Natural Family Planning Project

1. Natural Family Planning Project Paul G. Whittaker, Linda Hock-Long, Rebecca Merkh Family Planning Council Philadelphia, PA Funded by US DHHS, Office of Population Affairs

2. Background Family Planning Council • Title X grantee, SE Pennsylvania • 26 agencies, 75 clinics • 145,289 patients in 2007 • 49% Black, 32% White, 11% Hispanic • FPAR reports 0.16% (range 0-1.8%) use ‘natural methods’

3. Background Findings from our OPA-funded study ‘Couples and Contraceptive Practice’ suggested: • Many young adults believe condoms reduce pleasure and intimacy • It is common for women to avoid or discontinue hormonal methods due to access barriers or problems with regimens and side effects

4. Background • Use of withdrawal was common among our young adults (as an alternative to using barrier or hormonal methods) • More than a third of both men and women used withdrawal as their primary method of pregnancy prevention for more than one month

5. Background Participant quotes: • She said, “I can't be on the pill… I'm scared because I already got the pill before and look what it did to me.” So we started trying out the pull out method. • She was not on the pill… It’s not something she wants to put into her body. We tried to use condoms… That didn’t really work. So I switched to a combination of withdrawal and rhythm.

6. Background • Use of empirically-based Natural Family Planning (NFP) was not common among our young adults • One of 95 participants used an empirically-based NFP: • I feel comfortable with it now, because I’m used to it, and I still haven’t gotten pregnant - learning about tracking your ovulation, and the fertility awareness method was educational. It helped me feel a little more secure … knowing when to worry and when not to worry. • Withdrawal users may potentially be interested in using empirically-based NFP

7. Consumers – Other Studies Potential advantages of NFP: • Fertility unaffected • Lack of side effects • Leads to better understanding of reproductive physiology • Improved partner communication Potential disadvantages of NFP: • Perception of high failure rates • Requires understanding of reproductive physiology • Needs sustained motivation, partner cooperation • Monitoring fertile period and using alternatives therein

8. Consumers - Other Studies NFP methods most appropriate for women: • Willing and motivated to monitor fertile signs • Who accept potential for unintended pregnancy • With cultural beliefs for not using other contraception • With regular cycles

9. Providers – Other Studies Assumed that providers don’t recommend NFP because they: • Overestimate complexity of use and failure rates • Underestimate ability of consumers to use NFP • Perceive difficulty in offering & supporting NFP use • Believe increased NFP may lead to decreased use of other more reliable methods

10. Project Aim 1 • Assess female Title X consumers’ knowledge, attitudes & beliefs regarding NFP, plus experiences, barriers & facilitators to NFP use. • Consumer Surveys (N=384) • Consumer Qualitative Interviews (N=20-60)

11. Conceptual Model Theory of Planned Behavior (TPB). Intention to use NFP determined by: • Attitudes (advantages/disadvantages) • Subjective norms (support/oppose) • Perceived behavioral control (easy/hard) • Background influences (age, education etc.)

12. Consumer Eligibility Criteria • Females • 18-35 years of age • English-speaking • Established clinic patients (Survey only) • Have used NFP for a minimum of 3 consecutive months in the past year (Interview only)

13. Consumer Recruitment Consumer Survey • Participants will be recruited from Title X clinics Consumer Qualitative Interviews • Participants will be recruited from Title X clinics and elsewhere in the community (e.g. midwifery & doula practices, NFP training programs)

14. Consumer Surveys • Will be administered at Title X clinics via ACASI • Domains will include: • Socio-demographics • Fertility history & perceived pregnancy risk • Pregnancy intentions & contraceptive use • Fertility knowledge • Awareness, knowledge, attitudes & experiences re: NFP • Provider interactions re: NFP

15. Consumer - Survey Assessment • Are consumers aware of NFP options? • Do they have enough reproductive health knowledge to implement and correctly use NFP? • Do they use NFP? Why do they opt to use NFP? What are the perceived barriers to NFP use? • What are socio-demographics of those who use NFP? • Do they discuss the use of NFP with family planning providers? Do they think providers approve or disapprove of NFP?

16. Consumer Interviews • Qualitative interviews will approximate a natural conversation; participants will be encouraged to share their experiences in their own words • Probes will be used as needed to elicit further information, seek clarification or shift topics • Interviews will be conducted until saturation is reached (no new themes emerge from the data)

17. Consumer Interviews Domains will include: • Childbearing desires & pregnancy intentions • Contraceptive beliefs, attitudes & history • Individual, social & environmental factors influencing uptake & use of NFP • Perceived advantages & disadvantages of NFP use • Perceived barriers & facilitators to NFP use • Perceived efficacy in using NFP

18. Consumer Interviews Data : • Atlas.ti will be used to manage and analyze interview data • Themes identified using framework analysis – a priori concepts from conceptual model plus grounded theory

19. Consumer - Interview Assessment • Do pregnancy intentions, past contraceptive experiences, relationship status, partner attitudes, and socio-demographics influence decisions to use NFP? • Do women find NFP to easy/hard to use? • What types of barriers do NFP users encounter? How do they overcome these barriers? • What are the perceived advantages/disadvantages of NFP use? How do advantages outweigh disadvantages? • Do women feel supported by their male partners and providers in their use of NFP?

20. Project Aims 2 & 3 2) Assess Title X provider knowledge, attitudes & beliefs regarding NFP, plus barriers/facilitators to NFP service delivery. • Initial Provider Focus Groups (N=2) • Provider Surveys (N=225) 3) Identify potential strategies to reduce barriers to consumer use of NFP uptake. • Follow Up Provider Focus Groups (N=2)

21. Title X Provider Eligibility Criteria • Family planning clinicians & counselors providing direct care services • Have been employed at their respective agency for more than 3 months

22. Initial Provider Focus Groups • 6-12 participants per Focus Group (FG) • Will include individual free list exercises and group discussion • FG discussion will explore provider attitudes, beliefs & practices related to NFP

23. Provider Surveys • Will be completed by ~3 providers at each of 75 clinics • Paper and web-based versions will be available • Domains will include: • Socio-demographics • Knowledge, attitudes, beliefs & practice experiences re: NFP • Perceived level of consumer experience with NFP • Perceived consumer interest in & eligibility for NFP

24. Providers – Our Assessment • Do providers routinely assess consumer correct use of NFP? Does contraceptive counseling include a review of NFP methods and provide guidance? • What is the congruence between provider estimates of consumers’ NFP use and actual level of use? • What are provider level barriers/facilitators related to the provision of NFP counseling services? • Do providers have the requisite knowledge and perceived skills to deliver NFP counseling services? • Do providers view NFP as effective and appropriate contraceptive options for their consumers?

25. Provider Follow Up FGs • 6-12 participants per FG • Discussion will be organized around findings in following areas: • Use of NFP by their consumers • Gaps in consumer knowledge of NFP • Providers own attitudes, knowledge and skills in delivering counseling on NFP

26. Conclusion This research will help us: • Identify facilitators & barriers to: • Consumer uptake and successful use of NFP • Delivery of NFP-related services • Identify individual, social and/or environmental level (consumer & provider) strategies to maximize facilitators and overcome barriers to NFP uptake.