Highlights of the American College of Nurse Midwives 49th Annual Meeting

Barbara Hughes, CNM, MS, MBA, FACNM


July 08, 2004

In This Article

New Approaches to Family Planning

A session on fertility awareness-based methods of family planning was presented by Elaine Germano, CNM, DrPH, Nurse-Midwifery Program, Georgetown University Medical Center; Victoria Jennings, PhD, Institute for Reproductive Health, Georgetown University Medical Center; and Marcos Arevalo, MD, MPH, Institute for Reproductive Health, Georgetown University Medical Center, Washington, DC.[8] They provided an overview of 2 new fertility awareness-based methods of family planning: the Standard Days Method (SDM) and the TwoDay Method. Both methods are effective, simple, and acceptable to clients; feasible for providers; and meet unmet need, as evidenced by the number of women who, for personal or religious reasons, prefer a nonhormonal or nonmechanical method of contraception.

The SDM does not rely on a woman's symptoms. Instead, it uses the probability of pregnancy from intercourse on days relative to ovulation. The highest probability of pregnancy is between 5 days before ovulation and 1 day after ovulation. The key to the success of the SDM is the ability to identify the peak day for ovulation. The following information was highlighted regarding the probability of ovulation during different times in a woman's cycle:

  • 30% of ovulations occur at the midpoint of the cycle;

  • 60% of ovulations occur within 1 day before or after midpoint;

  • 78% of ovulations occur 2 days before or after midpoint; and

  • 95% of ovulations occur during an 8-day window, 4 days before or after the midpoint.

Using these probabilities, it is possible to identify when pregnancy is very likely or unlikely to occur. In general, if a woman's menstrual cycle is between 26 and 32 days, the days pregnancy is likely to occur are day 8 to day 19 of the menstrual cycle. Due to the variation in "normal" menstrual cycle length, this 12-day window provides the greatest degree of accuracy in either planning for or avoidance of a pregnancy.

The SDM identifies days 8-19 of a woman's menstrual cycle as fertile. Using this method helps a couple avoid unplanned pregnancy by knowing the days they should avoid unprotected intercourse. CycleBeads, an inexpensive, color-coded string of beads, will help a woman keep track of where she is in her cycle and clarify when she is fertile. CycleBeads are available from The Institute for Reproductive Health at Georgetown University. Patient and provider education materials are also available online at this site.

Data investigating the efficacy of the SDM by Arevalo, Jennings, and Sinai were reviewed. This multisite prospective study[9] provided services through existing programs, and clients were followed monthly for 13 cycles. In this study, couples used the method correctly in 97% of cycles. Of the 478 women in the study, 43 became pregnant (9%). With correct use, the failure rate for the SDM is 4.8%, and with typical use, the failure rate is 12%.

The SDM counseling includes screening to determine if this method is right for this woman; teaching about the method, and supporting the couple by discussing couple issues and correct method use. Appropriate candidates are women with menstrual cycles between 26 and 32 days long and couples who will avoid unprotected sex on days 8-19. If a woman has 26-32 day cycles and if she knows her last menstrual period, she can begin using the SDM as soon as she learns about it. Women who are breastfeeding may not use this method. In fact, a breastfeeding woman should wait until she has had at least 1 cycle that is 26-32 days long before beginning the SDM.

The TwoDay Method is another new contraceptive approach developed and tested at Georgetown. This method is based on identifying cervical secretions. Women check every day for the presence of cervical secretions. The concept is simple: if a woman notices any secretions today or yesterday, she considers herself fertile today and avoids unprotected intercourse today. The TwoDay Method is useful to meet the needs of women who have irregular cycles, have cycles outside the 26- to 32-days range required by the SDM, or prefer a symptom-based method. During the 11-day fertile window, secretions follow ovulation very closely. Therefore, this method is a prospective method to identify signs of fertility for the current cycle.

The TwoDay Method involves 3 simple steps:

  1. Identify secretions;

  2. Apply the algorithm; and

  3. Communicate with your partner.

An efficacy trial performed to evaluate the TwoDay Method was a prospective, multisite study using public and private sector patients in Guatemala, Peru, and the Philippines.[10] There were 450 clients using the method for up to 13 cycles. In this study, 47 women became pregnant, resulting in a high efficacy rate (90%). Final study numbers were not available due to pending publication of the results in the Journal of Fertility and Sterility later this year.

In summary, those who can use the TwoDay Method include:

  • Women with cycles of any length;

  • Women with normal secretions (if a woman has vaginitis, her secretions will not be normal);

  • Women willing to check for secretions; and

  • Couples who can use condoms or abstain several consecutive days each cycle.

Next steps in the roll-out of the TwoDay Method include publication of efficacy results, refining service delivery (via development of tools for patients and providers), and the development of training protocols.


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