Scaling up health innovation: Fertility awareness-based family planning goes national

There is no guarantee that a successful pilot program introducing a health innovation can be expanded successfully to the national, regional, state or even metropolitan level because scaling up is typically complex and difficult.

A new study from Georgetown University's Institute for Reproductive Health reports on the results of the successful large-scale implementation, in a low resource environment, of the Standard Days Method, a highly effective fertility awareness-based family planning method developed by Institute researchers. Lessons learned from making this family planning method available on a national level in a low resource environment may help in scaling up health innovations of many types in the United States and around the world.

The study describes how a successful pilot program to integrate the Standard Days Method into existing Ministry of Health services was scaled up nationally in Rwanda, one of the poorest countries in the world. The researchers report that much of the success of the Standard Days Method scale-up effort was due to systematic use of monitoring and evaluation of data enabling midcourse corrections.

Based on reproductive physiology, the Standard Days Method identifies the days in the menstrual cycle when a woman can get pregnant if she has unprotected sex. CycleBeads®, a color-coded string of beads, helps women track the days of their cycles when they are most likely to get pregnant. The method works best for women with cycles that usually range from 26 to 32 days.

If the woman does not want to get pregnant, she and her partner avoid unprotected sex on days 8 through 19 of her cycle. A 2002 study found the Standard Days Method to be 95 percent effective when used correctly. The U.S. Agency for International Development and the World Health Organization have recognized the Standard Days Method as a modern, evidence-based contraceptive practice.

"Scaling up isn't easy in any environment, especially a low resource one. Many successful and promising projects never go beyond the pilot stage," said Institute for Reproductive Health Director Victoria Jennings, Ph.D., a co-author of the new study.

"Our success is due, in large part, to the fact that we began the project with the end in mind—with a design that encourages the buy-in of diverse stakeholders, is sensitive to political change, and allows us to make mid-course modifications." Jennings is a professor of obstetrics and gynecology at Georgetown University and a co-developer of the Standard Days Method and CycleBeads.

The study, "Systems Approach to Monitoring and Evaluation Guides Scale up of the Standard Days Method of Family Planning in Rwanda" is published in the current (May 2014) issue of Global Health: Science and Practice, an open access peer-reviewed journal. Authors, in addition to Jennings, are Susan Igras, MPH; Irit Sinai, Ph.D.; and Rebecka Lundgren, MPH, of Georgetown University's Institute for Reproductive Health in Washington; Marie Mukabatsinda, R.N. of the Institute's Kigali, Rwanda office and Fidele Ngabo, M.D. of the Rwandan Ministry of Health in Kigali.

With a national fertility rate of more than six children per mother, almost 40 percent of women of reproductive age in Rwanda had unmet need for a modern contraceptive method at the time the project described in the Global Health: Science and Practice paper began. Scale-up of the Standard Days Method program is continuing in Rwanda.

The Institute for Reproductive Health has worked to introduce and scale-up the Standard Days Method around the globe including in the United States, India, Philippines, Guatemala, Bolivia, Peru, Albania, Benin, Uganda and Madagascar, in addition to Rwanda. Tool-kits and other online resources are available in English and additional languages on the Institute website.

"As our study shows, we are successful in Rwanda in bringing new women to family planning, many of whom had no interest in permanent, in long acting or in chemical contraceptive methods," Jennings said. "The highly effective, low-cost Standard Days Method, which is easy to use and has no side effects, fills an unmet need. That need exists around the world. For a growing number of women and their partners the answer is the Standard Days Method using Cyclebeads or the online iCycleBeads™ smartphone app."