Fertility Awareness Benefits Couples

Fertility awareness involves education about the menstrual cycle and its relationship to reproductive health. In a broader sense, it includes an understanding of attitudes and cultural beliefs as they relate to reproductive functions. This knowledge is an important element of quality care in family planning programs.

Often, fertility awareness is taught only to couples who want to use natural family planning methods, and teaching is limited to recognition of biological signs that indicate ovulation is taking place.

However, learning about the broader topic of male and female fertility can benefit users of all types of contraceptives. Couples are better able to understand when pregnancy is most likely to occur and when it is least likely to occur; better able to understand how contraceptives affect women's menstrual cycles and ovulation, such as the presence of amenorrhea among some hormonal contraceptive users; better able to understand how some contraceptives affect men's fertility; better able to understand the effects of contraception on other aspects of health; and better able to recognize changes that may indicate potential reproductive health problems, such as sexually transmitted diseases (STDs). In addition, fertility awareness can help women and men understand the process of menopause and the physical and emotional changes that occur when women's reproductive capabilities end.

"To regulate your fertility, you first have to be aware of it," says Dr. Roberto Rivera, FHI corporate director for international medical affairs. "Fertility awareness goes beyond family planning, but it has an important relationship to family planning. Incorrect use or discontinuation of contraceptives is sometimes because of limited awareness of fertility."

A drawing, by a Guatemalan woman after she received fertility awareness training, correlates the menstrual cycle with the agricultural seasons. The days when conception may occur are depicted by rainy weather. PAMI/PATH/IRH

"Knowledge is an enabling factor," adds Dr. Carlos Huezo, medical director of the International Planned Parenthood Federation (IPPF) in London. "The more individuals know, the better they will be able to cope with the important practice of family planning. Knowing how the process of reproduction works is important for both members of a couple because they will be able to share the responsibilities and behaviors required to meet reproductive health goals."

Fertility awareness is often narrowly defined as a basic understanding of reproductive anatomy and physiology.1 But many experts emphasize that fertility awareness is more than the ability to detect physical changes related to the menstrual cycle. Fertility awareness also involves understanding how emotions, behaviors and cultural factors relate to fertility. Many experts have expanded the definition to include a couple's ability to use and apply this basic information in their everyday lives and the ability to discuss the information with sexual partners and with health providers, says Dr. Victoria Jennings of the Institute for Reproductive Health (IRH) at Georgetown University in Washington.

"Knowing about reproductive physiology helps women and men to make informed decisions, not just about family planning but about their reproductive behavior," says Dr. Soledad Dםaz, a consultant with the Instituto Chileno de Medicina Reproductiva in Santiago, Chile.

While men's bodies are capable of producing sperm at any time after puberty, women's bodies normally produce only one egg a month in a cyclical process that is governed by a series of hormonal changes. Pregnancy is most likely to occur at or around the time the egg is released from the ovary (ovulation), about midway in the woman's menstrual cycle. If pregnancy does not occur, the lining of the uterus sheds and a woman experiences vaginal bleeding. This biological process, known as menstruation, begins during adolescence (menarche) and continues until the woman reaches menopause at about 50 years old. If a woman is pregnant, the lining of the uterus does not shed. A missed menstrual period is often the first sign of pregnancy for many women.

Lack of understanding

Although women typically have their menstrual periods for some 40 years, many people worldwide do not understand how menstruation occurs or how the menstrual cycle is related to conception. A study of more than 10,000 women of reproductive age in Honduras found that most women could not correctly identify the fertile phase of the menstrual cycle -- only 7 percent said correctly that the fertile time was around the midpoint of the menstrual cycle.2 In Rumania, a 1993 reproductive health survey found that 54 percent of respondents knew when during the menstrual cycle pregnancy was most likely to occur, but 33 percent did not know a woman could get pregnant the first time she had sexual intercourse.3 A study of nearly 3,000 young adults in Senegal, conducted by FHI and the Comitי d'ֹtude sur les Femmes, la Famille et l'Environnement en Afrique, found that only one-third of men and women ages 15 to 19 correctly identified the time of the menstrual cycle when a woman can become pregnant.4

Education about all phases of the menstrual cycle should be a key component of fertility awareness programs, say health experts. Yet, in many cultures, menstruation remains a subject shrouded by myth and mystery, and a topic discussed by women, not men.

In some cultures, menstruation is viewed as a sign of uncleanness. Women's activities, including participation in domestic chores and religious rituals, may be restricted during menstruation. A study in India found that about half of 65 rural adolescent girls surveyed were restricted from taking part in religious activities, attending marriages and playing. A smaller percentage were restricted from attending school.5 In Zimbabwe, a young woman asked health experts "if your father sees the blood from your monthly period, will he die?" Another asked if a menstruating woman who holds a newborn baby will cause the infant to lose weight.6

In addition to limiting women's activities, menstrual bleeding also can affect a couple's sexual life. Some religions prohibit sexual intercourse during menstrual bleeding, and other couples avoid sex during menstruation because they believe it is unhealthy or unclean. A study of more than 500 men and women in Chile found that some 70 percent avoided sex during menstrual bleeding.7 The reasons couples gave were that sex during menstruation was not hygienic, uncomfortable, "dirty" and something they were taught not to do.

"Many women we see believe the time immediately after menstruation is the fertile period. They use this time to avoid pregnancy, and that is the wrong way," says Margarita Dםaz, director of training and education on sexual and reproductive health at the Centro de Pesquisas e Controle das Doencas Materno Infantis de Campinas (CEMICAMP) in Brazil.

While understanding the menstrual cycle is an important part of fertility awareness, understanding the absence of menstrual bleeding (amenorrhea) also is important. Menstrual blood is viewed by some as "bad blood" that must be expelled in order for the woman to remain healthy.

Women who use hormonal contraceptives should be counseled that these family planning methods can alter their menstrual bleeding patterns and that amenorrhea is common among women who use progestin-only methods, such as progestin-only pills (or mini-pills), the injectable depot-medroxyprogesterone acetate (DMPA or Depo-Provera) and the Norplant implant. For users of hormonal contraceptives, amenorrhea is rarely a sign of pregnancy, or a sign of disease. Some women in a variety of cultures view this side effect of progestin-only methods as an advantage.8

Lessons learned

Family planning and women's health programs typically offer fertility awareness education in connection with teaching natural family planning techniques. In so doing, they also improve clients' knowledge about family planning choices, prevention and treatment of STDs, and other reproductive health issues.

In Brazil, women who come to family planning clinics offered by CEMICAMP in the state of Sדo Paulo attend a one-hour session on how contraceptive methods affect a woman's body, including her menstrual cycle; how the methods prevent pregnancy; and potential side effects of contraceptive use. Afterward, each woman is counseled privately about which method she may want to choose.

"It is very useful for women to understand what menstruation is and what it means, why women have menses each month," says Margarita Dםaz of CEMICAMP. "When they understand, they understand why some contraceptives change their menstrual patterns. When they understand, they can better accept side effects. If a woman uses Depo-Provera, she needs to know amenorrhea is a potential side effect. That is an important thing to know."

Knowing how to identify the fertile phase can be helpful to some users of barrier contraceptive methods, Margarita Dםaz says. Some couples prefer to use contraception, such as condoms or diaphragms, only during the fertile time.

Often a first step in educating clients is training providers, Margarita Dםaz says. "There are physicians and nurses working in family planning clinics and they are not sure how to calculate the fertile period," she says. "They divide the month into three sections -- 10 infertile days, 10 fertile days, 10 infertile days." This approach would only be effective among women with 28- to 31-day cycles, the average for all women. From woman to woman, however, cycles can very significantly.

A man remains fertile until death, as this handkerchief by a client in Guatemala shows. Different life stages are depicted, with a border of sperm from puberty to death. PAMI/PATH/IRH

In the southeast African country of Tanzania, a program designed to educate urban slum dwellers in Dar es Salaam about family planning begins with information on menstruation. Illiterate women and men are taught about menstruation and reproductive physiology by community workers, who provide education sessions in people's homes, at social gatherings and in markets.

"We begin by letting them know how their body works and what benefits they can gain from family planning," says Margaret Kotta, project director of Shirika La Uchumi La Wanawake Tanzania (SUWATA). Fertility awareness education has been "a very important way of helping communities accept family planning," she says. In some cases, education extends to community leaders, who are essential in promoting the family planning programs.

In Bolivia, the Program for Appropriate Technology in Health (PATH) and the Centro de Investigaciףn y Educaciףn Social conducted research among a group of 120 people living in poor urban and rural communities, says Carolina Godinez, a program officer for PATH. Most couples said they would like to space births and felt that the mother was healthier when children were born three years or more apart. Nearly three-fourths of couples said periodic abstinence was the best way to avoid pregnancy, yet only some 15 percent could identify the fertile phase of their menstrual cycle. Most focus group participants avoided sex during menstrual bleeding, believing incorrectly that this was the most fertile time in a woman's cycle.

In Guatemala, PATH worked with the Programa de Apoyo Materno Infantil to conduct research among 129 men and 114 women who were sexually active. Many of them viewed menstruation as a sickness, but a "good sickness," says Godinez. Menstrual bleeding was considered healthy because it was expulsion of "dirty" blood. Women were unaware of changes in cervical mucus. Couples knew amenorrhea could be a sign of pregnancy, but there was confusion about when during the menstrual cycle a woman was most likely to get pregnant.

PATH used the information to develop training materials on fertility awareness. For example, women are taught to use coins, yarn or rulers to help measure the length of their menstrual cycle and to anticipate their fertile days. "Fertility awareness should not only be seen as a vehicle to promote family planning," says Godinez. "We believe this is a reproductive right."

Some experts note that more research is needed on how a person's knowledge about fertility awareness affects contraceptive use and other aspects of reproductive health.

Teaching adolescents

Some health programs that offer fertility awareness education place special emphasis on adolescents. One of these is the Family Life Movement of Zambia. In-school and out-of-school programs are offered for young people ages 11 to 25 in Lusaka, and topics of discussion include reproductive health, self-esteem, and family relationships. A central component of the family life curriculum is fertility awareness.

"We try to help young people understand how their bodies work from a reproductive perspective, and this helps them understand the relationship between puberty and fertility," says Mwape Lubilo, national youth programs coordinator. "This helps to reduce teenage pregnancies, particularly those that occur as a result of ignorance. We also look at STDs, with emphasis on early treatment and prevention.

"Fertility awareness has to be the basis for any family planning education," she says. "Young people need to see the relationship between family planning and [reproductive] physiology. If we could get young people to understand their fertility, we could dispel a lot of myths and misconceptions about reproductive health and family planning."

The Girls Power Initiative (GPI) in Nigeria is a nongovernmental program for adolescents that now reaches more than 200 teens in Calabar and Benin City. The program offers weekly classes and discussions for girls ages 10 to 18 on reproductive health and reproductive rights.

Discussions on reproductive health begin with education about the menstrual cycle. To help teens better comprehend the relationship between the menstrual cycle and fertility, GPI has developed a manual called Understanding and Knowing Your Body. The manual contains an explanation of the menstrual cycle, including menses and ovulation; information on how to monitor the menstrual cycle and predict ovulation; information about how a girl can and cannot get pregnant; and a chart, listing methods of family planning and their effectiveness "if you are very careful each time" and "if you are not very careful each time."

Dr. Bene Madunagu, one of two program coordinators, said one of the reasons the program is offered is that young girls say they want information on reproductive health but are often too embarrassed to talk with their parents. GPI encourages girls to discuss concerns with parents; one recent assignment was for each girl in the class to discuss a reproductive health issue with her mother.

Involving men

Because most modern contraceptive methods are designed for use by women, men are often overlooked in both family planning and fertility awareness programs. In Bolivia, more than 1,500 couples in seven cities were questioned about family planning use. While women received most of their information from health clinics and hospitals, men received most of their information from male friends or work colleagues.9

"Involvement of men is critical," says Geeta Oodit of IPPF's Africa liaison office. "It's very critical in pregnancy prevention as well as AIDS prevention. You cannot avoid educating men, but educate women, and then the woman asks the man to wear a condom. Education can lead to cooperation."

At the CEMICAMP clinic in Brazil, men are invited to attend fertility awareness sessions with their female partners. Only a few men have come since the program was first offered a year ago, but Margarita Dםaz says inclusion of men is an important step.

"At the clinic, we are trying to work with men to teach about pregnancy and STD prevention," she says. "They need to know how women's bodies function, and women need to know the same things about men. In order to have a better understanding about reproductive health issues, men and women need to have the same knowledge, not different."

The SUWATA project in Tanzania sees male involvement as an important factor in contraceptive acceptance and continuation. "Many women complained of resistance from husbands and boyfriends," says Margaret Kotta. "Women used family planning secretly." Involving men in fertility awareness programs can make it easier for couples to discuss family planning and "can even bring them to make a joint decision."

-- Barbara Barnett

References

1. Hermann CB, Williamson NE, McCann M, et al. Periodic Abstinence in Developing Countries. (Columbia; MD: Institute for Resource Development, 1986) 2.
2. Honduran Ministry of Public Health, the Association for Family Planning in Honduras, Management Sciences for Health, and Family Health International. Epidemiology and Family Health Survey, Honduras 1987, Final Report. Research Triangle Park: Family Health International, 1989.
3. Serbanescu F, Morris L. Reproductive Health Knowledge and Attitudes, Rumania Reproductive Health Survey, 1993, Final Report. Bucharest: Institutl de Ocrotire a Mamei si Copilului, 1995.
4. Nare C, Katz K, Tolley E. Measuring Access to Family Planning Education and Services for Young Adults in Dakar, Senegal. Research Triangle Park: Family Health International, 1996.
5. Drakshayani DK, Venkata RP. A study on menstrual hygiene among rural adolescent girls. Indian Journal of Medical Sciences 1994;48(6):139-43.
6. Getting to Know Our Bodies. Harare: Women's Action Group, Nd.
7. Barnhart K, Furman I, Devoto L. Attitudes and practice of couples regarding sexual relations during the menses and spotting. Contraception 1995;51(2):93-98.
8. For a more thorough discussion of this topic, see Snowden R, Christian B, ed. Patterns and Perceptions of Menstruation. New York: St. Martin's Press, 1983.
9. The Population Council. Male barriers to family planning: Myth or reality? Research News. New York: The Population Council, 1994