Addressing Other SDM Service Delivery Issues
In addition to the programmatic elements that have proved
critical to successful SDM introduction, there are additional issues
to be considered including:
1) the critical role of men in using the SDM and how men have
been successfully integrated into programs; and
2) the importance of addressing medical barriers imposed by providers
and provider biases about a fertility awareness-based method,
3) the feasibility of making SDM available through social marketing
Men in SDM Use
Programs have identified creative strategies to involve men
in the use of the SDM. Although initially providers often
are skeptical about the abilit of men to use a natural method,
experience with the SDM demonstrates that men are supportive
of the method. Men often welcome the opportunity to become
involved in family planning and participate in using the method.
Several pilot projects have been designed specifically to
integrate men. Their experience suggests that it is possible
to reach men if programs identify an appropriate approach
and if they are flexible and innovative. Research also suggests
that acceptance and correct use of the SDM are better when
men are involved.
At the same time, reaching men can be challenging. For
example, in community settings, they often are not at home when
a promoter would normally visit the woman. Men often don’t
feel comfortable going to a clinic, and clinic hours may not be
compatible with their schedules. In addition, some providers may
view men as obstacles to—rather than participants in—change.
Some opportunities to involve men in SDM services are:
- Inviting women to bring their partners
- Giving women take-home materials to
share with their partners
- Relying on male workers to talk with
- Providing information in community
settings where men will have access to the it
Other SDM Service Delivery Issues
How women and men
learn about the SDM
Many women learn about the SDM from health providers when
they seek advice on birth spacing. They have confidence in
the advice that providers offer because they feel it comes
from trusted sources. In
Rwanda, male partners learned about the SDM at community
meetings and from the radio. Initially, most men were resistant
to information about the method that their wives provided
and only became receptive to using the SDM after meeting with
a provider. In Rwanda, it was easier for men who learned about
the SDM to convince their wives to use it, than for women
to convince their husbands. In Benin, men came to the clinic
to learn about the SDM so they could inform their wives about
it and encourage them to use it.
One way of involving men in the use of SDM, is to engage them
in promoting the method. In
El Salvador, male extensionists of a community water management
project included information about family planning and the
SDM in talks they conducted at meetings of the community water
board and other community events. Men comprised most of their
audience. In India,
CARE used male volunteers to conduct group meetings for men,
while women participated in community meetings led by a woman.
When husbands participated in these meetings, they tended
to be more informed and interested in the method than men
who learned about the SDM from their wives or other village
Addressing Biases Toward the SDM
One of the strengths of the SDM is that it can be offered by all
types of service providers, including physicians, nurses, counselors,
social workers, community promoters, and volunteers. Most providers,
program managers and policy makers are receptive to the SDM after
learning about its solid scientific underpinnings, the rigorous
testing of the method and program experiences in offering the SDM
Despite the overall positive reaction toward the SDM, some providers
will have initial doubts about the method as reflected in Table
3. which summarizes common myths and misperceptions related to the
SDM. One strategy for addressing these biases is to ensure that
providers have access to the scientific data from research studies
that has been conducted on the SDM. This information should be shared
with healthcare personnel at all levels, including medical directors,
clinic directors, and providers, and included in training sessions,
conferences, and meetings.
Table 3. Common Myths and Misperceptions
Related to the SDM
Most women do not know the length
of their cycle, so they won’t be able to use the SDM.
Studies have found that a simple
series of screening questions can help determine whether
a woman’s cycles are usually between 26-32 days.
Do your periods usually
come about when you expect them?
When did your last period
When do you think your next
period will start?
If the woman knows the first day of her last menstrual
bleeding and the day she next expects her period, the expected
length of her cycle can be calculated. Even if she does
not know the exact day her last period started, the answers
to these questions are sufficient to determine whether her
cycles are with the 26 to 32 day range.
If a woman cannot answer these questions, she is encouraged
to keep track of her cycles using the beads or a calendar.
But she should not rely on the SDM to prevent pregnancy
until she is sure her cycles are usually between 26 and
32 days long.
The method has been shown to be equally
effective for highly educated women and women with no formal
education, who may not be literate.
There is no need for women to be able to read in order
to use the SDM. CycleBeads are helpful because they provide
a visual aid for women, regardless of their educational
Using a natural method harms the
couples’ sexual relationship.
Study results show that couples who use
the SDM have sex about the same number of times a month
as other couples - they just have sex on the days outside
the fertile window.
Most couples who use the SDM find acceptable strategies
to manage the fertile days. In India, for example, many
couples use condoms during the fertile days. Some couples
report that increased couple communication and changes in
the timing of intercourse actually enhance sexual pleasure.
The SDM is just another name for
the rhythm method.
Actually, the SDM is very different from
rhythm. The rhythm method involves having exact information
about the last 6 menstrual cycles and making calculations
– adding and subtracting – each month to figure
out which days in the current cycle a woman is likely to
get pregnant. Also, the rhythm method has never been tested
in a well-designed efficacy study.
On the other hand, the SDM is simple, doesn’t involve
any calculations, works the same way every cycle, and has
been tested in a well-designed efficacy study, with excellent
Women will forget to move the band
on the CycleBeads and lose count of the days.
SDM users are encouraged to mark the first
day of their period on a calendar. That way, if a woman
is not sure whether or not she has moved the ring that day,
or whether it may have been moved accidentally, she can
check her calendar. She counts the days from the day she
started her period to today, and then she counts the same
number of beads. The ring should be on the corresponding
Men will not be able to use this
In the clinical trial of the SDM, only about
2% of women dropped out of the study because their partners
did not want to use the method. The results of introduction
studies of the SDM show that most men help their partners
use the method and are very satisfied with it. CycleBeads
are an excellent tool to help women and men talk about avoiding
unprotected sex during the fertile days. And even if they
don’t talk about it, CycleBeads are very visual –
the man can see when the woman is on a fertile day, and
he understands what they need to do to avoid pregnancy.
Offering SDM through social marketing outlets
Integrating the SDM into social marketing programs can help increase
access by making the method available in non-clinical settings such
as pharmacies. For this reason, the feasibility of adding SDM to
social marketing programs should be explored. The successful marketing
of SDM requires that it be accompanied by communication efforts
to make people aware of the method and where it can be obtained,
and to help them use the method correctly. A price for CycleBeads
would also need to be set so that it is attractive to users and
provides sufficient incentives to providers.
CycleBeads as a Fertility Awareness Tool
addition to being used as a method to prevent or plan pregnancy,
the SDM has proven to be useful in teaching fertility
awareness to adolescents. Many programs include community
health education and outreach in public schools, after-school programs,
community agencies, and other sites. CycleBeads, for example, is
also a good educational tool for teaching girls about their menstrual
cycles—an activity that could easily be introduced into school-based
programs. The curriculum, My Changing Body, Fertility Awareness
for Young People, was field tested in Jamaica, India, and
the US. This manual includes an activity that utilizes CycleBeads
to help girls understand their menstrual cycle. (Available in English,