summarize the issues that came up for the group regarding sexual expression and the use of male and female condoms. Emphasize that issues viewed as a disadvantage for one person may not be a concern for another person. State the importance of finding out how clients view the possible impact on their sexual expression and ways to deal with possible concerns. 9. Next, ask participants to discuss questions about gender issues and interpersonal communication in relation to male and female condom use. This may be done in the large group or in small groups. (If you divide the class into small groups, you may wish to form all male groups and all female groups, and then compare the gender perspectives of these groups.) The following is a list of possible discussion questions and their respective answers (in italics). What might make it challenging for couples to use male or female condoms? (Possible answers include: men are dissatisfied with condoms, condoms are associated with infidelity, condoms need to be used during lovemaking, etc.) What gender issues might influence a persons ability to use condoms effectively? (Possible answers include: Power dynamics and decision-making within the relationship such as who decides whether to have a child soon, whether to use a method, which method to use, whether to have sex, and whether to protect against STIs/HIV; how desires and needs are communicated within the relationship; who has the power or desire to end the relationship if undesirable conditions continue, etc.)
10-21
Since dual protection is still an option even when partners do not use condoms, how would you use the information on the handout ABCs of Prevention of STIs/HIV to talk with clients who do not wish to use condoms. Brainstorm ways to help others (intimate partners or the clients with whom participants work) communicate about dual protection and follow the practices that provide dual protection.
10. Use colored marking pens to record responses on large pieces of paper. Summarize main points.
Wrap-up
Close the activity with points like the following.
Our overall reproductive health benefits in very important ways when

we plan the number and spacing of our children and actively protect others and ourselves against HIV/AIDS and other STIs.
The correct and consistent use of male or female condoms is a practice

that provides dual protection against both pregnancy and STIs, including HIV/AIDS.
An individual may experience a variety of personal and cultural

challenges to adopting dual protection practices. Peers and the media may also influence the persons perceptions and attitudes about condom use.
Often we can find creative and meaningful ways to approach the topic
of dual protection with intimate partners and with the clients we serve. (Review a summary of the main points in step 8 of this activity.)
Evaluation
During the course of the activity participants will list the methods of family planning that offer dual protection, describe how these methods might affect sexuality and gender issues, and list ways to improve couple communication about dual protection. As trainers observe participant responses during this activity, they will determine how well participants are able to do this. To further evaluate the participants and their ability to communicate effectively about dual protection, trainers may conduct role-play situations or observe participants as they perform their jobs in the future.
How to Use Male Condoms

Explaining How to Use
IMPORTANT: Whenever possible, show clients how to put on and take off a condom. Use a model, a stick, a banana, or two fingers to demonstrate putting on the condom. Suggest to a new user that he practice putting on a condom by himself before he next has sex.
Handout
2. Any lubricant used should be water-based. Good lubricants include spermicides, glycerine, and specially made products. Water can be used, also. They help keep condoms from tearing during sex. Natural vaginal secretions also act as a lubricant. Do not use lubricants made with oil, most of them damage condoms. Do NOT use cooking oil, baby oil, coconut oil, mineral oil, petroleum jelly (such as Vaseline), skin lotions, suntan lotions, cold creams, butter, cocoa butter, or margarine. 3. After ejaculation, hold the rim of the condom to the base of the penis so it will not slip off. The man should pull his penis out of the vagina before completely losing his erection. 4. Take off the condom without spilling semen on the vaginal opening. 5. Throw the condom away in a pit latrine (toilet), burn it, or bury it. Do not flush it down the toilet. Do not leave it where children will find it and play with it. Do not use a condom more than once.
Give Specific Instructions

1. Put the condom on the erect penis before the penis touches the vagina.
Hold the pack at its edge and open by tearing from a ribbed edge. Hold the condom so that the rolled rim is facing up, away from the penis. Pull the foreskin back if the penis is uncircumcised. Place the condom on the tip of the penis. Unroll the condom all the way to the base of the penis. The condom should unroll easily. If it does not, it is probably backwards. Turn it over and try again. If using the condom to avoid passing an STD, throw away the condom that was on backwards and start over with a new one.
Putting on a Condom
Taking off a Condom
Disposing of a Used Condom
Slip off the condom without spilling semen. Hold the condom with the rim away from the body and unroll all the way to base of the penis. Burn the used condom, throw it in the latrine, or bury it.
Source: Adapted from Hatcher, et al., 1997, pp. 11-9 to 11-10.
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How to Use Female Condoms

1. Open End (Outer Ring)
The open end covers the area around the opening of the vagina. The inner ring is used for insertion and to help hold the sheath in place.
Handout
2. How to Hold the Sheath

a. Hold inner ring between thumb and middle finger. Put index finger on pouch between other two fingers; or b. Just squeeze.
3. How to Insert the Condom

Squeeze the inner ring. Insert the sheath as far as it will go. Its in the right place when you cant feel it. Dont worry it cant go too far, and IT WONT HURT! It can be inserted when squatting, standing with a foot on a stool, or lying down.
4. Make Sure Placement Is Correct

Make sure the sheath is not twisted. The outer ring should be outside the vagina. For easy insertion the first time, practice putting in the condom prior to sex.
5. Removal
Remove before standing up. Squeeze and twist the outer ring. Pull out gently. Dispose with trash, not in toilet.
Use more lubricant if N N N N N The penis does not move freely in and out The outer ring is pushed inside There is noise during sex You feel the female condom when it is in place The female condom comes out of the vagina during use
Remove and insert a new female condom if N N N N N The female condom rips or tears during insertion or use The outer ring is pushed inside The penis enters outside the pouch The female condom bunches inside the vagina You have sex again
Add lubricant to inside of sheath or to the penis. Start with two drops and add more if desired.
Source: Adapted from the Female Health Company, n.d. (Reprinted with permission)
The ABCs of Prevention of STIs/HIV

When talking about with clients or community members about preventing sexually transmitted infections including HIV/AIDS and protecting against pregnancy, providers may want to refer to the ABCs of prevention. These ABCs help people remember the three main ways to stay healthy.
Handout
A is for Abstinence
Abstain from penetrative sex (vaginal, anal, and oral intercourse) to prevent diseases that can be spread during sex. Abstaining from vaginal intercourse also prevents pregnancy.
B is for Be Faithful
Make sure you and your partner are not infected, and that you only have sex with each other. If both partners are not infected, then being faithful to one another prevents sexually transmitted infections. Being faithful, however, does not prevent pregnancy.
C is for Condoms
Use condoms every time you have penetrative sex. Condoms significantly reduce the risk of getting a sexually transmitted infection. They also significantly reduce the risk of pregnancy. To prevent pregnancy, condoms can be used alone or together with another method of family planning.
10-25
A
Time
ctivity Body Awareness and Self-Care Practices for Family Planning Method Users
By the end of the session, participants will be able to
Objective
List one self-observation message and one self-referral message clients

should know when using a family planning method
Describe how they will discuss body awareness and self-care practices
with family planning clients 55 minutes to 1 hours Participants should be very knowledgeable about all family planning methods in order to use this activity. (If not, see the alternate activities in this chapter for ways to review family planning methods. Then, consider using this activity.) For this activity you will need sample family planning methods or pictures of each of the available methods and a list of questions to be discussed in the small groups. It is also helpful to have information sheets or pamphlets on each of the methods, which can be reviewed by the members of the small groups, if needed. The handout Family Planning Methods: Body Awareness and Self-Care Practices (page 10-30) and Important Terms (pages 10-16 to 10-18) may also be distributed at the end of the activity.
Preparation
Directions
1. Review basic fertility awareness information including what a normal, healthy person can observe about his or her body on a regular basis, as well as signs of a possible health problem. (See chapters 3 and 4.) Review the important terms for family planning, especially terms related to selfobservation and self-care. 2. Ask participants to divide into small groups. Give each group a birth control method or a picture of one of the birth control methods. Each small group should have a different birth control method. (If the class size is small, give each small group two different birth control methods to discuss.)
3. Ask each small group to discuss the following questions regarding their specific method(s). For clients or community members who select this method, what would you teach them about self-observation? What physical changes might the user notice in her or his body? What are the side effects (if any) associated with this method? Are there noncontraceptive benefits? For clients or community members who select this method, what would you teach them about self-referral? When should a client return to see a provider? What are the signs of a possible health problem (if any) that should be checked by a trained provider? How would you educate and counsel family planning clients about self-observation and self-referral in order to enhance the successful use and continuation of their chosen method?
Discussing body awareness and self-care information with a woman interested in Norplant 4. Ask a representative from each small group to present their conclusions to the large group. Provide additional information and correct misinformation, if needed. 5. You may then distribute the handout Family Planning Methods: Body Awareness and Self-Care, if appropriate, or use large pieces of paper and marking pens to create your own table of body awareness and self-care messages for family planning methods. To do this fill in the table with the appropriate information as participants report on their small group discussions. 10-27
Wrap-up
Close the session with the following points.
When family planning clients learn about basic fertility awareness

information and self-care practices, they learn to understand their bodies well and can recognize what is normal for them, as well as the signs of a possible reproductive health problem. They also have the foundation from which to learn more about body awareness and selfcare as it relates to their selected method of family planning.
If clients know to anticipate possible side effects associated with the

use of their chosen method, they will be less alarmed, should these changes occur. They may also be less likely to discontinue using the method when they know that self-observation of one or more of these side effects is usually not a sign of illness.
Clients also need to know when to return to see a provider. This

includes when they need more supplies, have a question or concern, or if they observe any signs of a possible health problem.
When discussing family planning methods with clients and community

members, it is important to provide the method-related body awareness and self-care information in a balanced, positive, and informative way. Be sure not to create unnecessary concern about these very safe and effective methods of family planning, which are available to women and men in the community.
Evaluation
During the course of the activity participants will list at least one selfobservation message and one self-referral message clients should know to use a given method of family planning. They will also describe how to discuss this information with clients. As trainers observe participant responses during this activity, they will determine how well participants are able to do this. Knowledge of self-observation and self-referral messages for family planning may be evaluated through a pretest and posttest. (If designing a test, see the handout Family Planning Methods: Body Awareness and Self-Care Practices for content information.) To further evaluate the participants and their ability to effectively discuss body awareness and self-care messages with family planning clients, trainers may conduct role-plays or observe participants as they perform their jobs in the future.
Note to Trainers
This activity includes important information about body awareness and self-care but does not cover all the elements necessary for client education and counseling on family planning. Prior to participating in this activity, participants should already have a good understanding of basic fertility awareness and self-care practices (chapters 3 and 4). Also they should already know basic information about all the methods of family planning, including possible side effects and any warning signs. This activity should be conducted together with other family planning method activities. If the activity is done in isolation, participants may get an unbalanced viewone that does not include all the information family planning clients need to know in order to use a method successfully.
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Family Planning Methods: Body Awareness and Self-Care Practices

Method Fertility Awareness-Based Methods Self-observation
What you might notice
Handout
Self-referral
When to see a provider
Non-contraceptive benefits Questions or concerns about the method - Learning about fertility awareness, signs of a healthy reproductive More supplies needed like system, and signs of a possible CycleBeads*, charts, reproductive health problem thermometer, etc. Unusual changes in body secretions or fertility signs Non-contraceptive benefits - Protection against STIs including HIV/AIDS - Added lubrication - Male condoms may help a man maintain an erection longer Side effects - Wetness from the lubricant or spermicide, if used - Genital irritation or allergy Questions or concerns about the method More supplies Genital irritation
Condoms (male and female)
Non-contraceptive benefits Diaphragm, Cervical Cap, and - Added lubrication Spermicides Side effects - Wetness from the spermicide - Genital irritation or allergy - Burning sensation when urinating
Questions or concerns about the method More supplies Genital irritation Burning sensation when urinating For diaphragm and cervical cap users: Signs of Toxic Shock Syndrome (rare) - Sudden high fever - Vomiting, diarrhea - Dizziness, faintness, weakness - Sore throat, aching muscles and joints - Rash (like sunburn)
* CycleBeads is a trademark of Georgetown University.
Family Planning Methods: Body Awareness and Self-Care Practices, continued Method Combined Oral Contraceptives Self-observation
What you might notice Non-contraceptive benefits - Reduced risk of uterine and ovarian cancer - Less menstrual cramps and pain - Improves some medical conditions, including mood disorders - Less acne Side effects - Changes in menstrual bleeding - Nausea or vomiting - Tender or full breasts - Mood changes or changes in sex drive - Weight changes - Skin changes, changes in hair growth
Self-referral
When to see a provider Questions or concerns about the method More supplies Signs of a health problem (rare) - Abdominal pain (severe) - Chest pain (severe) - Headache (severe) - Eye problems (vision loss, blurring) - Severe leg pain
Progestin-only Pill (Minipill)
Non-contraceptive benefits - Less menstrual cramps and pain - Less menstrual blood flow - Reduced risk of uterine cancer, pelvic infection, and other diseases Side effects - Changes in menstrual bleeding - Tender or full breasts - Mood changes or changes in sex drive - Weight changes - Headaches
Questions or concerns about the method More supplies Late period after several months of regular cycles Signs of a health problem (rare) - Abdominal pain - Severe headaches
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Family Planning Methods: Body Awareness and Self-Care Practices, continued Method Injection (DMPA or Depo-Provera) Self-observation
What you might notice Non-contraceptive benefits - Less menstrual cramps and pain - Less menstrual blood flow - Reduced risk of uterine cancer, pelvic infection, and other diseases - Less risk of sickle cell crisis - Decreases seizures Side effects - Changes in menstrual bleeding, including no bleeding at all - Tender or full breasts - Mood changes, changes in sex drive or depression - Weight changes - Headaches - Changes in bone thickness
Self-referral
When to see a provider Questions or concerns about the method Allergic reaction The next scheduled injection Late period after several months of regular cycles Signs of a health problem (rare) - Severe headaches - Heavy bleeding - Depression - Severe abdominal pain - Pus, pain or bleeding where injection was given
Implants (Norplant)
Non-contraceptive benefits - Less menstrual cramps and pain - Less menstrual blood flow - Reduced risk of uterine cancer, pelvic infection, and other diseases Side effects - Changes in menstrual bleeding, including no bleeding at all - Tender or full breasts - Mood changes, changes in sex drive, or depression - Weight changes - Changes in skin or hair growth - Headaches
Questions or concerns about the method When implants need to be replaced If taking anti-seizure drugs Late period after several months of regular cycles Signs of a health problem (rare) - Severe abdominal pain - Heavy vaginal bleeding - Arm pain, bleeding, or pus where implant was put in - Implant starts to come out - Severe headaches
Family Planning Methods: Body Awareness and Self-Care Practices, continued Method IUD (Intrauterine Device) Self-observation
What you might notice Side effects - Longer, heavier menstrual periods - Bleeding or spotting between periods - More cramps or pain during periods - Allergy to the copper in some IUDs - Reaction to the hormone in some IUDs
Self-referral
When to see a provider Questions or concerns about the method When the IUD needs to be replaced Signs of a health problem - Period late, abnormal spotting, or bleeding - Abdominal pain, pain with intercourse - Exposure to any STI - Abnormal discharge - Not feeling well, fever, chills - String missing, shorter or longer Questions or concerns about the method To get a test to be sure all sperm have cleared Signs of a health problem soon after procedure - High fever - Bleeding or pus from wound - Pain, heat, swelling, or redness at incision Questions or concerns about the method Follow-up visit Signs of a health problem soon after procedure - High fever - Dizziness with fainting - Constant, increasing abdominal pain - Pus or bleeding from the wound - If she thinks she is pregnant
Male Sterilization (Vasectomy)
Side effects After procedure men may feel - Brief feeling of faintness after procedure - Uncomfortable for 2 to 3 days - Pain in scrotum, swelling, and bruising
Female Sterilization (Tubal occlusion)
Side effects - After procedure women may feel pain for several days
Note: The methods described in this list are available throughout the world. Other methods with more limited availability (the Patch, Leas Shield, Contraceptive Sponge, etc.) have not been included.
Source: Adapted from Hatcher, Trussell, et al., 1998; and Hatcher, Rinehart, et al., 1997
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A
Time
ctivity HomeworkFamily Planning Services and Supplies in Our Area

By completing this assignment, participants will be able to
Objectives
Identify where to receive family planning information, supplies, and

services in the local community You will need about 5 minutes to describe the assignment. Remember to schedule an additional 30 minutes on the day the assignment is due to discuss the homework experience and share lessons learned. Find out where to receive local family planning information, supplies, and services as well as the quality of these resources. 1. Encourage participants to visit local pharmacies, stores, clinics, their own agency, and other health service centers to find out about the extent to which family planning information, supplies, and services are available in their area. 2. You may want participants to find out specific information such as Which methods of family planning are available and how much do they cost? Is the advertising clear? Appealing? To what extent is there counseling and education about how to use the methods? Are the providers well trained and respectful? Are family planning supplies easy to find in pharmacies or are they hidden behind store counters? Is someone able to answer questions about the method? How comfortable would you feel asking these questions in this environment? An unmarried girl? Boy? An older person? Men? Women?
Preparation Directions
3. Allow participants a few days to a week to complete this assignment. Then, discuss their findings with the large group.
Wrap-up
Close the activity by highlighting the following points.
If people know about family planning methods and where to find

information, supplies, and quality services before they are sexually active, it may be easier for them to get these services when they need them.
By understanding the availability and the distribution of family

planning methods in our area, we may develop an appreciation for the challenges that people may face when trying to access and use these methods.
Evaluation
When participants discuss their findings with the large group, the trainer observes the discussion and determines whether participants are able to accurately list and describe family planning services and supplies available in the local community.
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Alternate Activities and Handouts
Risk of Pregnancy and Gender Issues Basic Facts about Family Planning Methods What Are Fertility Awareness Methods? The Standard Days Method and CycleBeads Steps in Male Condom Instruction
A
Time
ctivity Risk of Pregnancy and Gender Issues

By the end of the activity, participants will be able to
Objective
Describe the risk of pregnancy if no method of family planning is used List three ways that gender issues may influence a couples ability to
plan their families 45 to 60 minutes Make a sign that says Pregnant and a sign that says Not Pregnant. Tape the signs on opposite sides of the room. You will also need large pieces of paper, colored marking pens, and tape for this activity. 1. Ask participants to imagine they are all sexually active women who would not like to become pregnant during the next year, although they are not using a method of family planning. 2. Then, ask 85 percent of the participants to stand at one end of the room, under the sign that says Pregnant. Ask the remaining 15 percent to stand at the other end of the room, under the sign that says Not Pregnant. (For example, if there are 20 participants, 17 go to the side of the room that says Pregnant and 3 go to the other side of the room.) 3. Tell participants, If a couple has sex during a years time, without using a family planning method, there is about an 85 percent chance that the woman will become pregnant. Imagine if all the participants in this room were women who had unprotected sex during a years time, this many people would be pregnant. (Point to the side of the room with the sign that says Pregnant where 85 percent of the participants are standing). And, only these few people would not be pregnant. (Point to the side of the room where 15 percent are standing, under the sign that says Not Pregnant.) A lot of women would be expecting a child! 4. To show the impact of using a family planning method, ask all the participants (if less than 20 in the class) to stand under the sign that says Not Pregnant. Say something like, Now, if everyone used their chosen family planning method correctly and consistently during the past year, less than one person in the room (probably less than 5 out of 100) would become pregnant during a years time! Although some methods have higher effectiveness rates than others, all methods help prevent pregnancy if used correctly every time the couple has sex.
Preparation
Directions
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5. Ask participants to reflect on the impact of unintended pregnancy in their community and the role of gender issues in pregnancy prevention. They may discuss questions like the following in small groups or in the large group. If small groups of participants discuss the questions, ask a representative of each group to present a summary to the large group. The following are possible discussion questions and their respective answers (in italics). How does unintended pregnancy impact women, men, adolescents, nonmarried people, older individuals, and others in the community? (Answers depend on the group.) List reasons why a woman might not use a family planning method, even though pregnancy is not desired. List reasons why a man might not use a method or discourage the use of a method. (Lack of information, fear of side effects, lack of available services, unwilling partner, unprepared, desire to please a partner, fear of rejection, fear of losing economic support, etc.) In thinking about the men and women you know well or your own personal experience, which typically decides whether to initiate a sexual relationship? When to have sex? Whether to use a family planning method? Which method to use? Whether to protect each other against HIV/AIDS and other STIs? (Answers depend on the group.) How might gender inequities (regarding power and decisionmaking within the relationship) affect a couples use of a family planning method? (A person with minimal power and decisionmaking in a relationship may not be able to negotiate method use, even if this is desired.) How do gender roles and expectations influence whether and how partners communicate about pregnancy prevention, family planning, and protection against HIV/AIDS and other STIs? (Answers will depend on the group.)
6. Summarize the responses to the questions. If available, present research regarding gender issues and family planning in this community. Brainstorm how participants can support others (a partner, friend, or clients) in their desire to plan their families and avoid contracting HIV/AIDS and other STIs. List responses on large pieces of paper.
Wrap-up
Close the activity with points like the following.
When used correctly, family planning methods work very well to

prevent pregnancy. They are safe, effective and easy to use.
For a variety of reasons a person may or may not use a method of

family planning, or may not use it effectively, even though pregnancy is not desired at that time.
By developing our awareness of gender issues and other factors that

influence whether and how effectively people are able to plan their families, we can find ways to support others in attaining their family planning goals.
Men and women interested in family planning have the right to receive
accurate and unbiased information about the methods of family planning. Then, they are better prepared to select the method that might work best for them.
You can help clients and community members

Recognize their chance of pregnancy Learn about family planning method options Determine which family planning method is best suited for them Receive method services and related supplies Explore ways to facilitate the effective use of their chosen method
Evaluation
By the end of this activity, participants will describe the risk of pregnancy if no method of family planning is used. Following the small and large group discussion, they will list three or more ways that gender issues may influence a couples ability to plan their families. This knowledge may be measured through question and answer or on written tests.
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Note to Trainers
Prior to conducting the first part of this activity, be sure to calculate how many participants will be in the 85 percent group and how many will be in the 15 percent group. (E.g. 0.85 times the number of participants = 85 percent; and 0.15 times the number of participants = 15 percent.) If there are not enough participants, you can use pictures and other images to represent pregnant and nonpregnant women. To discuss the questions regarding gender issues and family planning, you may divide the class into small groups of men only and women only. After the small groups discuss the questions, ask a member of each group to present a summary of their discussion to the large group. This takes longer but the class will have the benefit of seeing the perspective of male-only groups and female-only groups. Compare how the male and female groups responded to the same set of questions. Share insights and lessons learned.
A
Time
ctivity Basic Facts about Family Planning Methods

By the end of this activity, participants will be able to
Objective
Identify rumors and myths about family planning methods in their

community
Describe correct information about three family planning methods Correctly name all methods of family planning when given a
description of these methods 60 to 90 minutes Collect samples of the family planning methods to be demonstrated in this activity and place them in a brown bag or covered box. (For fertility awareness methods use CycleBeads, a natural family planning chart, and a basal body temperature thermometer. For methods like male or female sterilization, use a picture that represents the method.) Find or make anatomical models and posters of the male and female reproductive systems. See sample posters in chapter 3 on pages 3-29 and 3-33. Review and make copies of the handout Name the Method. The tool for trainers includes an answer key for this handout. To conduct this activity, trainers need to be able to present detailed information about all the methods of family planning in an accurate and nonjudgmental way. For content information on all methods of family planning, see the list of resources at the end of this chapter. If needed, review basic information about fertility awareness and how the male and female reproductive systems work before doing this activity.
Preparation
Directions
1. Use anatomical models and posters of the male and female reproductive systems to briefly review basic fertility awareness information and how the reproductive systems work. Ask participants, If you were inventing a method of family planning, how might it keep a woman from getting pregnant? (Answers include all forms of nonpenetrative sex that will keep the egg and sperm from meeting, ways to block the Fallopian tubes or vas deferens, cover the opening of the cervix, cover the penis, kill sperm, create a valve to filter out sperm, etc.) Show how this might be on a poster or anatomical model. 2. Ask participants to form small groups, one group for each family planning method available in your area. Invite a representative from each group to put their hand in your bag or box of methods, without looking, and select
10-41
one method. In each small group, participants will try to determine the name of their method and quickly discuss what they have heard about that method. (Or, you may place each method on a table or chair, scattered throughout the room. Ask each small group to circulate from method to method, guessing the name of each method and talking about what theyve heard about the method.) 3. Before fully describing each method, ask participants to share what they (or members of the community) have heard about the method. If participants include myths or relate misinformation, provide accurate information in a sensitive and appropriate way. Possible myths and misinformation include Pills cause cancer Women should take a break after using hormonal methods for a few years The IUD can get lost in your body Natural methods dont work well
4. Conduct a demonstration/discussion of each method of family planning. During each demonstration of a family planning method include basic information on What the method is How it works to prevent pregnancy How effective it is How to use it Factors that may influence its use Common changes people may notice in their bodies when using this method and what the changes might mean When to see a health provider
5. Ask participants questions about any myths or misinformation that may have been expressed during step 3 in the directions. Assess whether they have learned the correct factual information about the methods. Encourage participants to practice how they would dispel myths about family planning in a respectful way when talking with others. 6. Distribute the handout Name the Method. During class time or for homework ask participants to write the name and draw a picture of the family planning method in the box next to the description. 10-42 Reproductive Health Awareness
Wrap-up
At the end of the activity, summarize with the following points.
With previous knowledge about fertility awareness, it is easier for

people to understand how a method works to prevent pregnancy. Also, if they have already developed body awareness and self-care practices, they may be better able to notice and appreciate the relevance of possible changes that may occur in the body when using certain methods of family planning.
A person is more likely to use a family planning method well, and

continue to use it, if he or she freely chooses the method from many options and is well informed about the selected method. (i.e., knows how the method works, how to use it correctly, the effectiveness, common changes that may be noticed in ones body when using the method, and when to return to see a health provider.)
When presenting basic information about family planning methods to

clients and community members, providers should ask key questions to find out What clients already know about the methods Their previous experience What beliefs they have Their plans for protection against HIV/AIDS and other STIs How the use of a particular method might fit into their daily lives How they might overcome possible obstacles to successful use What the person has learned
By asking key questions, the session can become more interactive and client-centered.
Evaluation
During the activity participants will list myths or misconceptions about the methods and then discuss accurate information to dispel these myths or rumors. Upon completing the handout they will correctly identify all the methods of family planning. Knowledge about family planning methods may also be measured by a written test. Following additional training activities and practice, participants can be tested on their ability to discuss accurate information about family planning with others through role-plays or during on-the-job observations.
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Note to Trainers
This activity is designed for participants who have little or no background in family planning methods. It is also a good activity for providers who are very knowledgeable about some methods but have very little or incorrect information about others. If, however, participants already have accurate information on all of the methods, modify the small group work. Instead of asking a representative from each small group to merely share what they have heard about their selected method, ask the group to show (for the large group) how they would counsel and educate clients about this method. Provide feedback on both the content presented and the counseling techniques demonstrated. For a fun addition to this activity, ask participants to make up new names for the methods. For example Norplant could be renamed the family planning fan. If participants have not yet learned about body awareness and self-care and how the male and female reproductive systems work, it is important to present this information first, before beginning an activity on family planning methods. See chapters 3 and 4 for more information.
Name the Method

Answer Key
Family Planning Method Description
Tools for Trainers
This method fits over an erect penis. To prevent pregnancy, it traps semen and keeps it from going into a womans vagina. This method not only prevents pregnancy, but also protects against HIV/AIDS and other STIs. For this method to work well, it should be used every time the couple has sex. It can also be used together with a spermicide. If this method causes an irritation, the person may try using a different brand or different spermicide. Male Condom This method is placed into a womans vagina. It fits over her cervix and hangs out of the vagina. It comes with a lubricant. This method prevents pregnancy by blocking sperm from entering the uterus and tubes. It not only prevents pregnancy, but also protects against STIs. For this method to work well, it should be used every time the couple has sex. It should not be used together with a male condom. This method is put in a womans vagina to kill sperm. It comes in different forms including contraceptive foam, suppositories, film, and cream. It can be used alone or with condoms, diaphragms, or cervical caps. Some men and women may experience an irritation when using this method. If so, they can try another brand or type.
Female Condom
Spermicides These two different methods cover a womans cervix and are used together with a spermicide. They prevent pregnancy by blocking sperm from entering the uterus and tubes and by killing sperm. For women who have had a vaginal birth, one of these two methods (cervical cap) is less effective. Some women using these methods may experience urinary tract infections. Diaphragm and Cervical Cap
(Diaphragm shown)
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Name the Method: Answer Key, continued Family Planning Method Description
A woman swallows this method every day, about the same time of day. The hormones in the method prevent pregnancy by keeping the woman from ovulating, by thickening her cervical secretions, which help block sperm, and by thinning the lining of her uterus. Some women who take this method may experience changes in the body like nausea, or spotting between menstrual periods. These are side effects, not signs of sickness. Some women may have medical problems or other health concerns that make this method inappropriate for them. Some Pills forms of the method are not advised for breastfeeding women. (Combined Oral Contraceptives and
Progestin-only Pills)
Injection
(DMPA or Depo-Provera) (Noristerat or NET EN)
This method is given as a shot (injection) in a womans arm or buttocks every two to three months, depending on the hormone in the shot. This hormone prevents pregnancy by keeping the woman from ovulating, by thickening her cervical secretions, which help block sperm, and by thinning the lining of her uterus. Many women who use this method have an increased number of days of light bleeding, or no menstrual bleeding at all. These are common side effects, not a sign of sickness. Some women may have medical problems or other health concerns that make this method inappropriate for them.
Implants
(Norplant)
For a woman to use this method, a trained provider puts small, soft rods under the skin in her upper arm. The rods slowly release a hormone, which prevents pregnancy by keeping the woman from ovulating, by thickening her cervical secretions, which help block sperm, and by thinning the lining of her uterus. This method works for 5 years. Some women who use this method experience changes in their menstrual bleeding pattern. This is a common side effect, not a sign of sickness. Some women may have medical problems or other health concerns that may make this method inappropriate for them.
Name the Method: Answer Key, continued Family Planning Method Description This is a small plastic device (often containing copper) that is placed in a womans uterus through her vagina by a trained provider. It keeps a woman from getting pregnant by preventing the sperm and egg from meeting. Depending on the device, it can work for up to 10 years. Some women who use this method may experience longer or heavier periods or more painful menstrual cramps. Some women have medical problems or other health concerns that may make this method inappropriate for them. This is a permanent method used by men. To prevent pregnancy, a trained provider makes a small opening in a mans scrotum and cuts or blocks the tubes that carry his sperm. Once the procedure is complete, and a man has had about 20 ejaculations, sperm will be cleared from his tubes. Then, he can still ejaculate and have erections but his partner does not become pregnant. There are no apparent long-term health risks from this method.
Intrauterine Device
(IUD)
Male Sterilization
(Vasectomy)
Female Sterilization
This is a permanent method for women. To prevent pregnancy, a trained provider makes a small opening in a womans abdomen and blocks or cuts the tubes that carry her eggs from the ovaries to the uterus. The woman continues to have menstrual periods and can still have sex. But, her egg does not meet with a mans sperm and this keeps her from becoming pregnant. There are no apparent long-term health risks from this method. This method is slightly more risky and often more expensive than male sterilization. These methods can be used to either plan or prevent pregnancy. In order to avoid pregnancy, a couple learns to identify the fertile days of the womans menstrual cycle and avoids unprotected intercourse on those days. (Some couples abstain from sex on the fertile days. Others choose to use another method of family planning method only during the fertile days.) To use one of these methods to plan a pregnancy, the couple identifies the fertile days and then makes sure they have intercourse during those fertile days.
CycleBeads
Fertility Awareness Methods*
* These include the Standard Days Method and CycleBeads, Cervical Secretions Methods, Basal Body Temperature (BBT) Method, Sympthothermal Method, and Calendar Rhythm. Family Planning and the RHA Approach
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Name the Method: Answer Key, continued Family Planning Method Description This method is also based on fertility awareness information. It can be a temporary method for a breastfeeding woman if all of the following three conditions are true. 1) She fully or nearly fully breastfeeds her baby (gives little or no other food or drink except breast milk, and breastfeeds often, both day and night) and; 2) Her menstrual periods have not returned, and; Lactational Amenorrhea Method (LAM) 3) Her baby is less than 6 months old. Whenever any one of these three points is not true, the woman should use another method of family planning and keep breastfeeding her baby, if possible. With this method the couple has intercourse, and then the man pulls his penis out of the womans vagina before he ejaculates. If he is able to ejaculate away from the womans vagina, it is unlikely she will become pregnant. However, for some men it is hard to control their ejaculation. If so, this method will not work. Often, this method provides protection against pregnancy when no other methods are available. If a couple does not have vaginal sex, the woman will not get pregnant. This is true for people who have never had sexual intercourse, and for people who decide not to have sex during a certain period of their lives. Also, if a couple does not have any type of intimate sexual contact, they protect themselves against STIs. For this method to work well, a person needs to make a clear decision not to have sex, and be able to effectively communicate this to a partner. This can be used after intercourse to prevent pregnancy. It is not recommended for routine use as a family planning method. However, it can used infrequently if a condom breaks, if the IUD is dislodged, if unexpected and unprotected sex occurs and in other emergency situations. Typically the woman takes a prescribed regimen of oral contraceptive pills within 48 to 72 hours of unprotected intercourse. Or, she has a copper-releasing IUD inserted within 5 days of unprotected intercourse.
Withdrawal
Abstinence
Emergency Contraception
Name the Method

Directions:
In the rectangle on the left-hand side, write in the name of the family planning method that is described on the right-hand side. You may also draw a picture of the method. Description
Handout
Family Planning Method
...............................................
This method fits over an erect penis. To prevent pregnancy, it traps semen and keeps it from going into a womans vagina. This method not only prevents pregnancy, but also protects against HIV/AIDS and other STIs. For this method to work well, it should be used every time the couple has sex. It can also be used together with a spermicide. If a person causes an irritation, the person may try using a different brand or different spermicide. This method is placed into a womans vagina. It fits over her cervix and hangs out of the vagina. It comes with a lubricant. This method prevents pregnancy by blocking sperm from entering the uterus and tubes. It not only prevents pregnancy, but also protects against HIV/AIDS and other STIs. For this method to work well, it should be used every time the couple has sex. It should not be used together with a male condom. This method is put in a womans vagina to kill sperm. It comes in different forms including contraceptive foam, suppositories, film, and cream. It can be used alone or with condoms, diaphragms, or cervical caps. Some men and women may experience an irritation when using this method. If so, they can try another brand or type. These two different methods cover a womans cervix and are used together with a spermicide. They prevent pregnancy by blocking sperm from entering the uterus and tubes and by killing sperm. For women who have had a vaginal birth, one of these two methods (cervical cap) is less effective. Some women using these methods may experience urinary tract infections.
...............................................
...............................................
...............................................
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Name the Method, continued Family Planning Method Description A woman swallows this method every day, about the same time of day. The hormones in the method prevent pregnancy by keeping the woman from ovulating, by thickening her cervical secretions, which help block sperm, and by thinning the lining of her uterus. Some women who take this method may experience changes in the body like nausea, or spotting between menstrual periods. These are side effects, not signs of sickness. Some women may have medical problems or other health concerns that make this method inappropriate for them. Some forms of the method are not advised for breastfeeding women. This method is given as a shot (injection) in a womans arm or buttocks every two to three months, depending on the hormone in the shot. This hormone prevents pregnancy by keeping the woman from ovulating, by thickening her cervical secretions, which help block sperm, and by thinning the lining of her uterus. Many women who use this method have an increased number of days of light bleeding, or no menstrual bleeding at all. These are common side effects, not a sign of sickness. Some women may have medical problems or other health concerns that make this method inappropriate for them. For a woman to use this method, a trained provider puts small, soft rods under the skin in her upper arm. The rods slowly release a hormone, which prevents pregnancy by keeping the woman from ovulating, by thickening her cervical secretions, which help block sperm, and by thinning the lining of her uterus. This method works for 5 years. Some women who use this method experience changes in their menstrual bleeding pattern. This is a common side effect, not a sign of sickness. Some women may have medical problems or other health concerns that may make this method inappropriate for them.
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Name the Method, continued Family Planning Method Description This is a small plastic device (often containing copper) that is placed in a womans uterus through her vagina by a trained provider. It keeps a woman from getting pregnant by preventing the sperm and egg from meeting. Depending on the device, it can work for up to 10 years. Some women who use this method may experience longer or heavier periods or more painful menstrual cramps. Some women have medical problems or other health concerns that may make this method inappropriate for them. This is a permanent method used by men. To prevent pregnancy, a trained provider makes a small opening in a mans scrotum and cuts or blocks the tubes that carry his sperm. Once the procedure is complete, and a man has had about 20 ejaculations, sperm will be cleared from his tubes. Then, he can still ejaculate and have erections but his partner does not become pregnant. There are no apparent long-term health risks from this method. This is a permanent method for women. To prevent pregnancy, a trained provider makes a small opening in a womans abdomen and blocks or cuts the tubes that carry her eggs from the ovaries to the uterus. The woman continues to have menstrual periods and can still have sex. But, her egg does not meet with a mans sperm and this keeps her from becoming pregnant. There are no apparent long-term health risks from this method. This method is slightly more risky and often more expensive than male sterilization. These methods can be used to either plan or prevent pregnancy. In order to avoid pregnancy, a couple learns to identify the fertile days of the womans menstrual cycle and avoids unprotected intercourse on those days. (Some couples abstain from sex on the fertile days. Others choose to use another method of family planning method only during the fertile days.) To use one of these methods to plan a pregnancy, the couple identifies the fertile days and then makes sure they have intercourse during those fertile days.
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Name the Method, continued Family Planning Method Description This method is also based on fertility awareness information. It can be a temporary method for a breastfeeding woman if all of the following three conditions are true. 1) She fully or nearly fully breastfeeds her baby (gives little or no other food or drink except breast milk, and breastfeeds often, both day and night), and 2) Her menstrual periods have not returned, and 3) Her baby is less than 6 months old. Whenever any one of these three points is not true, the woman should use another method of family planning and keep breastfeeding her baby, if possible. With this method the couple has intercourse, and then the man pulls his penis out of the womans vagina before he ejaculates. If he is able to ejaculate away from the womans vagina, it is unlikely she will become pregnant. However, for some men it is hard to control their ejaculation. If so, this method will not work. Often, this method provides protection against pregnancy when no other methods are available. If a couple does not have vaginal sex, the woman will not get pregnant. This is true for people who have never had sexual intercourse, and for people who decide not to have sex during a certain period of their lives. Also, if a couple does not have any type of intimate sexual contact, they protect themselves against STIs. For this method to work well, a person needs to make a clear decision not to have sex, and be able to effectively communicate this to a partner. This can be used after intercourse to prevent pregnancy. It is not recommended for routine use as a family planning method. However, it can used infrequently if a condom breaks, if the IUD is dislodged, if unexpected and unprotected sex occurs and in other emergency situations. Typically the woman takes a prescribed regimen of oral contraceptive pills within 48 to 72 hours of unprotected intercourse. Or, she has a copper-releasing IUD inserted within 5 days of unprotected intercourse.
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A
Time
ctivity What are Fertility Awareness Methods?

By the end of the session, participants will be able to
Objectives
List three different fertility awareness methods Describe one fertility awareness method and explain how it works to
prevent pregnancy 30 to 45 minutes Write the name of one of the following terms on the top of each sheet of paper
Preparation
Fertility Awareness Methods Natural Family Planning (NFP) Standard Days Method/CycleBeads Cervical Mucus Method (Billings Method/Ovulation Method) Basal Body Temperature (BBT) Method Symptothermal Method Calendar/Rhythm Method Lactational Amenorrhea Method (LAM) Withdrawal Abstinence
Tape these large sheets of paper around the room prior to conducting activity and review the tools for trainers Fertility Awareness Methods. Additional materials to use during this activity include large sheets of paper, several colored marking pens, and masking tape.
Directions
1. Ask participants to circulate around the room and write on each sheet of paper what they know or have heard about that particular method or term. As they do this, pay attention to the descriptions and perceptions recorded on the sheets of paper.
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2. In a large group review the responses on the large sheets of paper. Ask participants about their beliefs and perceptions of fertility awarenessmethods. Possible discussion questions include What is your overall impression of these methods? What you heard? What do you believe? What percentage of couples in your area uses a fertility awareness method? How effective do you think these methods are? What would you say or do if a client requested information about one of these methods?
3. Provide basic information on each of the fertility awareness methods and define the other terms listed on the large sheets of paper. Answer questions and correct any misinformation, as appropriate. Discuss where clients and community members may receive fertility awareness methods. (An introduction to fertility awareness methods can be found in the tools for trainers for this activity.)
Wrap-up
Close the session with the following points.
Fertility awareness methods can be used to prevent or plan a

pregnancy.
With a good understanding of fertility awareness, couples can then

learn how to determine whether a woman is fertile and can become pregnant on a given day of her menstrual cycle. If the couple desires pregnancy, they have sex during the womans fertile days. If pregnancy is not desired, they abstain from sex (or use another method of family planning) on the fertile days.
Fertility awareness methods are just a few of the many family planning
options available to couples. As with all methods, providers can assist clients and community members to make an informed choice regarding their method selection. Providers can help in this process by providing accurate, unbiased information; and by assisting clients to think through and explore which method appears best suited to them, at this particular stage of their lives.
Evaluation
Through question and answer, or on a written test trainers will assess whether participants can list three different fertility awareness methods and describe how one of the methods works. See the tools for trainers with this activity for content information for the written test.
Note to Trainers
Before, or after this activity, it is a good idea to present content information on fertility awareness. See chapter 3, Body Awareness and Self-Care: Focus on Fertility. If natural family planning and fertility awareness methods are not your area of expertise, you may ask a local service provider of fertility awareness methods to conduct a brief presentation on the methods and describe the services available in the community. For detailed information about natural methods of family planning and fertility awareness methods, contact the Institute for Reproductive Health at Georgetown University. You may also visit their web site at http://www.irh.org or send an email to irhinfo@georgetown.edu.
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Fertility Awareness Methods
Tools for Trainers
These methods depend on identifying days during each menstrual cycle when intercourse is most likely to result in a pregnancy. To accurately identify the potentially fertile days, a woman needs to develop skills in applying knowledge about fertility to her own body. This includes
Recognizing mens and womens reproductive potential Observing and interpreting the signs and patterns of fertility that occur Understanding how to use this information to avoid or achieve a pregnancy
To avoid pregnancy, couples can abstain, engage in other nonpenetrative sex, use a barrier method, or practice withdrawal during the fertile time. If couples use barriers or withdrawal during the fertile time, they are using fertility awareness combined methods (FACM). If they abstain during the fertile time, they are using natural family planning (NFP). The term natural does not imply other methods are unnatural, only that the natural signs and symptoms associated with the menstrual cycle are observed, recorded, and interpreted to identify the fertile time. (Jennings, Lamprecht & Kowal, 1998.) During the first year of perfect use of a fertility awareness method, the probability of pregnancy ranges from 1 percent to 9 percent, depending on the particular method that is used. For typical users, however, between 12 percent and 25 percent of women experience a pregnancy during the first year. Some fertility awareness methods are inherently more effective than others. (Hatcher, et al., 1998) The effectiveness also depends upon how well a woman observes and notes her fertility signs and how well the couple follows the guidelines for the use of their chosen fertility awareness method. Fertility awareness methods do not provide protection against HIV/AIDS and other sexually transmitted infections.
Cervical Mucus or Billings Ovulation Method

This is a method that was developed by Drs. John and Evelyn Billings. A woman determines her days of infertility, possible fertility, and greatest fertility by observing changes in her cervical secretions and sensations of wetness and dryness in the vulva. To avoid pregnancy, abstinence is practiced during the fertile days. The Billings method refers to the authentic method as outlined by Drs. John and Evelyn Billings. Several adaptations of this method have been developed. These modified, generic methods are often referred to as cervical mucus methods or cervical secretion methods. (Institute for Reproductive Health, Georgetown University, 1993)
Fertility Awareness Methods, continued
Basal Body Temperature (BBT) Method

This is a method that uses the womans basal body temperature (temperature of the body at rest) to identify the infertile days of the menstrual cycle after ovulation has occurred. With this method, unprotected intercourse only occurs during the infertile days after ovulation until the next menstruation begins. For couples who are planning a pregnancy, it helps them determine whether ovulation has occurred during a given menstrual cycle.
Symptothermal Method
With this method the fertile and infertile days are identified by observing and interpreting the variations in cervical secretions, basal body temperature, and other signs and symptoms of ovulation. These other signs and symptoms include cervical changes, abdominal pain, intermenstrual bleeding, and breast tenderness. Calendar calculations may also be used to help identify the first fertile day of each menstrual cycle.
Calendar or Rhythm Method

With this method the fertile days of the menstrual cycle are determined by first calculating the length of at least six previous menstrual cycles. Then, the beginning of the fertile phase is determined by subtracting a set number of days (usually a number between 18 and 21) from the length of the shortest of these cycles. The end of the fertile phase is determined by subtracting a set number (usually a number between 9 and 11) from the longest of these previous cycles.
Lactational Amenorrhea Method (LAM)

Breastfeeding can be used as a temporary method of family planning for women who follow the Lactational Amenorrhea Method (LAM) criteria. A woman can use LAM if 1. She fully or nearly fully breastfeeds her baby (the baby gets at least 85 percent of his or her feedings from her breast milk, and she breastfeeds her baby often both day and night), and 2. Her menstrual periods have not returned, and 3. Her baby is less than 6 months old When any one of these three criteria is no longer true, the woman should use a complimentary method of family planning for pregnancy protection. She should also continue to breastfeed her child so the baby continues to get the needed nutrients and the protection from disease that breast milk provides.
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Fertility Awareness Methods, continued
Standard Days Method

The Standard Days Method (SDM) is a new modern and natural method of family planning with an efficacy rate of better than 95 percent when used correctly. This method is based on physiological evidence that women have a fertile phase during each menstrual cycle when it is possible for them to get pregnant. Women with menstrual cycles between 26 and 32 days can use SDM to prevent pregnancy by avoiding unprotected intercourse on days 8 through 19 of their menstrual cycle. Most women using SDM find that a simple device, a color-coded string of beads called CycleBeads, helps them to identify the days of their cycles when they can get pregnant and the days when pregnancy is very unlikely (Institute for Reproductive Health, 2002).
Two-Day Method
This is a simplified approach to the cervical mucus method that is being developed and tested by the Institute for Reproductive Health, Georgetown University. With this method, a woman checks her cervical secretions and vaginal sensations every day. Then, every night before going to bed she asks herself the following two questions: 1) Did I see or feel cervical secretions today? and 2) Did I see or feel cervical secretions yesterday? Based on the womans answer to these two questions she determines whether she is fertile that evening and the next morning. For pregnancy prevention, the woman and her partner avoid unprotected intercourse on her fertile days. If they wish to have a child, they plan to have intercourse on her fertile days. People learning this method are also taught when to seek assistance from a health provider.
Withdrawal
With this method the couple has intercourse, and then the man pulls his penis out of the womans vagina before he ejaculates. If he is able to ejaculate away from the womans vagina, it is unlikely she will become pregnant. However, for some men it is hard to control their ejaculation. If so, withdrawal will not work well. Often, this method provides protection against pregnancy when no other methods are available.
Abstinence
Some people define abstinence as refraining from vaginal or anal intercourse. Others have a more broad definition that may range from not having any genital contact with another person to avoiding all sexual behavior altogether, including masturbation. (Hatcher, et al., 1998) If a couple does not have vaginal sex, the woman will not get pregnant. If the couple does not have any type of genital contact they are protected from sexually transmitted infections. Nonpenetrative sex also protects against pregnancy and sexually transmitted infections. This includes forms of sexual pleasuring that do not include vaginal, oral, or anal sex. Abstinence can work for people who have never had sexual intercourse, and for people who decide not to have sex during a certain period of their lives. For this method to work a person needs to make a clear decision not to have penetrative sex and be able to effectively communicate this to her or his partner.
A
Time
ctivity Standard Days Method and CycleBeads

Objectives
Identify a womans fertile days during a 26- to 32-day cycle Demonstrate how to use CycleBeads correctly
30 to 45 minutes Review the tools for trainers and the handout for this activity. You may also want to review pages 3-59 through 3-67 for more information on the menstrual cycle, Standard Days Method, and CycleBeads. To conduct this activity you will need enough CycleBeads for participants to handle them (at least one string of beads for two to three people). Distribute the information card or package insert with the CycleBeads or copy the handout for all participants.
Preparation
Directions
1. Holding CycleBeads in your hands, describe how to use them. (Follow the instructions as described in the tools for trainers and handout for this activity.) 2. Answer any questions participants might have about Standard Days Method (SDM) and how to use CycleBeads. If necessary, define menstrual cycle and show participants how to tell whether a woman typically has cycles lasting 26 to 32 days. See page 3-59 through 3-67. 3. Review that a woman with menstrual cycles lasting 26 to 32 days is possibly fertile, and can become pregnant on the days when the rubber ring is on the white beads (days 8 through 19 of her menstrual cycle). Pregnancy is highly unlikely when the rubber ring is on the brown beads. Remind participants how a woman can tell if her cycles become shorter or longer than is optimal for the effective use of the method. Review when a user of CycleBeads should see a provider. 4. Ask participants to turn to the person next to them and take turns demonstrating how to use CycleBeads. 5. Remind participants that the purpose of this activity is to provide basic information about SDM and CycleBeads. To actually use the method or teach it to others, participants need more information.
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6. Discuss availability of SDM and CycleBeads in your area. Tell where interested clients may receive the method and where providers may be trained to offer the method.
Wrap-up:
Summarize and conclude with points like the following.
SDM is an effective and easy-to-use natural method of family

planning. It is based on fertility awareness information. CycleBeads are a tool for using SDM.
Women with menstrual cycles between 26 and 32 days long can use
this method.
When women with 26 to 32 day cycles use SDM correctly it is very

effectivegreater than 95 percent.
Like many other methods of family planning SDM does not protect
against HIV/AIDS and other STIs.
Evaluation:
To determine whether participants can identify a womans fertile days during a cycle lasting 26 to 32 days, trainers may use a question and answer format or written test. Trainers may also observe and assess accuracy as participants demonstrate to each other how to use CycleBeads. See the tool for trainers and the handout for this activity for content information relevant to the evaluation.
Standard Days Method Description
Tools for Trainers
The Standard Days Method (SDM) is a new, modern method of family planning developed by the Institute for Reproductive Health at Georgetown University. The method is scientifically sound and enables a woman to identify the days she can and cannot become pregnant during each menstrual cycle. Women with menstrual cycles that last between 26 and 32 days can use SDM to prevent pregnancy by avoiding unprotected intercourse on days 8 through 19 of their menstrual cycles. To do this, couples either abstain from intercourse when the woman is on cycle days 8 through 19, or they use another method on these days. When using SDM most women track the days of their menstrual cycles by using a special string of color-coded beads called CycleBeads. Each bead represents one day of the cycle, with different colored beads to identify the days when she can get pregnant and the days when pregnancy is highly unlikely. A woman moves a rubber ring over one bead every day to visibly track where she is in her cycle.
Scientific Rationale
Early in the development of SDM the Institute for Reproductive Health analyzed a large data set of womens menstrual cycles obtained from the World Health Organization. SDM was then developed using rigorous scientific methodology. SDM is based on physiological evidence that a womans fertile phase (e.g., days during her menstrual cycle when she can become pregnant) starts 5 days prior to ovulation and lasts through the day of ovulation. The fertile phase is related to the life span of sperm, which can remain viable in a womans reproductive tract for up to 5 days, and to the fact that the egg can be fertilized for up to 24 hours. The probability of pregnancy increases from 4 percent 5 days before ovulation to almost 30 percent just before ovulation. By the day of ovulation the probability of pregnancy decreases to 8 percent. Then the probability of pregnancy is virtually zero for the rest of the cycle. (Wilcox, Weinberg & Baird, 1998)
Effectiveness
To determine how effective SDM is in helping women avoid unplanned pregnancy, the Institute for Reproductive Health conducted a study of nearly 500 women in Bolivia, Peru and the Philippines who used the method for up to one year. The study incorporated the same internationally-recognized criteria that are used in efficacy studies for all modern family planning methods. Results showed that when women used SDM correctly, it was very effectivegreater than 95 percent. The study also confirmed that women are able to use CycleBeads correctly, and that men can participate and support their partners in using the method as well. The complete results of this efficacy trial are published in the May, 2002 issue of Contraception. (Arvalo, Jennings, & Sinai, 2002) 10-61
Potential Standard Days Method Users

A couple can use SDM to plan their family if the womans menstrual cycles usually range between 26 and 32 days and if both partners can avoid unprotected intercourse during the womans fertile time. Most women can begin using SDM right away. Breastfeeding women and other postpartum women, however, need to have three menstrual cycles within the range of 26 to 32 days before beginning the method. Users of the 3-month contraceptive injection should have at least two cycles within the range before beginning the method. SDM clients need to learn
How to use CycleBeads (or some other educational tool) and identify the womans
fertile days
When and how to protect against pregnancy How to communicate with a partner about the method When to see a provider.
SDM is easy to teach, learn, and use. It is effective, acceptable to many women and couples, and is feasible for programs to offer. To use SDM as a family planning method or to teach this method to others, providers need more information than is presented here and on the following page. For more information, contact Institute for Reproductive Health 4301 Connecticut Ave. NW Suite 310 Washington DC, 20008 (202) 687-1392 http://www.irh.org irhinfo@georgetown.edu
Standard Days Method and CycleBeads
Tools for Trainers
Standard Days Method
CycleBeads
PROVIDER CUE CARD
GENERAL INFORMATION CycleBeads are based on a natural family planning method called the Standard Days Method (SDM). This method is more than 95% effective when used correctly. CycleBeads help a woman know on which days she can get pregnant. Using CycleBeads a woman keeps track of her days to know when to avoid unprotected intercourse in order to prevent a pregnancy. CycleBeads represent the menstrual cycle. The menstrual cycle begins on the first day of the period (menstrual bleeding) and ends the day before the next period. Each bead is a day of the cycle. The RED bead marks the first day of the period. The WHITE beads represent days when a woman CAN GET PREGNANT. The BROWN beads represent days when pregnancy is unlikely. A woman can use this method if her cycles last between 26 and 32 days. To use it effectively, the couple needs to avoid unprotected intercourse on days when the woman can get pregnant. INSTRUCTIONS FOR USE On the first day of your period, move the ring to the RED bead. Also mark that day on your calendar. Every morning move the ring to the next bead. Always move the ring in the direction of the arrow, from narrow to wide end. Move the ring even on days when you have your period. If you forget whether you moved the ring, check in your calendar when your period began. Count the days since your period began and move the ring the same number of beads starting with the RED bead. When the ring is on a BROWN bead you can have sexual intercourse. These are days when pregnancy is very unlikely.
When the ring is on a WHITE bead day, avoid unprotected sex. These are days when you can get pregnant if you have unprotected sex. The day your next period starts, move the ring to the RED bead again. Skip over any remaining beads. Your period signals that a new cycle has started. Contact your provider if you start your period before you put the ring on the DARK BROWN bead. Also contact your provider if you have not started your period by the day after you put the ring on the last BROWN bead. Also contact your provider if You have any vaginal bleeding between your periods You think you may have a sexually transmitted disease You have unprotected intercourse on a WHITE bead day
Excerpt from CycleBeads Provider Cue Card (Cachan & Lundgren, 2002)
Prototype material
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INSTRUCTIONS FOR USE

RED bead
CycleBeads represent the woman's menstrual cycle. Each bead represents a day of the cycle. CycleBeads are appropriate for women with cycles between 26 and 32 days.
BROWN beads (Very low probability of pregnancy)

On the day you start your period, move the ring to the RED bead. Also, mark this date on your calendar. Every morning move the ring to the next bead. Always move the ring in the direction of the arrow on the cylinder. (The cylinder does not count as a day of the cycle.) On BROWN bead days you can have intercourse with very low probability of pregnancy. On WHITE bead days you can get pregnant. Avoid unprotected intercourse to prevent a pregnancy. When you start your next period, move the ring directly to the red bead to start a new cycle.
If you have not started your period by the day after you put the ring on the last brown bead, your cycle is longer than 32 days.
If you start your period before you put the ring on the darker brown bead, your cycle is shorter than 26 days.
CycleBeads: Instructions for Use
WHITE beads (High probability of pregnancy)
Handout
2002 Georgetown University, Institute for Reproductive Health
A
Time
ctivity Steps in Male Condom Instruction

Objectives
Describe correctly how to use a male condom

30 minutes Review the tools for trainers Steps for using Male Condoms. To conduct this activity you will need pieces of cardboard or large pieces of paper with one of the condom instructions on each piece. You will also need sample condoms, sample spermicide, and male penis model. You may wish to copy and distribute the handout How to Use Male Condoms from page 10-23. If participants will be teaching others about how to use condoms, review the Sample Checklist for Male Condom Instruction in tools for trainers.
Preparation
Directions
1. Invite 12 participants to volunteer for this activity. Give each participant a card with a description of one of the steps that should be followed in order to use condoms correctly. Ask the volunteers to form a line, putting the steps for correct condom use in the proper order. Once the line has been formed, ask another volunteer to read the steps, one by one. 2. Ask the rest of the participants whether the steps are in the correct order. If not, adjust the order until it is correct. 3. Then, read the steps again as another volunteer uses a penis model and a male condom to demonstrate the steps as they are being read. See the tools for trainers for the list of steps. 4. Discuss other issues that enhance correct condom use every time the couple has sex, including partner negotiation. Ask participants how they felt when arranging the steps of condom use and reading them out loud, to the class. Ask participants how they might help others (an intimate partner or client) feel more comfortable talking about and using condoms. 5. Discuss which steps can be performed by either partner and which steps should be performed by a man or woman. 6. Demonstrate how to provide condom instruction to a family planning client. (See the tools for trainers Sample Checklist for Male Condom Instruction.) If appropriate, distribute a copy of this tool for trainers to participants and ask them to review and practice the steps. At a later time ask participants to demonstrate how they would counsel a family planning
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client about condom use, using the checklist as a guide. At that time provide suggestions for improvement.
Wrap-up
When concluding this activity, address the following points.
There are many steps that must be followed in order to use a condom
correctly.
If condoms are used correctly every time the couple has sex, the
condom can both prevent pregnancy and protect against HIV/AIDS and other STIs.
Condoms can also be used with a spermicide (contraceptive cream,

jelly, foam or film). The spermicide helps kill sperm and germs. Condoms used together with spermicides can make the method even more effective in preventing pregnancy.
It takes more than just knowing about how to use condoms to always
use them correctly and consistently. Clients and community members need to pass through distinct stages of change before they can adopt new health behavior into their every day lives. Providers can help clients and community members move through these stages of change and build the skills they need to become successful condom users. (See chapter 11, Creating Change: Achieving Healthy Behaviors.)
Evaluation
Through observation of the activity trainers will assess whether participants can place the condom instructions in the correct order. For more advanced participants, trainers may also observe as they demonstrate how to educate family planning clients on condom use. This may be done during a role-play or real-life situation. The tool for trainers Checklist for Condom Instruction may be used as a guide to evaluate how well participants can demonstrate condom instruction.
Note to Trainers
The first part of this activity can be modified and used with different methods of family planning when describing the steps for how to use the method. If female condoms are available in your area, you may want to do an activity similar to this with the female condom. Use the Sample Checklist for Female Condom Instruction in the tools for trainers to write up the steps for female condom use. After experiencing this activity, participants may role-play how they might present condom information to clients and community members.
Source: Part of this activity adapted from Hunter-Geboy, 1992, p. 471
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Steps for Using Male Condoms
Tools for Trainers
The steps listed below may be cut out and pasted to separate pieces of cardboard or written on separate index cards.
Buy condoms at a store or get them somewhere Check the expiration date Have condoms with you when you go out Have an erection Remove the condom from the wrapper Roll the condom onto the penis, pinching the tip of the condom to squeeze the air out
Steps for Using Male Condoms, continued
Have intercourse Ejaculate Remove the condom from the penis Withdraw the penis, holding the condom on at the base of the penis Throw the condom away in the trash If having sex again, use a new condom
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Sample Checklist for Male Condom Instruction

Name of Educator: _________________________________ Date: _________________ Instruction:
Tools for Trainers
Rate the performance of each step observed using the following rating scale. 0 1 2 3 N/A Step omitted Step incorrectly performed Step correctly performed but not systematic Step correctly performed with confidence Step not observed Dates Observed
Steps in Using the Male Condom
1. Greets the client with respect 2. Briefly discusses the purpose of the visit 3. Asks about reproductive goals 4. Tells the health benefits of family planning 5. Determines what the client already knows about condoms 6. Appropriately addresses myths and misconceptions about condoms 7. Discusses ways to talk with a partner and negotiate condom use 8. Briefly explains
Condom is a thin, rubber sheath worn by men during sexual

intercourse. It protects a woman from pregnancy because it traps the semen inside, thus preventing the semen from entering the womans body. It has benefits (easy to use, cheap, easily available, protects the couple from HIV/AIDS and other STIs, and protects against cancer of cervix). It has limitations (requires correct use by male partner each time).
Checklist for Male Condom Instruction, continued Steps in Using the Male Condom Dates Observed
9. Shows condom and packet to the client 10. Gives basic instruction on condom use
A new condom should be used every time one has sex. If condoms are not used each time, the woman is at risk for
pregnancy and both the partners are at risk for HIV/AIDS and other STIs. Condom should be put on an erect penis before it comes near the vagina, anus or mouth.
11. Explains how to put on a condom (may demonstrate on a penis model)
Tear the packet from one side and take out the rolled condom,
taking care not to tear the condom. Hold the rolled rim of the condom on the outside, away from the body. Hold the tip of the condom between the fingers to expel air Roll condom down the penis. Do not use oil or Vaseline as a lubricant.
12. Explains how to take off a condom (may demonstrate on a penis model)
Withdraw the hard penis immediately after ejaculation to avoid

spilling semen into the vagina. Hold the rim of the condom while pulling the penis out.
13. Explains how to dispose of the condom
Tie a knot on the upper portion of condom. Bury condom.

OR Wrap it in a paper and throw it in a dustbin.
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Checklist for Male Condom Instruction, continued Steps in Using the Male Condom Dates Observed
14. Checks that the client understands how to use condoms by
Giving a condom to the client and asking the person to explain how
to use it Asking the client questions and restating correct information, if necessary Encouraging the client to ask any questions
15. Explains how to look after condoms before using them Keep in a cool, dark place. Keep away from direct sunlight or heat. Check the date of expiration on the packet. Take care when handling condoms: fingernails can tear them. Do not unroll condoms before using them. An unrolled condom may be weakened and is difficult to put on.
16. Provides condoms OR Sells as many condoms as the client wants 17. Asks the client about questions/concerns and responds appropriately 18. Shares plans for follow-up/re-supply visit with the client
Source: CEDPA 2001
Sample Checklist for Female Condom Instruction

Name of Educator: _________________________________ Instruction:
Tools for Trainers
Date: __________________
Rate the performance of each step observed using the following rating scale 0 1 2 3 N/A Step omitted Step incorrectly performed Step correctly performed but not systematic Step correctly performed with confidence Step not observed
Steps in Using the Female Condom
Dates Observed
1. Creates a comfortable and private environment 2. Greets the client with respect 3. Asks about the reason for the visit 4. Tells about the female condom
The female condom is a new, safe pre-lubricated (covered with oil)

contraceptive. (Let the client handle and feel it.) It is made of strong, soft polyethylene (rubber). When worn it lines (covers) the vagina (private part) gently. It is reliable, provides sensitivity for the couple, and is natural and enjoyable. It acts as a barrier against germs that cause STIs including HIV/AIDS. It prevents unintended pregnancy by preventing the male seed (sperm) from reaching the female egg (ovum). It has a double advantage in protecting a womans health by both preventing unintended pregnancy and protecting against STIs including HIV/AIDS.
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Checklist for Female Condom Instruction, continued Steps in Using the Female Condom Dates Observed
It has a flexible ring at each end (show the condom). The inner ring is used for insertion to help keep the condom in
place. The outer ring remains outside the vagina (female private part and can be seen) and covers the outside of her genitals. It is one size, which fits all. It can be inserted up to 8 hours before sex or just before sex. It should be used only once and then discarded. (Some programs suggest the female condom can be used up to five times, if properly cleaned and checked between each use. Review female reproductive system.
5. Demonstrates how to use the female condom
Wash your hands with soap. Check manufacture and expiration dates. Open the package carefully where an arrow points on the top right
N
N N N N N N
of the package. Dont remove the condom with long or rough nails. Find a comfortable position. (Standing with one foot on a chair or bed, sitting with knees apart, or lying down.) Rub the condom to spread the oil on it. For extra moisture and comfort use any water or oil based lubricant. For example dip several fingers into palm oil and apply. Squeeze the inner ring. Insert the condom into the vagina (private part) as far as it will go. (Use model or half-clenched first.) Push it up with a finger and ensure that it is not twisted. During sex guide the penis inside the condom with your hand. Hold the outer ring in place. You may hear noise during sex.
6. Shows how to remove the condom after sex
Squeeze and twist the outer ring and pull it out while still lying
down, to prevent spilling of semen (sperm). Tie it. Wrap the used condom and throw it into dustbin or pit latrine.
Checklist for Female Condom Instruction, continued Steps in Using the Female Condom Dates Observed
7. Encourages the client to visit again after having used the female condom 8. At a follow-up meeting with the client
Greets the client. Finds out about the persons health. Asks about any problems encountered. Counsels again if necessary. Reviews the steps for using the female condom. Counsels about changing the dual protection methods (protection against both unintended pregnancy and STIs/HIV/AIDS) if necessary.
Source: CEDPA, 2002
10-75
Resources
Reference List
Arvalo M., Jennings, V., & Sinai, I. (2002). Efficacy of a new method of family planning: the Standard Days Method. Contraception 65, 333-338. Cachan, J.& Lundgren, R, (2002). Standard days method of family planning: Reference guide for counseling clients. Washington DC: Institute for Reproductive Health, Georgetown University. Centre for Development and Population Activities (CEDPA). (2002). Sample checklist for female condom instructions. Washington, DC: Author. Centre for Development and Population Activities (CEDPA). (2001). Sample checklist for male condom instructions. Washington, DC: Author. Family Health International. (2002). Choices must be informed, voluntary. Network, 1 2. Retrieved May 5, 2002, from http://www.fhi.org./en/fp/fppubs/network/v21-2/nt2123.html Female Health Company. (n.d.) Female condom insertion diagrams. Retrieved May 1, 2002, from http://www.femalehealth.com/insertiondiagrams.html Institute for Reproductive Health, Georgetown University. (2002). CycleBeads: Instructions for use [Educational material]. Washington, DC: Author. Institute for Reproductive Health, Georgetown University. (2002). Standard Days Method: A modern, effective method of family planning. Retrieved July 24, 2002, from http://www.irh.org/ru-sdm-modern.htm Institute for Reproductive Health, Georgetown University. (1993). Glossary of natural family planning (rev. ed.). Washington, DC: Author. Jennings, V., Lamprecht, V., & Kowal, D. (1998). Fertility awareness methods. In Hatcher, R., Trussell, J., Stewart, F., Cates, W., Stewart, G., Guest, F., et al. (1998). Contraceptive technology (17th Rev. ed.). New York: Ardent Media. Hatcher, R., Trussell, J., Stewart, F., Cates, W., Stewart, G., Guest, F., et al. (1998). Contraceptive technology (17th rev. ed.). New York: Ardent Media. Hatcher, R., Trussell, J., Blackburn, R., & Geller, J. (1997). The essentials of contraceptive technology: A handbook for clinical staff, Baltimore: Population Information Program, Johns Hopkins School of Public Health. Hunter-Geboy, C. (1992). Life planning: A youth development program. Washington, DC: Advocates for Youth.
Murphy, E., Rudy, S., Steele, C., & Kelbourne-Brook, M. (1999). Improving interactions with clients: A key to high-quality services [electronic version]. Outlook 17, (2):1-8. Retrieved October 22, 2001, from http://www.path.org/outlook/html/17_2.htm#articleimproving Speiler, J. (2000). Dual protection definition. Retrieved October 21, 2002, from Dr. Jim Sheltons Pearls Web site: http://www.jhuccp.org/pearls/ Wilcox, A., Weinberg, C., & Baird, D. (1998). Post-ovulatory aging of the human oocyte and embryo failure. Human Reproduction, 13(2), 394-397.
Other Resources
Aumack Yee, K. (2002). Standard days method of family planning: A training for service providers. Washington, DC: Institute for Reproductive Health, Georgetown University. Aumack Yee, K., & Mann, S. (1996). Family planning fundamentals: Self-study manual, Los Angeles: California Family Health Council. Billings, E., & Billings, J. (1997). Teaching the Billings ovulation method: Variations of the cycle and reproductive health. Part 1 and Part 2, Melbourne, Australia: Ovulation Method Research and Reference Centre of Australia. Binzen, S. (2000). Pocket guide to managing contraceptive supplies. Atlanta: Center for Disease Control and Prevention. Gardner, R., Blackburn, R.D., & Upadhyay, U.D. (1999, April) Closing the condom gap. Population Reports, Series H, No. 9. Baltimore: Johns Hopkins University School of Public Health, Population Information Program. Hatcher, R., Rinehart, W., Blackburn, R., Geller, J. & Sheldon, J. (2002). The essentials of contraceptive technology: A handbook for clinical staff, Baltimore: Population Information Program, Johns Hopkins School of Public Health. Kass-Annese, B., Aumack, K., & Goodman, L. (1990). Guide for natural family planning trainers, Los Angeles: Los Angeles Regional Family Planning Council. Kass-Annese, B., & Danzer, H. (1992). The Fertility awareness handbook, Alameda, CA: Hunter House. Kols, A.J., & Sherman, J.E. (1998, November). Family planning programs: Improving quality, Population Reports, Series J, No. 47. Baltimore: Johns Hopkins University School of Public Health, Population Information Program. Rinehart, W., Rudy, S. and Brennan, M. (1998). GATHER guide to counseling. Population Reports, Series J, no. 48. Baltimore: Johns Hopkins University School of Public Health, Population Information Program.
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Sullivan, R. (1998). Clinical training skills for reproductive health professionals (2nd ed.), Baltimore: JHPIEGO. Upadhyay, U.D. (2001). Informed choice in family planning: Helping people decide. Population Reports, Series J, No. 50. Baltimore: Johns Hopkins University Bloomberg School of Public Health, Population Information Program. Vargas, L., & Bustillos de Nez, G. (1984). Tcnicas participativas para la educacin popular [Participatory techniques for community-based education]. San Jose, Costa Rica: Centro de estudios y Publicaciones, ALFORJA. Velasquez Guerra, R. (1993). Capacitando sin letras [Training without written words]. Guatemala, C.A.: Asociacin Pro-Bienestar De La Familia De Guatemala.
MAIN OFFICE 1400 16th Street, NW, Suite 100 Washington, DC 20036, USA Tel: 202-667-1142 Fax: 202-332-4496 E-mail: cmail@cedpa.org EGYPT 53 Manial St., Suite 500 Manial El Rodah Cairo 11451, Egypt Tel: 2-02-365-4567 or 2-02-531-8149/8150 Fax: 2-02-365-4568 E-mail: cedpa@intouch.com GHANA P.O. Box CT 4977 Cantonments Accra, Ghana Tel: 233-21-234-175 Fax: 233-21-251-063 E-mail: cedpaghana@cedpa.org.gh GUATEMALA 2a Avenida 9-42 #4, Zona 9 Guatemala City 01009 Guatemala Tel: 502-360-7252 or 502-334-6047 Fax: 502-331-3482 E-mail: cedpa@terra.com.gt INDIA 50-M Shantipath Gate No.3, Niti Marg Chanakyapuri, New Delhi, India 110021 Tel: 91-11-26886172 Fax: 91-11-26885850 E-mail: marta@vsnl.com MALI BP 1524 Rue 939 Quizambougou, Zone Industrielle Bamako Mali Tel: 223-21-5429 Fax: 223-21-0246 E-mail: cedpa@cedpamali.org denotes countries with ENABLE projects
NEPAL Gairidhara G.P.O. 8975, EPC 5316 Kathmandu, Nepal Tel: 977-1-427-739 or 977-1-417-071 Fax: 977-1-421-696 E-mail: cedpa@wlink.com.np NIGERIA 18A &B Temple Road Off Kingsway Road Ikoyi, Lagos, Nigeria Tel: 234-1-260-0020 Fax: 234-1-260-0022 E-mail: cedpa_nigeria@usips.org RUSSIA The Latin American Institute of the Russian Academy of Sciences 21/16. Bolshaya Ordinka St. Moscow, Russia Tel: 7-095-951-0087 Fax: 7-095-951-1059 E-mail: policy@online.ru SENEGAL BP 259 Dakar Libert 1917 Sicap Libert 3 Dakar, Senegal Tel: 221-864-3705 Fax: 221-824-2071 E-mail: enablesenegal@sentoo.sn SOUTH AFRICA Kutlwanong Democracy Centre 357 Visagie Street 0002 P.O. Box 11624, The Tramshed Pretoria 0126, South Africa Tel: 27-0-12-320-2067 Fax: 27-0-12-320-5943 E-mail: info@cedpa.org.za
Headquartered in Washington, DC, CEDPA is an international nonprofit organization that seeks to empower women at all levels of society to be full partners in development. Founded in 1975, CEDPA supports programs and training in leadership, capacity building, advocacy, governance and civil society, youth participation and reproductive health. The Enabling Change for Women's Reproductive Health (ENABLE) project works to strengthen women's capabilities for informed and autonomous decision making to prevent unintended pregnancy and improve reproductive health. Initiated in 1998, ENABLE seeks to increase the capacity of non-governmental organization (NGO) networks to expand reproductive health services and to promote a supportive environment for women's decision making.
ENABLE is funded by the Office of Population and Reproductive Health, Bureau for Global Health, U.S. Agency for International Development, under the terms of Cooperative Agreement No. HRN-A-00-98-00009-00.
www.cedpa.org
ISBN 0-9742200-5-1

RH Awareness 10

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enable

Chapter 10 Family Planning and the RHA Approach

Close supportive relationships are the key to a healthy life.

Table of Contents Chapter 10

Family Planning and the RHA Approach

Family Planning and the RHA Approach

Key Questions How do gender issues affect unintended

Which methods of family planning provide dual

How do these methods affect a persons

When using a method of family planning, what

ntroducing Chapter Ten

Family Planning and the RHA Approach

Benefits of Family Planning

Reproductive Health Awareness

Integrating the RHA Approach

Family Planning and the RHA Approach

artum cy Post-p nan reg re fe P l Ca Sa a at en r P

Body Awareness and Self-Care

e e Exercis otenc Imp e Male us pa no y M e rtilit fe In

g rin ito on on M nizati h t u m w rty ro Im G Pube

TIs I/S RT S /AID HIV

Do women, men, and adolescents know

Reproductive Health Awareness

Do clients develop self-observation and self-referral skills necessary for effective

Are couples welcome? Are there relevant services for men?

Does a sexually active adolescent actually consider herself or himself to be sexually

Are providers trained to offer practical help with sexuality issues?

The Family Planning Client

10-10 Reproductive Health Awareness

Basic Family Planning Information and the RHA Approach

10-12 Reproductive Health Awareness

Family Planning and the RHA Approach

Family Planning and the RHA Approach

By the end of this session, participants will be able to

10-14 Reproductive Health Awareness

Sample Lesson Plan

Family Planning and the RHA Approach

10-16 Reproductive Health Awareness

Family Planning Methods

Informed Consent Mechanism of Action Noncontraceptive Benefits

10-18 Reproductive Health Awareness

Family Planning and the RHA Approach

Activities and Handouts for the Lesson Plan

Family Planning and the RHA Approach

ctivity Dual Protection and Sexual Expression

List ways to improve couple communication about dual protection

10-20 Reproductive Health Awareness

Family Planning and the RHA Approach

Close the activity with points like the following.

Our overall reproductive health benefits in very important ways when

The correct and consistent use of male or female condoms is a practice

An individual may experience a variety of personal and cultural

10-22 Reproductive Health Awareness

How to Use Male Condoms

Give Specific Instructions

Taking off a Condom

Disposing of a Used Condom

Source: Adapted from Hatcher, et al., 1997, pp. 11-9 to 11-10.

Family Planning and the RHA Approach

How to Use Female Condoms

2. How to Hold the Sheath

3. How to Insert the Condom

4. Make Sure Placement Is Correct