Health provider vol 4 no1

The

Health Provider A PUBLICATION OF THE NATIONAL FAMILY PLANNING BOARD

VOLUME 4 NUMBER 1

Fertility aWareness Based Methods

WithdraWal lactational amenorrhoea Method

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ertility awareness –based methods have been used for centuries and are still a part of the contraceptive method mix within the class of non-contraceptive methods.

This edition of the Health Provider Newsletter seeks to bring to the fore the importance of consistent and correct use to enhance the effectiveness of these methods while continuing to widen the options of contraceptive methods available to individuals within the reproductive age groups. This underlies the fact that the use of some form of contraceptive method is better than non use, especially when it relates to pregnancy prevention. It is indeed cheaper to use a contraceptive method than allowing circumstances of religion or partner preference; location and availability of one of the traditional contraceptive methods to deter the individual from practicing safe sex.

Credits newsletter co-ordinator Harriett M. Clarke- Communications Officer (Writer) CONSULTING EDITORS Dr. Olivia McDonald Executive Director Dianne Thomas Director Outreach Programmes Kevin Bell Director Policy Formulation, Monitoring & Evaluation

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Therefore, information on fertility awareness – based methods is a part of the ongoing objective of this newsletter to update and inform our health providers of all the available contraceptive options.

The RHS 2008 indicates that Jamaican women are very aware of the contraceptive methods available to them, however, most women of reproductive age (88.9%) were aware of the Withdrawal Method while fewer (60.6%) were aware of periodic abstinence or other “safe-period” methods such as the Calendar, Rhythm, and Billings methods.”

The article on “Fertility awareness – based methods” addresses some of these concerns as it relates to Standard days method, detection of cervical mucus and symptothermal method. It highlights the degree of effectiveness, the popularity of the method among persons of reproductive age and how to use the method effectively and successfully.

The article on Withdrawal looks at what this method involves, the degree of effectiveness, and the popularity of the method among persons of reproductive age. And lastly, the article “How to use Lactational Amenorrhoea method (L A M ) , d i s c u s s e s t h e l e n g t h o f protection from pregnancy offered to the mother and the popu lar ity of the me t h o d among persons of reproductive age.

Fertility awareness Based Methods

Written by Communication Officer (Writer) Harriett M. Clarke Introduction

popular method of contraception and for the purpose of this article will be viewed from the perspective of the findings in the 2008 Reproductive Health Survey (RHS) which indicates the prevalence rate for the Calendar, Rhythm and Billings methods as totalling 0.3 % for women currently in a union aged 15-49 years.

Effectiveness is an important and common concern when choosing a family planning method.

Like all family planning methods, fertility awareness-based methods are more effective when you use them correctly. How well fertility awareness-based methods work depends on both partners. That is why it is important for This article will focus on three effective methboth partners to be instructed on how to use the ods; Standard Days, Cervical Mucus (Billings) method consistently and correctly. and the Symptothermal. Less effective methods such as the calendar or rhythm method are no Fertility Awareness Defined: longer taught by natural family planning trainers.

Fertility Awareness based methods serve a dual purpose. The practices can be used to avoid or The Standard Days Method (SDM) to achieve a pregnancy. This is done by monitoring and observing the female reproductive SDM helps couples to recognise when they are system to determine the fertile and infertile most fertile. This helps them to avoid having unphases of a woman's menstrual cycle. Natural protected sex during the fertile periods of the Family Planning is based on full awareness of woman’s menstrual cycle if they wish to avoid the woman’s reproductive cycle. If a couple a pregnancy. wishes to avoid a pregnancy they will initiate sexual abstinence during the The Standard Days Method was developed using an fertile phase of the woman’s analysis of thousands of cycle (time when the woman menstrual cycles of different can become pregnant) or women lasting between 26 they will initiate sexual interand 32 days. Days 8 to 19 course specifically during were recognised as the most the fertile phase to achieve fertile days of a woman's pregnancy. cycle.

The practice is not a very 2

Fertility awareness Based Methods

Client Instructions

Bead necklace. This red bead stands for the first day in their menstrual cycle; the day that their period begins.

If the Standard Days Method is the method of choice, the client should monitor the length of her menstrual cycle to identify Days 8 through • Brown: The brown beads signify the days 19. during their cycle when it is highly unlikely that they will get pregnant.

• The first day that her period arrives, is Day • White: The white, glow-in-the-dark beads 1 of her cycle. This is to be marked on her represent the fertile days of their menstrual calendar. cycle (Days 8 to 19).

• Between Day 1 and Day 7, it is highly unlikely that she can become pregnant, so it As each day of the client’s menstrual cycle is would be safe to have sex at this time with- realised she is to slip the rubber ring on a out having to worry about using a family different bead. When the rubber ring is moved planning method. onto the white beads, this is an indication to her • Between Day 8 and Day 19, she would be at to abstain from sex or to use some form of her most fertile. She and her partner should contraception. abstain from sex or use an alternate type of family planning method, such as a condom. The Effectiveness of the Method • Between Days 20 and 32 it is most unlikely to get pregnant, so resuming sex is safe at When used regularly and consistently, SDM has this time. been shown to be a highly effective family planning method. When used perfectly, only five out Cycle Beads and the Standard Days Method of every 100 women will get pregnant. This means that the method is 95% effective against Women who intend to practise SDM may use pregnancy.

CycleBeads to help them keep track of the days in their menstrual cycle. CycleBeads are a string If she does not follow the method consistently, of 32 colour-coded beads, shaped into a neck- or if her cycle falls outside of the 26 to 32 day lace. There is a rubber ring that can be placed range, SDM will be less effective. With normal around individual beads on the necklace to help use, the Standard Days Method is approximately identify what day the client is at in their cycle. 88% effective in preventing pregnancy.

There are three colours of beads on the CycleCervical Mucus Bead necklace: • Red: There is one red bead on the Cycle- By observing her cervical mucus, and paying 3

Fertility awareness Based Methods

attention to the sensation as it passes the vulva, a woman can detect when her body is gearing up for ovulation, and also when ovulation has passed. When ovulation occurs, oestrogen production drops slightly and progesterone starts to rise. The rise in progesterone causes a distinct change in the quantity and quality of mucus observed at the vulva.

The first year probability of pregnancy is about 3% among perfect users and 22% among all users in clinical trials.

Symptothermal Method

needs to look at her pattern of previous cycles.

Her last "safe" day is one (1) week before the earliest recorded day of temperature rise, or five (5) days after the first day of her period.

Intercourse during the time before ovulation is less safe than the time after ovulation, because sperm have been known to live up to six (6) days. For this reason, couples should choose to have sex only after the fertile period. This practice, known as the post-ovulatory temperature method, is the most effective of all natural methods, with a failure rate of only 1% among perfect users. However, it is only recommended if the couple is able to abstain for the duration required for the method to work. This is why it is important to use as many body signs as possible to predict ovulation for maximum efficacy.

This method involves determining a woman’s fertile phase in two ways: her basal body temperature which rises after ovulation and by noting other symptoms that indicate fertility (such Benefits as a moody disposition, which may include irritability and anxiety; and cervical secretions).

• Can be used to avoid or achieve pregnancy.

• No contraceptive method-related health risks.

This method requires the woman taking her temperature each and every morning while in • No systemic side effects. bed and recording the reading. Her temperature • Inexpensive. should vary depending on where she is in her Non-contraceptive menstrual cycle. These measurements of her temperature are usually done with a special thermometer that has a range of only a few degrees • Promotes male involvement in family planning. known as a basal thermometer.

• Improves knowledge of reproductive system by both men and women.

When the temperature stays high for at least three (3) days, a woman may assume she has al- • Possible closer relationship for couple through improved communication. ready ovulated. Intercourse for the rest of the cycle will not result in pregnancy. To determine • Moderately effective as a contraceptive (9-20 pregnancies per 100 women during the the infertile phase before ovulation, a woman first year of use).

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Fertility awareness Based Methods

• Effectiveness depends on willingness to follow instructions.

• Considerable training required to use the most effective types of NFP correctly.

• Requires trained provider (nonmedical).

• Requires abstinence during fertile phase to avoid conception.

• Requires daily record keeping.

• Vaginal infections make cervical mucus difficult to interpret.

• Basal thermometer needed for some methods.

• Does not protect against STIs including HBV and HIV/AIDS. Conclusion Fertility awareness based methods are another alternative to contraception, widening family planning options to include natural family planning methods which do not affect the physiology of the female to include such symptoms like nausea, missed periods or heavy periods and weight gain usually associated with the taking of regular contraceptives such as the pill, injection and the IUD. These can be practiced even by persons whose religious persuasion is against these conventional types of contraceptive methods. However, it is to be noted that for these methods to work effectively or as efficiently as the conventional contraceptives, the couple has to become aware of their own bodies and knowledgeable about these methods, following instructions and requirements of each of these methods very strictly.

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References • Reproductive Health Survey-Final Report, National Family Planning Board,2008 • Contraceptive Technology 19th Revised Edition, Robert Hatcher et al,2007 • Jamaica Family Planning Service Delivery Guidelines, National Family Planning Board,2007

lactational amenorrhoea Method Written by Communication Officer (Writer) Harriett M. Clarke

The Lactational Amenorrhoea Method (LAM) is a highly effective yet temporary method of contraception for women who have just given birth and who decide to breastfeed their newborn exclusively for a period of more than three (3) months.

child reaches six (6) months old should another method of contraception be introduced.

The breastfeeding practices that contribute significantly to postponing the return of ovulation include a high frequency of breastfeeds, and the presence of night feeds.

Lactational Amenorrhoea-(LAM) is based on Milk production appeared to be reduced far the physiologic effect of suckling to suppress more by supplementary feeds than by suppleovulation. This method can only work effec- mentary cup and spoon feeds. tively if the woman follows strictly, certain steps such as breastfeeding the infant frequently. Ensuring the Contraception Effect of Based on the fact that a woman may have a Breastfeeding short interval of infertility during the postpartum period after childbirth, a woman who breast- • The infant must breastfeed at least every four (4) hours during the day and at least every feeds is likely to have this period of infertility six (6) hours at night. extended than the woman who is not breastfeeding.

• The infant must be less than six (6) months old.

Non-lactating mothers usually may resume their menses within 4 to 6 weeks of delivery while • The mother must not have had a period after 56 days post-partum (when determining the period of postpartum fertility can be fertility, bleeding prior to 56 days extended effectively to six months for lactating post-partum can be ignored). females.

To be used effectively as a contraceptive The probability that ovulation will precede the method, the female has to ensure that she first menses increases over time: intends to feed her newborn nothing but breast • 33% to 45% during the first 3 months milk for at least the next six (6) months. It postpartum nutrition. of source should be the infant’s only • 64% to 71% during months 4 through 12 Feeding formulas, expressing instead of directly • 87% to 100% after 12 months nursing the child or feeding it solids, will reduce the effectiveness of this method. She should be made aware that once her menses have resumed or she is breastfeeding less frequently or her baby has begun to have foods or breastfeeding is supplemented by bottle feed and/or when the 6

lactational amenorrhoea Method Ask the mother, or advise her to ask herself these 3 questions.

Source: Labbok M.K Cooney and S Coly, 1994 Guidelines for Breastfeeding and the Lactational Amenorrhoea Method, Institute for Reproductive Health.

Conclusion to return to a contraceptive method after the six The Lactational Amenorrhoea Method (LAM) (6) months especially as the child begins to have compares favourably with other contraceptive solids incorporated into his diet. methods when breastfeeding is adhered to strictly. At least 98% effective once the baby is under six months, the mother is still amenorReference rheic and she practices exclusive breastfeeding on demand, day and night. • Jamaica Family Planning Service Delivery Guidelines, National Family The LAM is a way both to space births and to Planning Board, 2007. support breastfeeding but it is usually advisable 7

WithdraWal Written by Communication Officer (Writer) Harriett M. Clarke Contraceptive Technology (Nineteenth edition) defines the withdrawal method or Coitus Interruptus as “the practice of withdrawing the penis from the vagina and away from the external genital organs of the woman before ejaculation with the intention of avoiding pregnancy.�

from 9.7% during the first year, 17.4 % after 2 years and 24.7% after 3 years; reports indicated that with the withdrawal method, when used, reports indicated high failure rates at 12, 24, and 36 months of use. One-in-four women reported becoming pregnant after one year of their partners practicing the withdrawal method.

Therefore, Coitus Interruptus involves the man Despite the inefficiency of the method it is still having to rely on his own sensations to know a very widely used method of contraception to the right time to pull out of the female’s vagina. date.

Consequently, this method is criticised by health professionals as being highly ineffective, espe- Degree of Effectiveness cially if the male is inexperienced using the method and or he is unable to predict when he Effectiveness is usually dependent on the is about to ejaculate. Although cost effective in willingness of the couple to use the withdrawal the short term, because a cost is not associated method with every act of intercourse, and even with the method unlike other contraceptive then there is the likelihood of approximately methods which requires them being purchased; 4-18 pregnancies occurring per 100 women who it may prove quite costly in the long run based use this method consistently during the first year on the increased risk of pregnancy, the con- of practicing it. Lack of self control is usually traction of a sexually transmitted infection and cited as the primary cause of failure for those quite possibly the cost of aborting the foetus if using the method, as well as poor timing of the the pregnancy is unwanted. withdrawal, resulting in semen being deposited accidentally and or unknowingly on to the Failure Rate of the Withdrawal Method vulva. Consequently, among the average user, 27% may experience a pregnancy during the Widely used throughout history and defined as first year of practicing coitus interruptus or a natural response to the discovery that ejacula- withdrawal as a method of contraception. tion into the vagina caused pregnancy; coitus interruptus is still deemed a very ineffective The withdraw method is even less effective method even when practiced consistently and because like all other methods including the Pill, the Intrauterine Device (IUD), the Injection or correctly.

Tubal Ligation, except for the condom, it does Failure rates vary considerably by the type of not protect against sexually transmitted infeccontraceptive method used. Compared to con- tions (STIs) including Human Papilloma Virus dom users who reported failure rates ranging and HIV/AIDS. The pre-ejaculation fluid 8

WithdraWal to use.

This method will not affect breastfeeding and promotes male involvement in family planning. It possibly enhances a closer relationship for the couple and is considered to be a better form of contraception than doing nothing to prevent pregnancy.

A limitation or the disadvantage to using the withdrawal method is that it may diminish sexual pleasure because of the need to pull out before the male ejaculates. The effectiveness of the method may be further decreased by sperm from a recent (less than 24 hours) ejaculation remaining in the penis (urethra).

released prior to the actual ejaculation may carry viral particles or bacteria which may infect the partner once it comes in contact with mucous membranes. However, a reduction in the volume of body fluids exchanged during intercourse may reduce the likelihood of disease transmis- Who Can Use Withdrawal sion, compared to using no method, due to the • Men who wish to participate actively in smaller number of pathogens present. family planning.

The attraction to the method for couples is that • Couples with religious or philosophical reasons for not using other methods. the method is free and readily available without having to affect the spontaneity and pleasure of • Couples who need contraception immediately. the sex act. However, the method is not recommended for adolescents, especially by medical • Couples needing a temporary method while awaiting another method. professions who already view the method as highly risky. The method can be used as a back • Couples needing a backup method. up to other methods especially the pill, the IUD • Couples who have intercourse infrequently. and fertility awareness methods.

Who Should Not Use Withdrawal

Couples of certain religious persuasions or those who do not want to have to deal with the com- • Men who experience premature ejaculation. mon side effects that the other methods such as • Men who have difficulty withdrawing the penis from the vagina prior to ejaculation. the pill or the injection are noted for; side effects such as headaches, weight gain, nausea, will see • Men who have other physical or psychological conditions that may affect timely the withdrawal method as an attractive method 9

WithdraWal • • • • •

withdrawal.

Couples in which pregnancy would pose a serious health risk to the woman.

Couples who need a highly effective method of contraception.

Couples who want a long-term contraceptive method.

Couples who want a method not related to intercourse.

Couples not willing to use withdrawal with every act of intercourse.

Client instructions • To enhance co-operation and avoid misunderstanding, before intercourse the couple should discuss their intention to use withdrawal (Coitus Interruptus).

• Before intercourse, the man should urinate and wipe off the tip of his penis to remove any remaining sperm from a prior ejaculation.

• When he feels he is about to ejaculate, the man should withdraw his penis from his partner’s vagina, making sure the ejaculation occurs away from his partner’s genitalia. (The woman can help by moving away at this time).

always wise to inform clients that this method should not be used as a long term contraceptive method, but that couples should explore and invest in other methods which are more effective and less risky than the withdrawal method.

References • Contraceptive Technology 19th Revised Edition, Robert Hatcher et al,2007 • Jamaica Family Planning Service Delivery Guidelines, National Family Planning Board,2007

Conclusion The Withdrawal or Coitus Interruptus method is considered by the health professionals as being a very ineffective form of contraception. However, with more information being disseminated about the method, it can prove effective enough to prevent a pregnancy in the short term and is much better to practice than to use no form of contraception at all. With this in mind it is 10