Introducing a Natural Family Planning Method in Albania

Family planning was an essential element of the 5-year Albania Child Survival Project (ACSP), which the American Red Cross (ARC) and the Albania Red Cross together implemented in mostly rural Diber Prefecture in eastern Albania. Following its conclusion in September 2008, ARC published this 8-page case study to explore the extent to which ACSP succeeded in its goal of improving the health of women of reproductive age and children 0 to 59 months old.

Statistics and historical data offered in the opening sections of the report serve to provide context for the ACSP. In short, the authors characterise Albania as a society with historically high fertility, due largely to rigid patriarchal norms. Although 9 of 10 Albanian women have heard of at least one modern family planning method, ACSP baseline research found that the contraceptive prevalence rate in Diber was 9% in 2003 and the unmet need for modern family planning methods was 94%. About 51% of respondents were trying to meet family planning needs with withdrawal, periodic abstinence, and a heavy reliance on abortion when other methods failed. In addition to the fact that physical access to a facility that offered family planning services was often hampered, less than half of current users felt that modern methods were safe, easy to use, and effective.

The authors detail the core ACSP activities, which centred around face-to-face communication designed to spread information about and shape behaviour around contraception use. The project organised a network of village nurse-midwives and Red Cross volunteers that worked to facilitate women's family planning support groups, offer household-level counselling, and refer women for Ministry of Health (MOH)-approved contraceptives, either at the nearest commune-level health centre or in a woman's own village if it contained a pilot delivery point. The project promoted all MOH-approved methods: oral contraceptives, condoms, injectables, the intrauterine device (IUD), and natural contraception, including the lactational amenorrhoea method (LAM). Included in this category of natural contraception - and the topic of the case study - was the Standard Days Method (SDM), which the ACSP introduced to Albania in 2006.

As explained here, SDM is a fertility awareness method developed by researchers at the Institute of Reproductive Health at Georgetown University School of Medicine in the United States. SDM has been determined to be especially attractive to couples who fear the side effects of other modern methods and/or in cultures where barrier and hormonal methods are viewed negatively. One tool used as part of this method are CycleBeads, a colour-coded string of beads that comes with a flexible rubber ring. On the first day of her period, the user moves the ring to the red bead. She then moves one bead every morning until the start of her next period. She (and her partner) can clearly see white beads (which mark the days that the user is likely to get pregnant) and brown beads (which mark the days that she is not likely to get pregnant).

ACSP and MOH staff trained 89 providers (family doctors, maternity health staff, counsellors, and village nurse-midwives) from the 25 health centres in 3 districts of Diber on the use of SDM. Data for this case study were collected from 17 of these sites, where family planning providers received one additional day of training on how to document their counselling experiences through intake forms, follow-up monitoring sheets, and exit forms. Detailed findings are shared in the case study; here is an excerpt illustrating central conclusions:

"...ACSP found that SDM was the second-most popular method (after the pill) among 254 women who chose a modern method to fulfill their stated interest in both spacing births and limiting their family size. Some women actually used the method to return to fertility. Most women who chose to discontinue SDM and switched to another modern method chose to use condoms. More educated and slightly older women chose SDM in the study....The study results show that women who chose SDM overwhelmingly did so because they felt that it had no adverse effect on their health. ACSP found that SDM was easily understood by both provider and client. Family planning clients found the method to be safe and easy to use, and only one case of method failure was recorded.

The Albanian MOH has since incorporated SDM training for health providers into its family planning curriculum. Supervision is crucial to ensure quality of counseling sessions and follow-up. This will require additional resources and management commitment by district health center directors. Even though individual counseling sessions for SDM users require somewhat more time than for user of other methods, it is notable that SDM discontinuation was not a direct result of client dissatisfaction or fear of side effects. It is also recommended that couples receive more than one counseling session and providers counsel clients while demonstrating how to use the method with Cyclebeads®."