Director’s Note: Have you heard about the TwoDay Method? Today, we are highlighting research published in Contraception that discusses this convenient and simple fertility awareness-based method (FABM) of family planning. Viola Currie, a medical student who learned about FABMs on the FACTS elective, summarized the study by Jennings et al titled, “TwoDay Method: A Quick-start Approach.” [1]The research addresses the two key questions of the TwoDay Method as well as strategies for teaching the method. Specifically, it explores whether it matters for a woman to learn how to use the method during the first seven days of her cycle versus a “quick-start” approach any day of her cycle.
Introduction
When it comes to family planning, women often want convenient options that are effective and easy to use. The TwoDay Method is a fertility awareness-based method (FABM) in which users ask two questions: (1) Did I note any cervical secretions today? (2) Did I notice any secretions yesterday? If the answer is yes to any of these questions on a given day, the woman is most likely fertile and could get pregnant if having sexual intercourse. If the answer is no to both questions, she is likely infertile, and having sexual intercourse would likely not end in pregnancy.
“The TwoDay Method is a fertility awareness-based method (FABM) in which users ask two questions: (1) Did I note any cervical secretions today? (2) Did I notice any secretions yesterday?”
The TwoDay Method is typically taught to patients on the first 7 days of their cycle. If their cycle is outside that window, they need to return to the clinic during that time frame to learn how to use the method. The study by Jennings et al [1] sought to answer the question: When teaching the TwoDay Method, does it make a difference for the user to learn the method during the first 7 days of a cycle versus a quick-start approach at any time during a cycle. The researchers wanted to eliminate the barrier of having a woman return to a clinic for proper training if interested in this method but presenting after the first 7 days of her cycle.
Methodology
The TwoDay Method was offered in a peri-urban site in Lima, Peru and a more rural site in Piura, Peru in partnership with the Ministry of Health and Instituto Peruano de Paternidad Responsable (Peruvean Institute for Responsible Parenthood). Medical professionals from both locations went through training using the Service Test methodology, including visits with simulated clients, though the clinicians were not aware these visits were simulated. There were 3 profiles of study participants: patient at day 4 of her cycle (before the onset of secretions), patient at day 13 of her cycle (having experienced some secretions), and patient at day 25 of a cycle (after secretions are complete). After the encounter, the simulated clients completed a checklist of their experience. The Service Test methodology was used to determine whether the quality of counseling was affected based on where a woman was in her cycle. The simulated visits revealed no difference for the profiles on days 13 and 25, so they were combined in the analysis.
Power calculations were not done to determine sample size because any woman who wanted to use the TwoDay Method was admitted into the study. A total of 176 women were enrolled and educated on the TwoDay Method regardless of where they were in the cycle. Participants were followed for 7 cycles and interviewed on months 1, 4, and 7 via a questionnaire. The survey explored correct use (self-reported), continuation, and acceptability of the method for the women and their partners.
For the analysis, women who were educated on the TwoDay Method during the first 7 days of their cycles were compared with women who were educated later in the cycle. T-tests and X2 were used to determine the significance of the difference between the 2 groups.
Results
Of the 176 women admitted to the study, 113 were from Piura and 63 were from Lima. Their mean age was 32.6 years. Of the participants, 43 (24.4%) had counseling on days 1-7 while the rest had counseling on day 8 or later (90 participants on days 8-20; 43 participants on or after day 21). There was no statistically significant difference between being counseled on days 1-7 vs. later in the cycle.
Two thirds of the participants completed 7 cycles successfully with the TwoDay Method. For women counseled on days 1-7, the 7-cycle failure rate was 3.45 (for 100 women using the method for 7 cycles) and 9.91 for women counseled later in the cycle. Of respondents who completed 7 cycles of the TwoDay Method, 73 said they would continue using the method after completion of the study.
When using the TwoDay Method, women needed to correctly: (1) identify the absence or presence of secretions, (2) make note of secretions today or yesterday (making a connection between fertility and secretions), and (3) abstain from unprotected intercourse on days they identified as potentially fertile. In this study, a record of secretions was based on the women’s perceptions of secretions. To identify secretions correctly, a woman had to note at least 5 consecutive days of secretions in the cycle. Most of the women were able to identify secretions correctly in cycles 1 and 4. The differences between the two groups were not statistically significant.
Coital logs were also reported based on participants’ recollection of having had only protected or no intercourse during the fertile window in the previous cycle. Most women (97% in cycle 1 and 98% in cycle 4) reported following the instructions and avoiding unprotected intercourse on fertile days. There was no statistically significant difference between the groups.
Participants were told to check for secretions at least twice a day, and most of them were able to check for secretions in the afternoon, evening or before bed (83% counseled on days 1-7 and 92% counseled later in the cycle). This was not a statistically significant difference between the groups.
Many of the women were happy with this method. In the exit interview, most participants said they would recommend the TwoDay Method to other women (94.7% counseled in days 1-7 and 92.7% counseled later). Again, this was not statistically significant.
“Many of the women were happy with this method… (and) most participants said they would recommend the TwoDay Method to other women.”
Six out of eight sections of the simulated client checklist indicated that clinicians performed better when counseling women who were later in their cycle. They also spent more time counseling clients on day 4 of their cycle than on days 13 or 25. The researchers concluded the quick-start approach did not affect the quality of counseling received.
Discussion
This study by Jennings et al provides evidence that a woman can start the TwoDay Method anytime during her cycle. This is especially important for women who may not have the luxury to make multiple trips to a clinic to receive education on FABMs or who cannot use other forms of family planning. This study also showed that in urban and rural areas, women were able to identify cervical secretions correctly independent of their educational status. The TwoDay Method is an easy FABM to learn and use regardless of socioeconomic status.
“This study by Jennings et al provides evidence that a woman can start the TwoDay Method anytime during her cycle… (And) women were able to identify cervical secretions correctly independent of their educational status.”
A limitation of this study was the follow up of participants in months 1,4, and 7. More frequent follow up may have led to an increase in correct use of the method. During follow-up interviews, participants were asked to simply recall their experience using the method, which may have created bias. It’s also possible differences between the groups were hidden due to the small sample size.
Strengths of the study included clinicians’ ability to educate on the method equally no matter where participants were in the cycle. Also, participants were able to correctly use this method regardless of when in the cycle they learned it.
The TwoDay Method is a valuable FABM for women who want something that is effective and simple to use. It doesn’t require additional equipment. It should be offered to every woman as an option for natural family planning regardless of where she is in her cycle, eliminating the barrier of having to return for education after menses has occurred.
Editor’s Note: Learn more about this simple FABM in The TwoDay Method: One More Modern Family Planning Tool.
