By Amanda Hale
Editor’s Note: As we recognize Men’s Health Month, this review highlights the important role men play in the successful use of fertility awareness-based methods (FABMs). In this article, Dr. Amanda Hale reviews the study by Sinai et al., “Fertility Awareness-Based Methods of Family Planning: Predictors of Correct Use,” which examined factors associated with correct use of FABMs among nearly 1,000 participants across multiple countries. In addition to identifying socioeconomic factors linked to method adherence, the study underscored the importance of partner cooperation, communication, and shared decision-making. Dr. Hale wrote this article while enrolled in the FACTS elective in February 2023 as a medical student at Des Moines University College of Osteopathic Medicine. By exploring both the original research and subsequent studies on male engagement in family planning, Dr. Hale highlights how educating and involving men can improve communication, strengthen method adherence, and support successful reproductive health outcomes for couples.
Introduction
The purpose of this study was to identify characteristics associated with the correct use of fertility awareness-based methods (FABMs) among patients who use them.[1] At the time this article was written, few studies explored compliance with FABMs, but research had concluded that communication, cooperation, and husband satisfaction were shown to be indicative of compliance with the chosen method. The researchers pulled data from participants using the Standard Days Method in Bolivia, Peru, and the Philippines, as well as participants using the Two-Day Method in Guatemala, Peru, and the Philippines. Both groups of participants were utilizing these methods to avoid pregnancy. The methods used to recruit participants were similar in the studies at individual sites; however, one study in Lima, Peru, recruited patients through canvassing door-to-door by research staff who were not healthcare professionals. Otherwise, participants were recruited through healthcare facilities or home visits in which healthcare practitioners provided counseling on the selected FABM.
“Few studies explored compliance with FABMs, but research had concluded that communication, cooperation, and husband satisfaction were shown to be indicative of compliance with the chosen method.”
Methodology
A total of 928 participants were recruited, and over 8,000 cycles were recorded and studied.[1] On average, participants were 29 years old with a mean partner age of 33. The majority were literate, and half of the participants had an income-earning occupation. The participants were broken up into three groups prior to statistical analysis: abstinence during fertile days, barrier use/withdrawal method during fertile days, and unprotected intercourse during fertile days. The majority—61% of participants—did not have intercourse on fertile days; however, 23% and 16% of couples used a barrier/withdrawal method or had unprotected intercourse, respectively.
The study described difficulty associated with learning a new method.[1] Within three months, the incidence of unprotected intercourse decreased for both groups, but this was particularly true for Two-Day Method users. Another cause for the unprotected intercourse, as described by the participants, was male partner coercion. Only 38% of the participants who had unprotected intercourse provided a reason as to why it occurred, and half of those participants stated it was due to their husband’s insistence.
“The majority, 61%, of participants did not have intercourse on fertile days; however, 23% and 16% of couples used a barrier/withdrawal method or had unprotected intercourse, respectively.”
Results
When determining statistically significant characteristics associated with compliance in The Standard Days Method or Two-Day Method, two characteristics were found.[1] The first was the housing quality index, which is determined by the source of water, availability of electricity, material used for cooking, main wall material (SDM only), and floor material (TDM only). Participants who scored a higher housing quality index were more likely to utilize the methods correctly compared to those who did not. The rationale provided for this finding was that a potential stress associated with poverty may hinder a couple’s ability to correctly utilize their FABM.
The second characteristic that was statistically significant for FABM compliance was having an income-generating occupation.[1] Participants who had an income-generating occupation outside the home were less likely to utilize the chosen method correctly compared to participants who stayed within the home. The rationale provided for this finding was that participants who worked outside the home were less likely than traditional women to understand the traditional rules of FABMs. The participants who had a more traditional profile were perhaps more invested and educated in FABMs as there was less emphasis on modern contraceptive methods in this subpopulation of participants. Other characteristics that were measured but statistically insignificant included age, number of children, age of youngest child, and ability to read well.[1]
“Participants who had an income-generating occupation outside the home were less likely to utilize the chosen method correctly compared to participants who stayed within the home.”
Discussion
Returning to an earlier point, the study found instances of marital coercion or force during intercourse when using these methods.[1] One key takeaway from the article is that clinicians should advise both partners in a couple about the importance of avoiding intercourse on fertile days. If the male partner is absent during the counseling, clinicians should assist the patient in developing negotiation skills. This underscores the importance of screening for intimate partner violence during fertility healthcare visits. While someone can accurately track their cycle, if their partner ignores the desire to abstain on fertile days, this family-planning method may not be suitable. Since the article was published in 2006, more research is needed to consider male compliance in FABMs and related issues.
One article on the topic examined four different studies in India, El Salvador, the Philippines, and Guatemala, in which the Standard Days Method was introduced to males and the various approaches to educate this population.[2] Every such study found a statistically significant decrease in unintentional pregnancy when males were targeted for education on these topics in a variety of methods: men-only educational talks, male health promoters, behavior change communication activities targeting men, and integration of family-planning content into non-health activities (such as agriculture and sanitation projects). Additionally, these male-focused interventions led to better outcomes regarding attitudes about family planning and gender, family-planning knowledge, intra-spousal communication, and family-planning use and continuation.
“Every such study found a statistically significant decrease in unintentional pregnancy when males were targeted for education on these topics in a variety of methods: men-only educational talks, male health promoters, behavior change communication activities targeting men, and integration of family planning content into non-health activities.”
In conclusion, the findings presented by the original article were that the housing quality index and income-generating profession for females were the only statistically significant characteristics in maintaining compliance with a chosen FABM.[1] Another finding was that a portion of participants who broke compliance did so because of coercion or violence against the participant. This highlights the importance of intimate partner violence screening during the initial consultation, in which the best family-planning method can be selected for the patient. Additionally, the presence and direct targeting of male partners is of great importance in maintaining compliance when utilizing an FABM because the outcomes related to maintaining compliance improve when there is male participation.[2] As such, healthcare practitioners would benefit greatly from including male partners in initial conversations regarding FABMs.
References
[1] Sinai I, Lundgren R, Arévalo M, Jennings V. Fertility awareness-based methods of family planning: predictors of correct use. Int Fam Plan Perspect. 2006 Jun;32(2):94-100.
[2] Lundgren R, Cachan J, Jennings V. Engaging men in family planning services delivery: experiences introducing the Standard Days Method® in four countries. World Health Popul. 2012;14(1):44-51.
ABOUT THE AUTHOR
Amanda Hale graduated from Des Moines University College of Osteopathic Medicine and is now a family medicine resident at Kaiser Permanente Orange County. Dr. Hale is passionate about health equity and LGBT+ healthcare and enrolled in the FACTS elective to gain a full understanding of fertility healthcare to learn how to bring fertility awareness-based methods to the LGBT+ community.
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