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, and

3) the feasibility of making SDM available through social marketing outlets.

Involving 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.

Testimonials

“With this method, we are both responsible. I didn’t feel comfortable with condoms because it was only his responsibility.” El Salvador.
“He likes this method. He doesn’t agree with other things to plan and he likes sex better “natural” on the days we can.”
“My husband says that CycleBeads and the rubber ring are our treasure.” Honduras.
“I feel good that my husband now understands how my body works. He pays attention to my suggestions and respects my wishes. For the first time he asks me if we can have intercourse. I am happy that he cares about me.” India.

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 partners
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.

Involving Men
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 people.

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 worldwide.

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

Myth	Fact
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 start? 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.
This method is for very educated people.	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 level.
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 results.
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 bead.
Men will not be able to use this method.	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

In 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, Spanish and French)

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