The FACT Project: increasing fertility awareness and expanding access to FAM 

Though population surveys in Nepal continue to show a declining total fertility rate (TFR), the contraceptive prevalence rate (CPR) has stagnated over the past several years. This stagnation has been attributed to a combination of factors including migration, fear of side effects from hormonal methods, and limited access to family planning among marginalized communities. The result is increased use of traditional family planning methods, higher rates of method discontinuation, abortion, and emergency contraception. 
To diversify the method mix, the USAID-funded Fertility Awareness for Community Transformation (FACT) project — in collaboration with the Family Welfare Division (FWD) (formerly known as Family Health Division or FHD) of the Ministry of Health and Population of Nepal, the National Health Training Center, and Save the Children — designed and supported the introduction and integration of the Standard Days Method (SDM), an effective and side-effect-free fertility awareness-based method in Rupandehi, Nepal. This intervention occurred over an 18 month period.

Integrating SDM in Services

Building Capacity for SDM Services: An assessment of FWD’s FP program helped stakeholders determine the program’s capacity to incorporate SDM in the method mix and design an integration strategy that was carried out in 32 health facilities in Rupandehi, Nepal. Buy-in from central and district stakeholders – who were engaged in orientation and planning workshops – was critical to integration. Stakeholders’ involvement paved the way for the integration of SDM in the Comprehensive Family Planning (COFP) curriculum used in training health facility providers nationwide. In Rupandehi, 68 trained healthcare providers – including health assistants, auxiliary nurse midwives (ANM), and auxiliary health workers – received the revised COFP training that included a focused SDM orientation which was later reinforced through monitoring visits. To support SDM integration system-wide, the FACT project team in Rupandehi implemented routine orientations for facility staff, community health workers, and stakeholders.
Getting the Word Out: Female community health volunteers (FCHVs) and Roving Auxiliary Nurse Midwives (RANMs) raised awareness about SDM during their interactions with clients and monthly health group meetings. RANMs also offered the method in the community. CycleBeads were introduced as “Malachakra” to the community. Other communication activities included a series of radio jingles appealing to marginalized groups (aired in Nepali and Awadhi), CycleBeads flyers (distributed during community meetings and home visits), and CycleBeads posters distributed to health facilities offering SDM.
Securing Availability of Commodities: To ensure availability within the supply chain, national level procurement systems provided CycleBeads to the District Public Health Office (DPHO) for distribution to the 32 health facilities. This distribution system included mechanisms to record uptake and maintain stock at health facilities. SDM service delivery quality was reinforced through IRH’s competency checklist, the Knowledge Improvement Tool (KIT) and a health facility supervision checklist assessing providers’ SDM-related counseling competency. Quality service delivery was also assessed through a series of client follow-up visits to measure clients’ correct use and understanding of the method.

FACT Project Accomplishments in Nepal 

Provider Competence: Ensuring Appropriate Screening & Quality Counseling: The success of SDM depends on providers’ ability to adequately screen for method eligibility and appropriately counsel eligible clients. FACT staff applied the KIT to 51 health facility providers and nine RANMs during the project as part of supportive supervision and to determine providers’ capacity for accurate screening and correct counseling on a fertility awareness-based method. 
  • 98% of health facility providers and 100% of the RANM correctly screened client for methods eligibility
  • Most FP providers accurately explained key SDM counseling messages 
Correct Use and Couple Satisfaction: Follow-up visits were conducted with 74 women three months after they were counseled and began using SDM. Questions focused on clients’ experiences, satisfaction with the method, and whether they had continued to use the method or not. All women knew to move the ring daily and see a provider or RANM if they had pregnancy concerns or questions about the method. Almost all knew to see a provider if their period started before the darker brown bead, i.e. short cycle (96%) or did not start after the last brown bead, i.e. long cycle (96%). The majority of clients (82%) reported discussing how to manage the fertile days and agreeing to adhere to abstaining or using a barrier method during those days.
Satisfaction and continuation:
  • 82% obtained CycleBeads from a health facility
  • 88% were still using CycleBeads after three months and were satisfied with the method 
  • 12% stopped method-use due to irregular cycles, switching to another method, or partner migration 
Managing fertile days: 
  • 97% used condoms or did not have sex during fertile days 
Knowledge of appropriate SDM use: 
  • 80% explained the essential points of correct SDM use 
Husbands’ support: 
  • 82% reported that their husband supports method-use in conversation and in practice 

Continued Expansion of SDM in Nepal

Following a successful pilot study, the Rupandehi experience – integrating SDM with CycleBeads using a systems approach that addresses several logistical concerns about distribution of the method – provides a model for further expansion of the method to other districts. While SDM’s effectiveness and method continuation by users has been amply tested through a clinical trial and multiple impact and operations research studies, the evaluation of the integration effort in Rupandehi confirmed local users’ ability to use the method correctly and its acceptability as a modern fertility awareness method in the Nepal context. Resources for services, logistics, and monitoring were adapted and remain available for further expansion of SDM services in Nepal and beyond. Resources for training are available upon request.