Natural Family Planning (NFP) Research Study

1. Natural Family Planning (NFP) Research Study David Fine Karen Dluhosh Sarah Goldenkranz Center for Health Training Seattle, WA January, 2009

2. Study Aims/Goals Exploratory and descriptive study which aims to: • Identify factors that affect the use of NFP 2. Assess predictors of contraceptive success among NFP users

3. Focus will be on the following areas: • Social, cultural, and demographic indicators associated with NFP use; • Individual and institutional barriers to use; • Factors that may impact compliance with NFP practices; • Indicators of self-efficacy among NFP users; and • Rate and indicators of contraceptive success in this service population.

4. What is Natural Family Planning (NFP)? • Contraceptive method / prevent unintended pregnancy • Relies on identification of days in menstrual cycle when woman is most fertile and most likely to be come pregnant • Teaches a woman to accurately monitor her cycle, identify her fertile period and either abstain from intercourse or use an alternative method of contraception

5. Definitions • Natural Family Planning (NFP) • Fertility Awareness Method (FAM) *FPAR definition: Broad term which includes “fertility awareness methods include rhythm/calendar, Standard DaysTM, Basal Body Temperature, Cervical Mucus, and Sympto-Thermal methods.” • Fertility Awareness-Based (FAB) methods • Cluster 1 - calendar based • Cluster 2 - sympto-thermal based *Source: Family Planning Annual Report: 2007 National Summary, Table 7

6. Who are the users? • Generally educated, young and single, or older and married • Most prevalent in sub-Saharan Africa, Latin America, and the Caribbean • NFP use in USA has decreased as more effective methods of contraception have become available

7. Reasons they use NFP • Limited availability of other methods to prevent pregnancy (globally) • Other reasons: • cultural beliefs about self-discipline and self-restraint • desire to use more natural methods of birth control • fear of side effects and adverse health impacts of modern hormonal methods

8. Research Population of Interest Who: • Title X providers (staff & clinicians) • Clinic clients using NFP as their primary method of contraception Where: • Title X-funded Family Planning clinics in Region X • Focusing on Washington State in particular

9. Research Partners • Washington State DOH Family Planning and Reproductive Health • Planned Parenthood of the Great Northwest • Research partners will: • assist with selection of project field sites • participate in staff needs assessments, staff and client interviews, staff focus groups & client interviews

10. Research Advisory Committee • Provide input on all phases of the research • Program-research linkages, NFP service financing issues, clinical staff needs, and NFP client service provision • Membership will include: • A state family planning grantee nurse consultant • A medical director from PPGNW • Title X grantee and delegate agency representatives • Key stakeholders from participating clinics

11. Research Methods & Data Sources Quantitative Data • Region X Title X needs assessment surveys Use: Describe agency and staff perspectives on NFP, program trends and variation in NFP service provision Source: Supplemental NFP questions added to annual web-based survey administered to clinic staff • Clinic Visit Records, 2004-2008 Use: Characterize clients that use NFP and client contraceptive success Source: existing electronic records of clinic client visits, regional data base used for program monitoring, FPAR

12. Clinic Visit Records (CVRs)--Completed in each Region X Title X FP site for client visits qualifying as Title X events • CVR domains • Client demographics • RH history • Medical and lab service provision • Counseling and education • Provider types • Contraceptive method, before/after visit • Referrals

13. Qualitative Data: • Focus groups and interviews with clinic staff Use: Explore knowledge and training on NFP, experiences with clients, collect clinician-client stories Source: face-to-face and phone interviews, selected FP clinics in WA state • NFP client interviews Use: Explore reasons for choosing NFP, methods used, training and information received, experiences at FP clinics, client expectations Source: face-to-face and phone interviews, selected FP WA state clinics

14. NFP Visits and Users • Data from CVRs, 2004-2008 (through June ’08) • 6,098 visits to FP clinics in Alaska, Idaho, Oregon and Washington where NFP was listed as BC method • 5,061 female patients using NFP methods, before/after their clinic visit • Aggregated by clinic and client ID • An additional ~13,000 visits for these 5,061 patients, 2004-08, where NFP was not listed as BC method • These records to be used to describe patterns of FP client BC method, services • Assess number of pregnancies and intention status

15. NFP Visits • Visit data, n = 6,098 • NFP after visit 24% • NFP before visit 29% • NFP before/after visit 47%

16. NFP Visits—Contraceptive Methods N = 6,098

17. NFP Users N= 5,061

18. NFP Clients N= 5061

19. N= 5061

20. Next Steps—Regional CVR Data • Update 2008 to annual data set • Add other ~13,000 clinic visits where NFP was not the BC method • Explore visit patterns • Generate aggregate patient data set (n=~5,000) with all relevant data from the ~20,000 visits • Pregnancy history (number/intention status), referrals, BC methods used

21. Other Next Steps • Implement regional needs assessment with NFP items • Finalize participating clinics • Generate qualitative tools, client recruitment protocols, consent procedures • Implement field qualitative study component