Increasing Social Acceptance of Family Planning in Communities: The experience withFertility Awareness Methods

1. Increasing Social Acceptance of
Family Planning in Communities:
The experience with
Fertility Awareness Methods
PRE-CONFERENCE WORKSHOP
Durban, June 19, 2010
Jeannette Cachan, MA and Marie Mukabatsinda, BN
Institute for Reproductive Health, Georgetown University

2. Workshop Objectives
 Review basic information about SDM, TwoDay
Method and LAM, three simple fertility awareness
methods.
 Learn about newest guidelines and training
resources available for these three methods.
 Understand what is involved in the counseling and
become familiar with simple tools for providing
each of these methods.
 Learn how programs add these method to existing
services

3. Fertility Awareness Methods (FAM)
 Modern FAM are effective options for many women
who want to space pregnancies without using a
hormonal method.
 FAM offer an opportunity to involve the partner in
optimal birth spacing and timing.
 They have no side effects and are economical.

4. How FAMs work
 Identify “fertile window” (days intercourse can result
in pregnancy) of the menstrual cycle
 Use one or more “indicators” to identify beginning
and end of fertile window. FAM method users:
• monitor indicators to identify fertile window
• avoid unprotected intercourse (use barrier
methods or abstain) on fertile days

5. Why develop new FAM?
 Very low use of current FA-based methods.
 Very poor understanding of fertility in the general
population.
 Significant unmet need for family planning.
 Most health providers do not have time to counsel
their patients/clients in FAM.
 Many women/couples who express interest in a
FAM do not actually use them
 FAM can contribute to efforts to reduce the gap
between contraceptive commodity needs and
donor capacity.

6. Use of family planning remains low in
many countries
Percentage aof married women using
contraception
40
35
30
Modern Methods
25
20
15 Traditional or folk
methods
10
5
0
Benin DR Congo Zambia India - UP
Source: PRB 2005 World Population Data Sheet and ORC Macro DHS

7. Use of periodic abstinence (with incorrect
or limited information) in many countries
Percentage married women using
periodic abstinence
25.0
20.0
Incorrect knowledge
15.0 of fertile time
10.0 Correct knowledge of
fertile time
5.0
0.0
Source: ORC Macro, 2006. MEASURE DHS STATcompiler

8. Context for FAM
FAM in the context of:
 Healthy Timing and
Spacing of
Pregnancies (HTSP)
 Informed choice in
family planning

9. What is HTSP? Is it different from birth
spacing?
 Previous birth spacing recommendations refer to
when to give birth.
 HTSP is about pregnancy spacing: when to
become pregnant – rather than when to give birth.
 After a live birth, wait at least two years before
trying to get pregnant again. Rather than wait two
years between births.

10. Healthy Timing & Spacing of
Pregnancies
After a live birth:
 Couples should use an
effective family planning
method of their choice,
continuously for at least 2
years before trying to
become pregnant again.
 The SDM, TwoDay Method
and LAM can offer women
and couples at least 95%
protection from pregnancy
when the method is used
correctly.

11. What is HTSP? Is it different from birth
spacing?
 Previous birth spacing
recommendations refer
to when to give birth.
 HTSP is about
pregnancy spacing:
when to become
pregnant – rather than
when to give birth.

12. What are the advantages of waiting two
years after having a baby to become
pregnant again?
 Increases likelihood of healthy outcomes for
the baby and the mother
 Reduces neonatal, infant and child mortality
 Reduces maternal mortality
 Improves nutritional status of children
 Addresses unmet need for contraception
among postpartum women
 Benefits family economically
12

13. Natural Family Planning – Method Comparison
Standard Days Method TwoDay Method LAM
with CycleBeads
Method  Women with cycles between 26 • Women who are willing and able 3 LAM Criteria
and 32 to monitor daily the presence or 2.Mother’s menstrual bleeding has
Eligibility days long absence or secretions; not returned since the bay was
Criteria (who  Couples who can avoid • Couples who can avoid born
unprotected sex on days 8 to19 unprotected intercourse during 2. Mother is only breastfeeding
can use the the days the method identifies as AND
method) fertile. 4.Baby is less than 6 months old
Exceptions Women in postpartum or Postpartum or breastfeeding Women who don’t meet at least
breastfeeding must have had at women, unless they have one of the criteria.
(who cannot least 4 periods about a month completed three cycles since their
use) apart. child was born.
Women who recently used a Users of hormonal contraception or
hormonal method must have 3 medication in the previous three
periods about a month apart after months
stopping hormonal.
Effectiveness 95% with correct use 96% with correct use 99% with correct use
88% with typical use 86% with typical use 98% with correct use
Pregnancies for every 100 woman-years Pregnancies for every 100 woman-years *6 months effectiveness rate
How it works The woman considers herself fertile The woman considers herself fertile • Put baby to breast as soon as
on days 8-19 of the cycle if she notes secretions of any type possible after birth
that day or noted them the day • Breastfeed as often as your baby
before. wants, day and night
•Women check everyday for the • Continue breastfeeding even if
presence of secretions the mother or infant becomes ill
•If she notices any secretions today • Do not give your baby any
or yesterday, she considers herself foods, water, or other liquids
fertile today and avoids • Do not use bottles, pacifiers or
unprotected intercourse today other artificial nipples.
Key Research • Multi-site prospective study • Prospective, multi-site study - Prospective 10-ciuntry multi-
• Services provided in existing • 450 clients followed for up to 13 center study established 98%
and Findings programs cycles effectiveness (Labbok, et al. 1997)
• Clients followed monthly for 13 • Results: more than 96% effective -LAM Leads to Higher
cycles preventing pregnancy Contraceptive Prevalence at 12
• Couples used the method • Results published: “Efficacy of a Months Postpartum and fewer

14. Contraceptive Failure of User-Directed Methods
*Percentage of women who
became pregnant 1st year of use Correct Use Typical Use
OCs .3 8
Condom 2 15
**TwoDay Method 4 13
***Standard Days Method 5 12
Diaphragm 6 16
Spermicides 18 29
No Method 85 85
6 month pregnancy rate Correct use Typical Use
LAM 1.0 2.0
*Adapted from Contraceptive Technology, 18th edition, 2004
**Source: Arévalo et al. Fertility & Sterility, October 2004
***Source: Arévalo et al. Contraception, 2002

15. Comparing effectiveness of FP methods
Source: Family Planning: A Global
Handbook for Providers 2007, WHO

16. Lactational Amenorrhea Method
(LAM)

17. LAM
 A Family Planning Method based on the
physiological infertility experienced by
breastfeeding women
 A “gateway” to other modern methods of
contraception
17

18. How does LAM prevent pregnancy?
LAM Mechanism of Action
1. Baby’s suckling stimulates
the nipple
3. Nipple stimulation triggers
signals that affect
hormones
5. Disruption of hormones
suppresses ovulation
18

19. Effectiveness of LAM
 LAM is 99.5% effective with consistent and
correct use and more than 98% effective as
typically used
 Effectiveness rates comparable to those of
other modern methods
19

20. What are the three criteria for LAM?
The 3 LAM criteria
• Mother’s menstrual bleeding has not
returned since the bay was born,
AND
2. Mother is only breastfeeding, AND
6. Baby is less than 6 months old
20
20

21. LAM Criteria
Mother’s menstruation has not returned since
1 the birth of the child (“Amenorrhea”)
 Bleeding during the first 2 months post-
partum does not count as menstruation
 Bleeding after 2 months post-partum can
be an indication of the return of fertility
21

22. LAM Criteria
2 Baby is being only breastfed; The baby is not
receiving any other solid food or liquids; only
breast milk
Why is this condition important?
When baby receives any food, water, or other
liquid:
 The baby becomes full and will not want the
breast as often.
 The mother will not produce as much milk.
 Infrequent suckling will make the mother’s
 fertility return. She can get pregnant.
22

23. LAM Criteria
The baby is less than 6 months old
3
 Biologically appropriate cut-off point.
 WHO recommends supplementing after 6
months.
 Supplemental food will decrease suckling.
23

24. Be sure that your clients understand:
BREASTFEEDING IS NOT
THE SAME AS LAM!
24

25. Why is contraception during the
postpartum period so important?
Fertility may return soon after delivery and
risk of pregnancy emerges
 If not breastfeeding, ovulation will occur at 45
days postpartum on average; may occur as
early as 21 days
 Breastfeeding women not practicing LAM are
likely to ovulate before return of menses
 Between 5% and 10% of women conceive
within the first year postpartum
25

26. Transition to Another Method: An Essential
Component of LAM
 LAM is a “gateway” to other modern methods
of contraception
 LAM provides the couple time to decide on
another modern method to use after LAM
How do you ensure that LAM facilitates transition?
 Another method should be started as soon as
any one of the three LAM criteria is not met
 The woman should be counseled to decide on
the method to which she should transition when
LAM counseling is initiated
26

27. Postpartum Contraceptive Options
Adapted from Contraceptive Technology Update 27

28. Methods That Are Safe while
Breastfeeding
 A number of contraceptive methods can be
safely used by the breastfeeding mother:
 Abstinence – any time
 Condom – any time
 IUD – inserted before 48 hours or after 4 weeks
 Combined oral contraceptives – after 6 months
 Progestin-only (pills, implants, 3-month injection)
– after 6 weeks
 Tubal ligation – performed before 7 days or
after 6 weeks
 Vasectomy – any time
28

29. Emphasizing timely transition
 Offer postpartum
women choice of all
appropriate FP
methods during first
post-partum visit
 During this and
subsequent visits,
discuss what she will
use after LAM
 Encourage women to
keep breastfeeding
after LAM

30. Job Aids
30

31. Case Studies
 Decide which women can rely on LAM for
contraception.
 Read each case study
 Discuss answers
 Review answers as a group
31

32. Optimal Breastfeeding Behaviors
 Allow newborn to breastfeed as soon as possible
after birth, and to remain with the mother after birth
 Breastfeed as often as baby wants, day and night
 Continue breastfeeding even if the mother or infant
becomes ill
 Do not give your baby any foods, water, or other
liquids for the first 6 months
 Do not use bottles, pacifiers or other artificial nipples.
These discourage the baby from breastfeeding as
frequently.
 Continue to breastfeed for the first two years, even
though also providing complementary foods
32

33. Contraceptive Advantages
of LAM
 Effectively prevents pregnancy up to six months
 Is provided and controlled by the woman
 Can be used immediately after childbirth
 Is universally available to postpartum women
 Does not require supplies or procedures
 Is economical
 Has no hormonal, or other, side effects (for
breastfeeding mother and her infant)
 Raises no religious objections
33

34. Contraceptive Advantages
of LAM (cont.)
 Facilitates transition by allowing time for decision
to use/adopt another modern contraceptive
method
 Facilitates modern contraceptive use by
previous non-users
 Supports and builds on infant-feeding
recommendation to exclusively breastfeed for six
months
34

35. Benefits of Breastfeeding
Specific Health Benefits for Mother
 Promotes involution (return of uterus to pre-
pregnancy state)
 Stimulates uterine contractions in early
postpartum
 Leads to less anemia because of less iron
depletion due to no menses
 Strengthens mother–baby bonding enhanced
35

36. Benefits of Breastfeeding
Specific Health Benefits for Baby
 Is more easily digested
 Adapts to needs of growing infant
 Promotes optimal brain development
 Provides passive immunity and protects from
infections
 Provides some protection against allergies
36

37. Limitations of LAM
 Offers temporary contraceptive protection only for
six months
 Is not usually appropriate if mother will be
separated from baby for periods of time
 May pose concerns for HIV-positive mothers
37

38. Can an HIV-positive woman use LAM?
A mother with HIV can use LAM…
 All HIV-positive women for whom replacement feeding
is not acceptable, feasible, affordable, sustainable
and safe (AFASS) should be encouraged to exclusively
breastfeed their infant for six months.
 A woman should be supported in her infant-feeding
decision and in her contraceptive choice; the choice
is hers
(WHO. HIV and Infant Feeding: Report of a Technical Consultation. 25-27 October 2006. Geneva.)
38

39. Special considerations for an HIV+
woman wanting to use LAM?
A mother with HIV who chooses to breastfeed or use LAM
should:
 Breastfeed exclusively for the first six months before
switching completely to replacement foods if
possible
 Receive care and treatment for herself
 Use condoms consistently
 Feed from unaffected breast (and express and
discard milk from affected breast) if she experiences
cracked nipples
 Seek immediate care for baby with thrush or other
lesions in mouth
39

40. Where can LAM services be provided?
Opportunities to Provide
LAM Counseling
 Antenatal clinic
 Child health (well-baby) clinic
 Postpartum ward
 Postpartum clinic
 Family planning clinic
 Labor ward (in early labor or after birth)
 Community health visits
40

41. Two sides of Room: “Agree” and
“Disagree”
Colleagues’ position on:
2) LAM is a very reliable method of contraception,
3) Healthcare providers should counsel on LAM
because it is as effective as other methods of
contraception,
4) Counseling about LAM is easy,
5) LAM requires too much time in counseling to be
offered in busy settings,
6) LAM is a difficult method for postpartum women to
understand.
41

42. Integrating LAM into Existing
Programs
 Integrating LAM into FP or maternal & child health
programs is similar to promoting any other
contraceptive method
 Education and advocacy at policy, facility and
community levels may be necessary to clarify that
LAM and breastfeeding are not interchangeable
terms

43. Program Implications
 Wherever women breastfeed, LAM is an
appropriate FP method
 LAM uptake improves when included in a broad
integrated program
 Community involvement is important
 Training alone is not sufficient
 Provider bias influences counseling
 Importance of supervision, monitoring & evaluation

44. Standard Days Method

45. Standard Days Method
 Identifies days 8-19 of the cycle as fertile
 Is appropriate for women with menstrual cycles
between 26 and 32 days long
 Helps a couple avoid unplanned pregnancy by
knowing which days they should not have
unprotected sex
 Helps a couple plan pregnancy by knowing which
days they should have sex

46. CycleBeads
The SDM is used with CycleBead®, a color-coded string
of beads to help a woman:
 Track her cycle days
 Know when she is fertile
 Monitor her cycle length

48. SDM Offered Worldwide
Albania Haiti Senegal
Angola Honduras Tajikistan
Armenia India Tanzania
Azerbaijan Kenya Timor Este
Bangladesh Malawi Turkey
Benin Mali Uganda
Bolivia Mauritius Ukraine
Burkina Faso Mozambique United States
DR Congo Nicaragua Zambia
Ecuador Nigeria
El Salvador Pakistan
Ethiopia Peru
Ghana Philippines
Guatemala Romania
Rwanda

49. What is Involved in SDM Counseling?
 Screening – Help client determine if the SDM is
appropriate for her. Screening Checklist
 Teaching – Provide information and instructions to
use the SDM correctly. CycleBeads Cue Card
 Supporting – Explore and discuss couple issues and
support correct method use. Screening Checklist

50. Screening
Who Can Use the SDM?
 Women with cycles 26 to 32 days long
 Couples who can avoid unprotected sex on days
8-19
 Couples not at risk of STIs

51. Screening to See if the SDM is
Appropriate for the Woman
 Is her cycle within the 26 and 32-day range?
 Simple questions to assess cycle length and regularity.
 Do you get your periods about once a month?
 Do you get your periods when you expect them?
 When did your last period start?
 Most women have a general idea of when their periods
will come.
 Women who know when their last period started can
use the SDM right away.
 Women who do not know can begin the SDM when their
next period starts.

52. Criteria for Starting the SDM
Date of the last period known Start immediately
Start on first day of next period
Date of last period unknown
Wait 90 days after lst injection, 2 most
Contraceptive Injection
recent periods about 1 month apart
OC, patch, implant, IUD/IUS Wait until last 3 periods are about a
month apart (after stopping the
Pregnancy loss hormonal method)
Wait until she has 4 periods and the
Postpartum/breastfeeding
two most recent are about a month
apart

53. Teaching - How to use the SDM
Provider Cue Card
 Teach client how to use the SDM
with CycleBeads
 Confirm client knows how to use the
method and when to return to the
provider
 Check the woman and her partner
know how to use a condom
 Both, the CycleBeads instructional
insert and the provider cue card
include essential information to help
women use the method.
CycleBeads Insert

54. Group work – Case studies for
cycle length and regularity
In pairs, spend 5 minutes
resolving the case study
assigned to your team.

55. Group work
In pairs, spend 5 minutes taking turns explaining
each other how to use CycleBeads. Use the beads,
insert and cue card to follow key points. Then
discuss the following points:
How to help women remember to move the ring
every day?
Why is it important for her to move the ring daily?
How can a woman know if her cycles are within
right range to use CycleBeads?
What should a woman do if she’s not sure if she
moved the ring on any given day?

56. Supporting the Couple
During counseling:
 Set the stage
 Encourage women to
discuss SDM use with their
partners
 Engage client in a
discussion on how
she/partner will handle the
fertile days
 Identify possible challenges
and solutions
BE SURE SHE LEAVES  Role play talking with her
WITH A PLAN! partner
 Offer to talk with her
partner

57. Involving Men- Issues to Consider
 SDM is a couple method. If men understand it,
couples are more likely to use it correctly.
 Special efforts should be made to involve men.
 Counseling men is ideal, but men can also be taught
about the method through: posters, flyers, radio, TV
and community networks.

58. Group Work Video Case Studies
In small groups, discuss the short
vignette using the discussion
points and be prepared to share
in the larger group.

59. Group work
 How would you engage this
couple in discussing how to
handle their fertile days?
 How would you feel about
this couple using the
TwoDay Method?
 If they decide to start using
the method, would you
schedule a follow-up visit?
Why or why not?

60. When to contact the provider
 If she has sex on a white bead day
 If her period starts before the dark brown
bead (cycle shorter than 26 days)
 If her period has not started the day
after moving the ring to the last brown
bead (cycle longer than 32 days)
 If her period has not returned and thinks
she might be pregnant
 If she wants to use another method

61. Lessons Learned
 Providers’ attitudes toward the SDM improve with
training and experience.
 The SDM can be offered by different kinds of
providers.
 The SDM can be taught in clinic and community
settings.
 Involving men increases method satisfaction and
continuation.
 Women can learn to use the SDM during a 20-
minute session.
 Offering the SDM helps programs reach new
clients.
 Many couples use condoms on fertile days

62. TwoDay Method

63. TwoDay Method
 Fertility Awareness method that relies on cervical
secretions as an indicator of fertility.
 The woman checks daily for the presence or
absence of secretions (of any type).
 If she notes secretions TODAY or YESTERDAY, she is
considered to be fertile TODAY. To prevent
pregnancy, avoid unprotected sex TODAY.

64. TwoDay Method Algorithm
Did I note YES
any I can get pregnant today
secretions
today?
NO
YES
Did I note any I can get pregnant today
secretions
yesterday?
NO
Pregnancy is not likely today.

65. Cervical Secretions: a reliable
indicator of fertility

66. Cervical Secretions during the
Menstrual Cycle
Pre-ovulatory Peri-ovulatory Postovulatory
Days Days Days
More Water
Less Water More Fluid Less Water
Less Fluid More Less Fluid
Less detectable detectable Less detectable
Detectable secretions = Sign of Fertility

67. How Is the TwoDay Method Offered
to Clients?
 Screening for method eligibility
 Explaining secretions and the menstrual cycle
 Teaching method use: observing and recording
observations
 Discussing couple’s ability to manage fertile days.
 Explaining when to return to provider

68. Screening
Who can use the TwoDay Method
Can be used by: Some women may need to
• Women with cycles of wait a while before using
any length the method if:
• Women with healthy
secretions  They had a recent
• Women willing to check pregnancy or are
for secretions breastfeeding.
• Couples who can use  Recently used a
condoms or abstain for hormonal method.
several consecutive
days each cycle

69. When to start using the TDM
Not using a method and meets Start immediately
TDM criteria
Postpartum/breastfeeding Wait until she has 4 periods
Wait until 4 months have passed
3-month contraceptive
after last injection, and her periods
Injection
have resumed
Wait until she has 4 periods after
OCs, patch, implant, IUD/IUS
stopping the hormonal method

70. What a woman needs to know to
use the TwoDay Method
 What secretions mean, how they look and when
they appear
 How to notice secretions and when
 When is pregnancy likely and unlikely
 How to prevent pregnancy on fertile days
 When to return to her provider

71. Steps to use TwoDay Method
●
o
x Asks herself if she
Identifies had secretions
secretions Asks herself if she today or yesterday.
had secretions Decides if she can
and records them. or cannot have sex
today.

72. What are secretions?
What does secretions look How to tell if you have secretions?
like?
• Secretions are not always • You can see them when you
the same and they look and go to the bathroom.
feel different as days go by.
• Once they start they
continue for several days in a
row.
• You can feel them by paying
attention for moisture in your
genital area while doing daily
• Even if they change in activities.
quantity or appearance, ALL
secretions tell you that you
can get pregnant.

74. How to use the TwoDay Method
1) CHECK for secretions 2) RECORD , before
at least twice a day starting going to bed,
at noon. whether you had
secretions.
If you forget to check secretions, consider
yourself fertile today.
3) DECIDE if you can get pregnant
today. If you had secretions today
or yesterday, You can get
Ask yourself these two questions: pregnant today. Use a
- Did I have secretions today? condom or avoid sex.
- Did I have secretions yesterday? If you are menstruating or if
you did not have secretions
today and yesterday, you can
have sex without using a
condom.

75. Managing Fertile Days
During counseling, providers:
Help women decide how to handle
fertile days with partner
 Identify potential problems and
solutions
 Encourage women to discuss SDM
use with their partners
 Role play talking with her partner
 Offer to talk with her partner

76. When to contact the provider
• If she has difficulty determining whether
or not she has secretions
• If she has less than 5 days with secretions
• If she has more than 14 consecutive days
with secretions
• If she has difficulty avoiding unprotected
sex during the fertile days
• If her secretions are smelly or itchy
• If her period has not returned and thinks
she might be pregnant

77. TwoDay Method Study Findings
 Women want to know how their bodies work.
 Women had no problems observing
secretions.
 They could identify their secretions in the first
cycle of method use.
 Most women in all three study countries were
able to note secretions and differentiate
between healthy and unhealthy secretions.
 Most women were not aware of the
relationship between fertility and secretions
and thus ignored them; they were not paying
attention to these.
Arevalo et al, Efficacy of the new TwoDay Method of family planning. Fertility and Sterility,
Vol. 82, No. 4, Oct 2004

78. TwoDay Method Resources
• Counseling job aids
• Client take-home card
• Training curriculum and support
materials
• IEC materials
• Supervision tool
• FAQs

79. Guidance Documents
 IPPF Medical Bulletin – 2000, 2003
 WHO Medical Eligibility Criteria – 2002, 2004
 Contraceptive Technology - Contraceptive
Technology – 2004, 2007
 USAID Global Health Technical Briefs – 2010
(coming soon)
 Pocket Guide to Managing Contraception –
2004
 Pop Report (New Contraceptive Methods) – 2005
 WHO Global Handbook for Family Planning –
2006
 Pop Council Balanced Counseling Strategy –
2006

80. Coming soon!
K4Health-TDM Toolkit
For More Information
www.irh.org
• Access TDM client cards
• Answer “frequently-asked
questions”
• Down-load published papers,
materials
• Link to related sites

81. Included in SOTA documents
 IPPF Medical Bulletin – 2000, 2003
 IRH Reference Guide – 2002
 WHO Medical Eligibility Criteria – 2002, 2004
 WHO Selected Practice Recommendations –
2004
 Contraceptive Technology – 2004, 2007
 USAID Global Health Technical Briefs – 2004
 Pocket Guide to Managing Contraception –
2004
 Pop Report (New Contraceptive Methods) –
2005
 WHO FP Decision-Making Tool – 2005
 WHO Global Handbook for Family Planning –
2008

82. Why Offer FAM?
 Increases choice
 Expands coverage
 Addresses unmet need
 Empowers women
 Involves men
 Offers low-cost method

83. Reference Materials
 Links to scientific
articles
 Technical Briefs
 SDM Service Training Materials
Protocol  Trainers’ Manual
 Sample Norms  Participant Handbook
 Frequently Asked  Training Video
Questions
 Online Training
www.irh.org

84. Common Misconceptions about FAM
and SDM
• “Natural methods don’t work”
• “Is this a modern method? “
• “Is there demand for this method”
• “Natural methods take too much time
in counseling”
• “Men don’t collaborate, women have
no power to decide when to have sex”
• “If we offer this method clients will start
switching from more effective methods”
• “Illiterate women cannot use this

85. “WOMEN WILL NOT HAVE THE POWER TO
DECIDE WHEN TO HAVE SEX.”
FACT: FAM ARE BEST SUITED FOR
COUPLES THAT CAN COMMUNICATE

86. “If we offer these methods, clients using
modern methods will switch.”
Fact: FAM integration has no negative
effects on FP use and method mix

87. “SDM counseling would take too much time,
just like other natural methods.”
Fact: SDM is easy to teach in about the
same amount of time as other methods

88. “It would be hard for
illiterate women to use
SDM.”
Fact: SDM appeals to
women from a range of
socio-economic
backgrounds
Fact: Low literacy or illiterate
women can learn how to “More educated women would
use SDM correctly not be interested in using
SDM.”