By: Melissa Jaskiewicz, DO
Editor’s Note: At FACTS, we appreciate the global community of women and couples from all walks of life who choose to plan their families and monitor their health using fertility awareness-based methods (FABMs). This week’s article features research from Nigeria and is titled, “Religion, Culture and Male Involvement in the Use of the Standard Days Method: Evidence from Enugu and Katsina States of Nigeria.” [1] Dr. Melissa Jaskiewicz was in medical school when she participated in the popular FACTS online elective and summarized this interesting article by Ujuju et al.
Introduction
Family planning discussions often focus on efficacy rates, medical applications, mechanism, and side effects of different methods. This is rightly so, as no method can be applied successfully without a thorough understanding of these areas. Still, family planning does not occur in a standard research bubble. The culture and community where fertility awareness-based methods (FABMs) are practiced is as important as the method chosen. Ujuju et al addressed this in their 2011 study [1] summarized below.
The Standard Days Method® (SDM) is a fertility awareness-based method of family planning for women who have regular cycles between 26 and 32 days long. If attempting to postpone pregnancy, users abstain from sexual intercourse or use condoms on days 8 to 19 of the woman’s cycle. The SDM utilizes a straightforward tool called CycleBeads® — a circle of beads of different colors that refer to phases of a woman’s cycle (menstruation, fertile, infertile). Using this tool, a woman moves a black rubber band to a new bead each day to track where she is in her cycle and when she must abstain from sexual relations with her partner.
“The Standard Days Method® (SDM) is a fertility awareness-based method of family planning for women who have regular cycles between 26 and 32 days long.”
Methodology
The study was designed by the Society for Family Health in Nigeria in collaboration with the Institute of Reproductive Health at Georgetown University. Researchers used qualitative methods to gauge attitudes and potential barriers to the SDM within the two different Nigerian states: Enugu and Katsina. Katsina is in the North of Nigeria and has a large Islamic population, while Enugu is in the South and has a large Catholic population. Research methods included six focus group discussions and six in-depth interviews with nurses, family planning community clinicians (mostly nurses), and SDM users. They were conducted in each state among three different local government areas (LGA’s) including rural and urban sections.
The focus group discussions were conducted with 56 men and 57 women ages 29 to 42 and included individuals in monogamous or polygamous marriage arrangements who had been using the SDM for at least 6 months. The interviews were with community clinicians trained to lead couples in using the SDM. The discussions and interviews were moderated by researchers, transcribed in full, and then watched by note takers who recorded additional information, including non-verbal communication.
Results
The discussion was broad as the interviews addressed many different topics. Some of the topics included: experiences with previous methods of family planning; user eligibility for the SDM; perceived effectiveness; ease of use; preferred methods to obtain information about the method; roles of community/religious leaders; accurate use; provider strategies; recorded effectiveness; management of abstinence; hindrances to adopting modern family planning methods; benefits and drawbacks of using the SDM.
The data revealed factors that contributed to participants switching to the Standard Days Method, including side effects of hormonal contraception and condoms (e.g., menorrhagia and decreased sexual pleasure). Some participants familiar with FABMs mentioned prior use of the Billings Ovulation Method but cited the more complex rules and guidelines as a reason for switching to the SDM.
Although participants had varied perceptions of eligibility to use the SDM, it was clear they understood the guidelines regarding regular cycle length and overall length of cycle as the method’s main criteria. Participants indicated they felt confident in the method’s effectiveness to postpone pregnancy and noted the method was easy to use. They commonly discussed the importance of partner collaboration and the need for backup systems in case women forgot to move their ring on the beads. Recording the first day of menses on a calendar was one important backup plan, and some male participants indicated reminding their partners to move the ring if necessary.
“Participants indicated they felt confident in the method’s effectiveness to postpone pregnancy and noted the method was easy to use. They commonly discussed the importance of partner collaboration.”
In regards to obtaining information about the SDM, male participants affirmed receiving information and giving it to their wives, and participants also noted their preference to receive information from trained instructors. Community and religious leaders also played a role in the positive reception of information for the SDM. In both Islamic and Catholic communities, accepting the method as in-line with their religious beliefs encouraged adoption of the method. It was also clear from the discussions that participants were obtaining accurate information about the method and retaining it well. In fact, the researchers noted “no perceived misconceptions” regarding correct use of the SDM.
Healthcare professionals contributed to the discussion by explaining the contexts in which they distributed information regarding the SDM. They noted a large variety of settings including religious prayer groups and hospitals. Clinicians also provided information about the method’s effectiveness. Among the 12 clinicians interviewed, only two circumstances of method failure were mentioned, and both patients later acknowledged their cycles were regularly longer than 32 days.
A significant portion of the discussion centered on how couples manage the fertile period when abstinence is required. This was consistently noted as the most challenging aspect of the SDM. Many couples reported condom use; others reported having discussions with their partners or using alternative ways to show affection during those times, such as special meals. There were differences between monogamous and polygamous relationships. In polygamous marriages, men would plan intercourse with their wives based on who was outside of their fertile window, and many different methods of arranging that switch were noted.
Barriers to the adoption of other types of modern contraceptives were also discussed. Perceived effects on future fertility were noted. Participants also reported many benefits to the SDM, including greater trust in their relationships, increased self control, and lack of side effects from hormonal agents. However, the SDM was not without drawbacks; participants consistently mentioned the length of abstinence required as the main obstacle.
“Participants also reported many benefits to the SDM, including greater trust in their relationships, increased self control, and lack of side effects from hormonal agents.”
Discussion
This research article had a relatively small sample size but was very thorough in the information gleaned from participants. Within the larger context of the adoption of FABMs for family planning, this research highlights the social, emotional, and cultural attitudes and circumstances that may affect someone’s use of FABMs. It also offers an easily replicable design for future qualitative research on FABMs that can be scaled to larger populations and other locations throughout the world.
References
[1] Ujuju C, Anyanti J, Adebayo SB, Muhammad F, Oluigbo O, Gofwan A. Religion, culture and male involvement in the use of the Standard Days Method: evidence from Enugu and Katsina states of Nigeria. Int Nurs Rev. 2011 Dec;58(4):484-90. doi: 10.1111/j.1466-7657.2011.00900.x. Epub 2011 Jun 2. PMID: 22092328.
ABOUT THE AUTHOR
Melissa Jaskiewicz, DO
Melissa Jaskiewicz, DO wrote this summary as a fourth-year medical student at Oklahoma State University in Tulsa, OK. She completed her undergraduate education at Saint Michael’s College in Colchester, VT and earned a Master of Education degree at the University of Notre Dame in South Bend, IN. She enrolled in the FACTS elective to deepen her understanding of the various FABMs of family planning in hopes of offering more comprehensive health care to her future patients.
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