Training in the symptothermal method to ameliorate unmet need for family planning: knowledge, attitudes and satisfaction

Abstract

Background

Addressing the unmet need for family planning to prevent unintended pregnancies is a high priority for women's health, and training as an element of the symptothermal method (STM) is deemed to be an effective strategy. This study assessed training on knowledge, attitudes and satisfaction with STM to ameliorate the unmet need for family planning.

Methods

The study adopted a pre–post study design. A total of 136 women participated in this study. Knowledge and attitudes were assessed pre- and post-training as well as the level of satisfaction, using cycle charts and questionnaires. The χ² test (p<0.05) was used to analyse data on sociodemographics, attitudinal characteristics and satisfaction. Paired samples t-test (p<0.05) was used to establish the mean difference of the two groups (knowledge and attitudes pre- and post-training).

Results

The paired samples t-test established that women have significant (t=−058.716, p=0.001) knowledge post-training (1.0000±0.00000) compared with pre-training (0.0682±0.01587) on STM. There was no significant (t=−1.419, p=0.158) difference in attitudes towards STM pre- and post-training. There was a significant level of satisfaction (p=0.001).

Conclusions

Our interventional study has enabled women to acquire robust knowledge, positive attitudes and satisfaction with the utilization of STM. This has ameliorated unmet need for family planning among participants.

Introduction

The symptothermal method (STM) is a fertility awareness–based method that combines cervical mucus secretion, basal body temperature and the application of calender guideline to identify fertile days and absolutely infertile days of a woman's cycle. It is aimed at the goal of either preventing or achieving pregnancy.^1,2 The utilization of STM enables women to have a robust understanding of their reproductive cycle for the purpose of family planning.³ The symptothermal method is highly effective for preventing pregnancy, as there is <1 pregnancy per 100 women per year when it is correctly utilized.⁴ Furthermore, STM does not involve pills or devices, it has no side effects, and it is affordable, accessible and involves no medical supervision. Once trained, a woman/couple usually can begin using STM at any time.^4,5

The term ‘unmet need for family planning’ refers to the proportion of fecund sexually active women who have a desire to either delay the next pregnancy for at least 2 y or stop childbearing, but not using any method of contraception.^6,7 These women have higher risks of unintended pregnancies and the associated consequences.⁸ In modern practice, devices and hormonal contraceptives such as the intrauterine device (IUD) and oral contraceptives, have been promoted as the best ways to prevent unintended pregnancy in most parts of the world.⁵ However, most women do not utilize nor do they want to use these devices/hormonal methods of birth control due to associated side and adverse effects as well as religious and cultural reasons, which has led to a high unmet need for family planning.^9,10

Training is vital for knowledge acquisition and attitudes towards utilizing STM, as training is a learning process whereby people acquire skills, concepts, knowledge and attitudes to aid the achievement of their goals.¹¹ Therefore, innovative training in STM will influence women's behaviour and yield results that will provide a long-term focus to enhance women's abilities to utilize STM.

Globally, STM natural family planning is a well-accepted approach across several Western cultures and it has always been viewed as being beneficial to couples’ self-knowledge, their relationship and satisfaction with the frequency of sexual intercourse.¹² In developing countries, >200 million women and girls who desire to space or limit pregnancy are not using modern contraceptives and lack access to effective or safe family planning methods.^13,14

In sub-Saharan Africa, 25% of women of reproductive age have an unmet need for family planning.¹⁵ In East Africa, according to the Demographic and Health Survey (DHS) of Tanzania, 22% of married women have an unmet need for family planning.^16,17 In Uganda, Rwanda, Burundi and the Democratic Republic of Congo, the reported unmet need for family planning is 34%, 21%, 32% and 28%, respectively.¹⁸

In Kenya, the unmet need for safe family planning in the country stands at 33%, of which 14% are married women and 19% are sexually fecund unmarried women. The unmet need for family planning across various counties in the country according to the Kenya National Bureau of Statistics in collaboration with the Ministry of Health is Kisumu County, 16.4%; Nyamira, 15.9%; and Migori, 20.1; among others.¹⁹

In Kisumu County, there is evidence of the unmet need for family planning, as most women complain of contraceptive-related complications including hypertension, deep vein thrombosis and inaccessibility to appropriate, effective and timely contraceptives.²⁰ The lack of safer family planning methods leads to a greater unmet need for family planning, which stands at 16.4% in the county.²¹

Despite the proven benefits of STM, no study has been conducted in Kisumu County on STM to ameliorate the unmet need for family planning. The approach for the successful utilization of STM requires innovative training techniques.²² Therefore, this study assessed training on knowledge, attitudes and satisfaction with STM to ameliorate the unmet need for family planning.

Methods

Study design

The study adopted a pre- and post-study design that involves measurement of the variable of interest before and after the intervention (training on STM) in the same participants.

Study population

The population for the study included married and fecund unmarried women of reproductive age (15–49 y) with an unmet need for family planning, who met the eligibility criteria and were recruited and exposed to STM for the first time.

Inclusion criteria were women of reproductive age (15–49 y), not using any contraceptives, with the intention to prevent pregnancy naturally, willing to record family planning intention (intention to avoid pregnancy) at the start of each cycle, who agreed not to use other forms of contraceptives during the period of the study, had used hormonal contraceptives but had not been using them for the last 3–6 months and who gave their consent to participate in the study for at least 12 menstrual cycles.

Exclusion criteria included women without sexual partners, those having medical reasons never to be exposed to conception and not living in the study area.

Recruitment of participants and procedure for data collection

The data collection team consisted of 3 community health workers (CHWs) and 15 community health volunteers (CHVs) working under the guidance and supervision of the CHWs. Before the commencement of data collection after obtaining all necessary approvals, the principal investigator (PI) provided adequate training to all team members on the nature of the study and the modalities of data collection. A total of 136 women were recruited into the study. After obtaining their informed consents, participants were trained in STM by the PI. The PI adopted the coaching style of training where the trainer tries to have the trainees focus on themselves.

The training was conducted for 3 months (June–September 2023) based on individual serial time (individual start date of menstruation) in selected sub-county hospitals within Kisumu Central and Kisumu East subcounties. The first month of the training exercise focused on the introduction of STM, establishment of menstrual cycle length and recognizing and recording of symptoms associated with the fertile phase in the menstrual cycle. The last 2 months aimed at recognizing, recording and confirming the start of the fertile phase; pinpointing or confirming that ovulation occurred; recognizing, recording and confirming the start of the absolutely infertile phase; and confirming when the next cycle (menstruation) begins after pinpointing ovulation.

The training was carried out in person twice in 1 week for 90 minutes per training session for the first 1-month menstrual cycle. Subsequently, training sessions continued with the researcher training participants via daily phone calls, WhatsApp Forums and short message services (SMS) for their second and third menstrual cycles. During the guidance via phone calls, participants were guided to confirm and record fertility signs in their cycle charts, such as their infertile (IF) days, fertile (F) days, peak fertile (PF) days, ovulation (O) day and beginning of the next menstruation (BM), as well as recording their basal body temperatures taken rectally or under the armpit each morning on waking up.

Training materials included cycle charts, a board and markers, human reproductive charts, cervical mucus secretion charts, a digital thermometer, a handbook for personal study, a laptop and a projector. Participants were given their individual thermometers to take their basal body temperatures every morning on waking up, a pen for recording data and the researcher-developed training manual within which cycle charts were incorporated for recording their fertility signs. The cycle chart for each month was in duplicate (participant's and researcher's copy). The cycle chart provides a visual display of the information/charting pattern of all fertile signs and the evolution of the ovulation process during a complete menstrual cycle (Table 1).

Table 1:

STM cycle chart (June 2023)

At the end of each menstrual cycle (June–September 2023), the completed cycle charts were collected from participants by the CHVs and submitted to the researcher. After 3 months post-training, based on the women's menstrual cycle length, the women were reassessed (post-training) on their knowledge, attitudes and satisfaction towards STM utilization using structured questionnaires. With respect to knowledge, information on safety, effectiveness, accessibility, affordability and interests were obtained. On attitudes towards STM, information on intentions, opinions, beliefs and needs were elicited. Regarding satisfaction, information on effectiveness, impact on sexual and reproductive health and impact on relationship dynamics were obtained.

Data analysis

Quantitative data obtained from this study were entered into Excel (Microsoft, Redmond, WA, USA), cleaned and transferred to SPSS version 23 (IBM, Armonk, NY, USA) for analysis. Using bivariate analysis, the χ² test at a level of significance of 0.05 was used to analyse data on sociodemographic and attitudinal characteristics. The paired samples t-test at a level of significance of 0.05 was used to establish the mean difference of the two groups in the knowledge and attitudes towards STM pre- and post-training, while the χ² test was used to establish the satisfaction of women towards STM at a level of significance of 0.05.

Results

Sociodemographic and attitudinal characteristics

It was revealed that there was a significant association between age and duration intended to prevent pregnancy (χ²=19.389, df=10, p=0.044). It was established that marriage duration had a significant association on family planning intention (χ²=24.491, df=12, p=0.015) and duration intended to prevent pregnancy (χ²=30.452, df=12, p=0.001). There was a borderline significance between parity and family planning intention (χ²=14.024, df=8, p=0.059) (Table 2).

Table 2:

Cross-tabulation and χ² analysis of sociodemographic and attitudinal characteristics of study participants (n=136)

	Family planning intention			Duration intended to prevent pregnancy
Variables	Spacer	Limiter	Undecided	1–2 y	3 y	≥4 y	Total
Age (years), n
15–19	2	0	0	2	0	0	2
20–24	30	4	8	12	11	19	42
25–29	23	3	2	3	13	12	28
30–34	18	2	3	4	5	14	23
35–39	25	3	3	6	12	13	31
40–44	7	3	0	3	0	7	10
Total	105	15	16	30	41	65	136
	χ2=8.220, df=10, p=0.596			χ2=19.389, df=10, p=0.044*
Marital status, n
Married <1 y	8	1	0	5	2	2	9
Married 1–2 y	13	2	0	8	4	3	15
Married 3–5 y	24	2	2	2	14	12	28
Married >5 y	46	5	6	8	15	34	57
Single	13	4	8	6	6	13	25
Divorced	1	0	0	1	0	0	1
Widowed	0	1	0	0	0	1	1
Total	105	15	16	30	41	65	136
	χ2=24.491, df=12, p=0.015*			χ2=30.452, df=12, p=0.001***
Parity, n
0	3	1	3	2	2	3	7
1	31	3	7	13	13	15	41
2	24	3	0	8	6	13	27
3	26	5	5	1	12	23	36
≥4	21	3	1	6	8	11	25
Total	105	15	16	30	41	65	136
	χ2=14.024, df=8, p=0.059*			χ2=12.568, df=8, p=0.140
Religion, n
Christian	102	15	15	28	41	63	132
Islam	3	0	1	2	0	2	4
Total	105	15	16	30	41	65	136
	χ2=1.071, df=2, p=1.000			χ2=2.705, df=2, p= 0.287
Occupation, n
Working	28	5	6	8	11	20	39
Trainee/student	8	2	3	2	5	6	13
Housewife	39	5	4	11	15	22	48
Unemployed	30	3	3	9	10	17	36
Total	105	15	16	30	41	65	136
	χ2=4.118, df=6, p=0.691			χ2=1.043, df=6, p=0.978
Education, n
Primary	28	1	2	7	10	14	31
Secondary	53	10	6	15	19	35	69
Tertiary	24	4	8	8	12	16	36
Total	105	15	16	30	41	65	136
	χ2=8.463, df=6, p=0.213			χ2=3.658, df=6, p=0.728

Statistically significant at *p≤0.05, ***p≤0.001.

Knowledge and attitudes of women towards STM pre- and post-training

On pre-training, the majority of the study participants (127 [93%]) did not have knowledge of STM, while 9 (7%) had knowledge of STM. On attitudes towards STM, most (99.8%) had positive attitude, while few (0.2%) did not have positive attitudes towards STM. Regarding post-training, our results revealed that after the intervention, which involved training women in STM, all the study participants (100%) had complete knowledge and showed positive attitudes towards STM (Table 3).

Table 3:

Frequency, percentages and mean scores of knowledge and attitudes of women (n=136) towards STM as a strategy to ameliorate the unmet need for family planning (pre- and post-training)

Knowledge of STM	Pre-training		Post-training
	Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)
Knowledge of STM
Have you heard about the symptothermal method (STM) of natural family planning?	25 (18.4)	111 (81.6)	136 (100)	0 (0)
Do you know how it works?	1 (0.7)	135 (99.3)	136 (100)	0 (0)
Do you know STM does not have side effects?	12 (8.8)	124 (91.2)	136 (100)	0 (0)
Do you know STM is highly effective in preventing pregnancy?	10 (7.4)	126 (92.6)	136 (100)	0 (0)
Are you aware you do not need medical supervision when using STM?	14 (10.3)	122 (89.7)	136 (100)	0 (0)
Do you know STM is affordable and readily accessible anywhere, anytime?	14 (10.3)	122 (89.7)	136 (100)	0 (0)
Are you aware that STM is not based on arithmetic calculation like the calendar method of natural family planning?	11 (8.1)	125 (91.9)	136 (100)	0 (0)
Are you aware that STM can be used irrespective of your menstrual cycle length, whether short, average or long?	6 (4.4)	130 (95.6)	136 (100)	0 (0)
Do you know STM will enable you to identify your fertile and infertile days in your menstrual cycle?	5 (3.7)	131 (96.3)	136 (100)	0 (0)
Are you aware that you need to check your cervical mucus secretion each day to identify your fertile and infertile days?	2 (1.5)	134 (98.5)	136 (100)	0 (0)
Do you know STM involves taking your body temperature every morning on waking to identify your fertile and infertile days to pinpoint ovulation?	2 (1.5)	134 (98.5)	136 (100)	0 (0)
Average score	9 (7)	127 (93)	136 (100)	0 (0)
Attitudes towards STM
Pre: Do you have need and would like to learn how to use STM in preventing pregnancy naturally? Post: Have you learned and need to continue preventing pregnancy naturally with STM?	136 (100)	0 (0)	136 (100)	0 (0)
Pre: Will your partner be supportive of your decision to learn about STM? Post: Will your partner continue to be supportive of your decision in utilizing STM?	135 (99.3)	1 (0.7)	136 (100)	0 (0)
Pre: Would you like to learn about the symptoms associated with your fertile and infertile days? Post: Have you learned about the symptoms associated with your fertile and infertile days?	136 (100)	0 (0)	136 (100)	0 (0)
Pre: Are you willing to learn how to check your cervical mucus secretion to identify your fertile and infertile days? Post: Have you learned and are willing to continue checking your cervical mucus secretion to identify your fertile and infertile days?	136 (100)	0 (0)	136 (100)	0 (0)
Pre: Are you willing to learn how to take your body temperature on waking each morning to pinpoint ovulation? Post; Have you learned and are willing to continue taking your body temperature on waking each morning to pinpoint ovulation?	136 (100)	0 (0)	136 (100)	0 (0)
Pre: Will STM use suit your religious and cultural beliefs? Post: Does STM use suit your religious and cultural beliefs?	135 (99.3)	1 (0.7)	136 (100)	0 (0)
Average score	135.7 (99.8)	0.3 (0.2)	136 (100)	0 (0)

Paired sample t-test analysis on mean difference in knowledge and attitudes towards STM (pre- and post-training)

Table 4 shows that for knowledge of STM pre- and post-training, there was statistical significance (t=−58.716, p=0.001). This implies that women have significant knowledge post-training (1.0000±0.00000) compared with pre-training (0.0682±0.01587). On attitudes towards STM, there was no statistical significance (t=−1.419, p=0.158) pre- and post-training. This implies that there was no difference between the mean attitudes of women towards STM pre-training (0.9975±0.00173) and post-training (1.0000±0.00000).

Table 4:

Bivariate (paired samples t-test) analysis on differences in knowledge and attitudes towards STM among women of reproductive age, pre-and-post training

Variables	Mean	SD	SEM	Mean difference	t	p-Value	Decision
Knowledge of STM
Pair 1
Pre-training	0.0682	0.18507	0.01587	−0.93182	−58.716	0.001	Significant difference in mean
Post-training	1.0000	0.00000	0.00000
Attitudes towards STM
Pair 2
Pre-training	0.9975	0.02014	0.00173	−0.00245	−1.419	0.158	No significant difference in mean
Post-training	1.0000	.00000	.00000

95% CI, df=135, p<0.05.

Level of satisfaction of STM post-training

The results show all participants (100%) agreed that STM is very effective in preventing pregnancy, has increased their self-confidence regarding sexual health and improved their understanding of fertility. At the bivariate level, women had a significant (p=0.001) level of satisfaction in the use of STM (Table 5).

Table 5:

Frequency, percentage and bivariate analysis of level of satisfaction with the STM among women of reproductive age, post-training

Satisfaction of STM	Agree, n (%)	Disagree, n (%)	Test statistics	p-Value	95% CI
STM is very effective in preventing pregnancy	136 (100)	0 (0)
Training in STM increases self-confidence regarding sexual health and improves the understanding of one's fertility	136 (100)	0 (0)
STM helps one's partner to understand her fertility	134 (98.5)	2 (1.5)	128.118	0.001***	0.000 to 0.022
Identifying the fertile days was easy	136 (100)	0 (0)
It was not challenging to abstain from sex during the peak fertile days	132 (97.1)	4 (2.9)	120.471	0.001***	0.000 to 0.022
Condom was used during most or all of the fertile days	12 (8.8)	124 (91.2)	95.559	0.001***	0.000 to 0.022
Abstinence was used during all of the fertile days	124 (91.2)	12 (8.8)	92.235	0.001***	0.000 to 0.022
The length of the absolutely infertile days, post-ovulation, was satisfactory	136 (100)	0 (0)
STM improves the sexual and social relationship between partners	136 (100)	0 (0)
Use of STM was very satisfactory	136 (100)	0 (0)
STM is worth recommending to others	136 (100)	0 (0)
Willing to continue utilizing STM for as long as possible	136 (100)	0 (0)

CI: confidence interval.

***Statistically significant at p≤0.001.

Discussion

This study was conducted to assess the knowledge and attitudes of women towards STM in both pre- and post-training and the satisfaction among women of reproductive age as a strategy to ameliorate unmet need for family planning in Kisumu County, Kenya. Our results revealed that there was significant (t=−58.716, p=0.001) knowledge post-training compared with pre-training in STM. This is in agreement with a previous report that training is imperative for STM to be successfully utilized and, once trained, women can begin utilizing it at any time.²²

On attitudes towards STM, there was no significant difference (t=−1.419, p=0.158) between pre- and post-training in STM. This is in line with previous studies showing that most women (92%) using the calendar method indicated substantial willingness to track additional biomarkers (e.g. daily temperature or cervical mucus) to enhance the effectiveness of their natural methods of contraception. This shows a positive attitude towards STM, which relies on tracking changes in multiple biomarkers, including cervical mucus and basal body temperature.²³

The findings on the level of satisfaction of women in STM utilization post-training showed that women are satisfied with the use of STM. The women (100%) agreed that STM is very effective in preventing pregnancy, has increased their self-confidence regarding sexual health and improved their understanding of fertility. They also agreed that identifying the fertile days was easy, identifying the length of the absolutely infertile days was satisfactory and that STM improved the sexual and social relationship between partners. As reported in a previous study, 75% of women who utilized STM said they were either ‘satisfied’ or ‘very satisfied’ with their frequency of sexual intercourse, 95% stated that using STM has helped them to know their body better and 65% stated that it has helped to improve their relationships.¹²

There was a significant association between sociodemographic (age, marriage duration and parity) and attitudinal characteristics (duration intended to prevent pregnancy and family planning intention), which is in agreement with previous studies showing that sociodemographic factors such as age, marital status, education level, religion and parity influence the use of natural family planning. Most of the participants were married (89%) and had three to four children.^12,24

Limitations

In assessing the level of satisfaction in STM utilization post-training among the women, our study did not capture the partners’ perspectives on their satisfaction level, which may cause selection bias.

Conclusions

Our study is the first to conduct a field trial on STM in Kisumu County as a strategy to ameliorate unmet need for family planning. Because of our interventional study, which involved training in STM, women have been able to acquire robust knowledge, positive attitudes and satisfaction with the utilization of STM. This has ameliorated the unmet need for family planning among these women in Kisumu County, Kenya.

STM as a natural family planning method does not have side effects, thus the women in this study who had concerns regarding the side effects of hormonal contraceptives are free from these concerns. STM does not need medical supervision and is readily available, affordable and accessible to couples everywhere, promoting socio-economic equality across the population as well as equity in the social distribution of health. Furthermore, since the participants were trained in STM, they can use it throughout their reproductive life. Their knowledge can in turn be passed to future generations, being beneficial to both the present and future generations.

More specifically, the acquired knowledge of STM has enabled these women to understand how their bodies work. The women are able to tell when they are fertile and infertile during their monthly cycles. This knowledge has helped them to prevent pregnancy and to enjoy pleasurable sexual experiences during their absolutely infertile days without fear of getting pregnant. This means they have the right to determine the number and spacing of their children and to have a satisfying sexual relationship.

To assess the effectiveness of this training, we conducted longitudinal monitoring with these same women as a follow-up study. Also, we plan to conduct further studies to evaluate other aspects of family planning beyond prevention of pregnancy with STM.

Appendix 1: Information for the STM

INTRODUCTION TO SYMPTOTHERMAL METHOD OF NATURAL FAMILY PLANNING

The symptothermal method (STM) is a natural family planning method that is used to avoid or aid pregnancy. It does not have any side effects that are associated with the use of pills or devices. The use of STM does not require medical supervision. It is affordable, reliable, easily accessible and highly effective when compared with other non-hormonal contraceptives such as intrauterine devices (IUDs) and condoms. Once learned, it can be used throughout a woman's reproductive life. It does not depend on prediction or arithmetic calculation like the calendar method of natural family planning. STM can be used by every woman irrespective of her cycle length—be it short, average or long. Women utilizing STM are able to tell when they are in their fertile days, when they ovulate and when they start their absolutely infertile days. However, for STM to be used, women need to spend a few months learning the method; it is not as useful as a birth control technique for those with multiple sexual partners, especially sex trade workers; there is a possibility of infection if fingers are unclean during cervical mucus observations; and unless couples communicate clearly and frankly with each other, this technique is not possible.

How to utilize STM

• Observing cervical mucus secretion each morning until the passing of the fertile phase.

• Taking body temperature each morning on waking until the end of the fertile phase.

• Looking out for other symptoms such as mid-pain and the position of the cervix until the passing of the fertile phase.

What to learn to avoid pregnancy

• Determining the time of the fertile phase

• Confirming the time of ovulation

• Determining the period of the absolutely infertile phase

Informed consent/information for participation in the research study

Title of the study: Utilization of the symptothermal method as a strategy to ameliorate unmet need for family planning among women in Kisumu County, Kenya

Principal investigator: Catherine Erosie Igben-Pender, Department of Public Health, School of Public Health and Community Development, Maseno University.

Before agreeing to participate in this study, it is important that you read and understand the following explanation. The content describes the purpose of the study, the study procedure (duration of the study, number of participants, benefits, risks and autonomy and confidentiality record), participants’ responsibility and contact details of the researcher.

Section 1: Study Description

The purpose of the study

• To determine training intervention of the symptothermal method as a strategy for ameliorating the unmet need for family planning among women in Kisumu County, Kenya.

• To establish the effectiveness of the symptothermal method as a strategy for ameliorating the unmet need for family planning among women in Kisumu County, Kenya.

The study procedure

Study duration, participants involvement and number of participants: In order to participate in the study ‘Utilization of the Symptothermal Method as a Strategy to Ameliorate Unmet Need for Family Planning among Women in Kisumu County, Kenya’, you have to undergo training in the symptothermal method (STM). The training will be conducted in the community and healthcare facilities as recommended by the Ministry of Health. The period of training will be 3 months followed by longitudinal monitoring. Therefore, you will be followed/observed by the researcher for a period of 12 months in order to determine the effectiveness of STM. The process of follow-up will involve you submitting your cycle charts (which will be provided to you) at the end of every menstrual cycle to the community health volunteers (CHVs).

There will be 136 participants for this study of women of reproductive age (15–49 years) who have an unmet need for family planning and satisfy the inclusion and exclusion criteria.

Inclusion criteria

• Women who are fecund and have never used or not currently using any contraceptives.

• Women with intentions to prevent pregnancy naturally.

• Women willing to record family planning intentions (intentions to avoid pregnancy) at the start of each cycle.

• Women who agree not to use other forms of contraceptives during the period of the study.

• Women who once practiced the use of hormonal contraceptives but have not used the method in the last 3–6 months.

• Women who give their consent to participate in the study for at least 12 monthly cycles.

Exclusion criteria

• Women without sexual partners.

• Women having medical reasons never to be exposed to conception.

• Women not living in the study area.

Benefits and risks

This research will be beneficial to women/couples who participate in the study. STM as a natural family planning method does not have side effects, thus women will be free from the physical and negative psychological effects of using most hormonal contraceptives. STM does not need medical supervision, protecting the individual's privacy. It is readily available and accessible to couples everywhere, thus promoting socio-economic equality across the population as well as equity in social distribution of health regarding STM. Furthermore, the participants will be trained in STM and, once learned, it can be used throughout their reproductive life. This knowledge can, in turn, be passed to future generations, which means that it will be beneficial to both the present and future generations.

More specifically, knowledge and correct application of STM will enable women to understand how their bodies work. A woman will be able to tell when she is fertile and absolutely infertile during her monthly cycles. This knowledge will help her to prevent pregnancy, aid in pregnancy and free her mind to enjoy pleasurable sexual experiences during her absolutely infertile days without fear of getting pregnant. This means she has the right to decide the number and spacing of her children and the right to a satisfying sexual relationship. Thus her self-esteem and confidence increases, which enhances positive emotional well-being. Also, knowledge of STM will perhaps give women freedom of opinion and expression concerning their fertility/sexuality with their partners. This communication will help their partners understand how their bodies work, which in turn will create intimacy and a positive impact on social health.

The risk associated with this study is unintended pregnancy, which can occur if couples engage in unprotected sex during the fertile phase, in opposition to the instructions.

Confidentiality and autonomy

All information obtained will remain confidential. Your identity as a participant will not be disclosed to any unauthorised persons. Your name will not be used openly in the written document. Participation in this study is voluntary. Refusal to participate will involve no penalty. Participants reserve the right to withdraw from the study should they perceive any harm or dissatisfaction.

Contact details of the researcher

Name: Catherine Erosie Igben-Pender

Address: Department of Public Health, School of Public Health and Community Development, Maseno University.

Telephone : 0794675719

All questions will be answered completely. Therefore, feel free to contact the researcher to answer all your questions before completing the informed consent form.

Section 2: Description of participants decision/agreement

• If you meet the inclusion/exclusion criteria above, would you like to become a participant in this study and learn how to use STM in preventing pregnancy naturally?

If you respond ‘yes’ to the above question, you are welcome to participate in the training and study of STM free of charge. This means you have read, understood and voluntarily agree to be a participant in this study. By writing your name, signature and date below, you indicate your voluntary informed consent to participate in this study.

Name of participant_________________________ Signature________________________ Date________

Authors’ contributions

CEI conceptualized the study, collected data and wrote the first draft. CEI, PO and GN conducted the data analysis, prepared the results and critically reviewed and approved the final article.

Funding

None.

Competing interests

The authors declare that there is no competing interests.

Ethical approval

Ethical approval was obtained from the Maseno University Scientific and Ethical Review Committee (approval number MUSERC/01221/23). A research permit was obtained from the National Commission for Science, Technology, and Innovation (license number NACOSTI/P/23/25312). Permission to access the health facilities in Kisumu County was also obtained. The ethical guidelines of the Belmont Report of 1979 was followed. The participants in this study gave their written informed consent after receiving adequate information about the study (Appendix 1). All participants had the autonomy to participate in the study at will.

Data availability

All data generated from this study are available within the article.