Effectiveness of a Standard-Rule Method of Calendar Rhythm Among Mayan Couples in Guatemala By Marianne C. Burkhart, Lidia de Mazariegos, Sandra Salazar and Virginia M. Lamprecht

is estimated) in each cycle.6 Under the tra- Context: Mayan couples in Guatemala have very low rates of contraceptive use but have long ditional formula, a woman would keep expressed an interest in natural family planning methods. track of her cycle length for six cycles and Methods: A simple calendar rhythm method of family planning was tested among 301 couples would determine the abstinence period by living in two departments in the Guatemalan highlands. The method requires couples to keep subtracting 11 days from the longest cycle track of the woman’s menstrual cycle, using a calendar and a necklace as a reminder, and to and 18 days from the shortest one. Like- abstain from intercourse on days 9Ð19 of each cycle. Participants—most of whom were Mayan, wise, under two of the alternative formu- had had fewer than seven years of schooling and had never used a contraceptive method—re- las, the abstinence period varied accord- ceived instruction in how to use the method and were followed up for one year. Data were ana- ing to women’s individual cycles. By lyzed using life tables. contrast, the “standard rule” proposed Results: Seventy-nine percent of couples successfully completed one year of use. Any diffi- that for all couples, the period of absti- culties they encountered with the method (i.e., with using the calendar or necklace, or abstain- nence would begin on a specified day of ing from intercourse for 11 days each month) occurred early in the study, and after one year, the woman’s cycle and would continue for couples were highly satisfied with the method. Eleven percent of couples conceived during the a specified number of days. study, and one-third of this group said that they had not had relations during the woman’s fertile The researchers developed a summary period. Among the 31 couples who discontinued method use for reasons other than pregnan- of the number of days of abstinence re- cy, the principal reason was personal factors. The only demographic characteristic that was sig- quired, using the various rules. Two rules nificantly associated with continuation and pregnancy rates was age. appeared to provide better protection than Conclusion: A fairly simple natural method is potentially effective and highly acceptable among the traditional rule, and the researchers the Mayan population of Guatemala. recommended that these be tested in clin- International Family Planning Perspectives, 2000, 26(3):131Ð136 ical trials. The simpler of the two is the standard rule 9–19, which is the basis for the method tested in this study. It calls for n the 1998–1999 Demographic and preference for natural methods among the abstinence to begin on the ninth day of the Health Survey in Guatemala, 8% of Mayan population of Guatemala.4 This woman’s menstrual cycle and continue Imarried Mayan women aged 15–49 re- preference may have arisen because the through the 19th day, for a total of 11 days. ported current use of a modern method Catholic Church has long been the of family planning, and 5% reported cur- Mayans’ principal source of information The Necklace rent use of a traditional method, princi- on family planning, or because of wide- Couples participating in the test of this pally periodic abstinence (2%). However, spread rumors about negative side effects method were given a device to help them 15% of all women surveyed, and only 40% of modern methods, the Mayans’ agrari- calculate the fertile time of the menstrual of those using the calendar rhythm an roots or such cultural factors as a tra- cycle: a necklace with 30 beads (one for method, knew when in the menstrual dition of postpartum abstinence and a each day in the cycle) of different colors cycle a woman’s fertile period occurs.1 positive attitude toward abstinence.5 and a marker that the couple moves daily Other studies have found even lower lev- To date, no clinical trials have been con- to indicate the day in the cycle. The neck- els of knowledge among the Mayans.2 ducted to determine the effectiveness of lace is kept in a safe place in the home, hid- Fertility awareness–based methods, the rhythm method among the Mayan den from children. often called “natural” family planning, are population. With contraceptive use ex- The colors for the beads used in the methods a woman uses to identify the fer- tremely low among Mayans, programs necklace were chosen to relate the tile time in her menstrual cycle, when she that aim to serve this population could be woman’s monthly fertile cycle to the an- practices periodic abstinence. These meth- strengthened by the addition of an effec- nual fertile cycle of the earth. Previous re- ods are widely regarded as less effective tive natural method that is simple to teach than modern methods of family planning. and use. Marianne C. Burkhart is program associate, Population They are considered “only somewhat ef- Council, Guatemala City; Lidia de Mazariegos is execu- tive director, La Asociación Pro Salud Preventiva para fective as commonly used, yet effective Scientific Basis of the Method la Mujer Vivamos Mejor (APROVIME), Guatemala City; when used correctly and consistently.”3 Researchers from Georgetown Universi- Sandra Salazar is deputy director, APROVIME; and Vir- Their effectiveness is highly dependent on ty and the U.S. Centers for Disease Con- ginia M. Lamprecht is epidemiologist, Research Trian- behavioral factors that may differ among gle Institute, Rockville, MD, USA. This study was made trol and Prevention compared the tradi- possible by funding from the U.S. Agency for Interna- cultures and individual couples. Yet nat- tional formula for determining the fertile tional Development (USAID) under cooperative agree- ural methods have a number of advan- time and three alternative formulas, using ment 520-0357-A-00-4169-00 with the Population Coun- tages: They involve little or no cost, have data on 7,514 menstrual cycles among 725 cil and a subaward to APROVIME. The opinions no medical contraindications or side effects, expressed herein are those of the authors and do not nec- women who observed their mucus pat- essarily reflect the views of USAID. The authors thank and can be taught by paraprofessionals. terns daily and recorded the day of peak James Trussell and Chiara Capoferro for their review and Several studies have found a strong mucus (from which the day of ovulation comments.

Volume 26, Number 3, September 2000 131 Effectiveness of a Standard-Rule Method of Calendar Rhythm

Table 1. Percentage distribution of men and tility; and beads 20–30 are brown. Couples interested in learning to use the women using a standard-rule natural family It is not clear where the use of a neck- method and participating in the study were planning method, by selected characteristics, lace for determining the fertile time of the screened by the trained instructors. They Guatemala, 1998 (N=301) menstrual cycle originated, but jewelry were included if they met all eligibility cri- and amulets have long been associated teria as individuals and as a couple, and if Characteristic Men Women with romance and sex.8 A study conduct- they gave their informed consent. Ethnicity ed in the early 1990s demonstrated that a Women were eligible if they were aged Mayan 95.0 95.7 Ladino 5.0 4.3 necklace somewhat similar to the one used 18–39, had regular menstrual cycles,* in this study was effective in teaching a wanted to avoid a pregnancy in the next Primary language rural Guatemalan population with a low 12 months, were not currently using a con- Spanish 45.5 43.9 literacy rate about the fertile period, but traceptive method and had not used any Mam 34.6 36.9 the study did not proceed to field trials.9 hormonal medication in the past three Kakchiquel 19.6 19.3 Kíche 0.3 0.0 By contrast, in a study conducted in months. Natural family planning studies 1996–1997 among an urban Brazilian pop- often exclude breastfeeding women be- Religion ulation, only 48 of 1,084 couples screened cause lactation may offer protection from Catholic 51.2 51.5 chose to use a necklace, and only 31 (64%) pregnancy. However, because rural Evangelical 38.9 41.5 10 Mayan 3.3 2.7 were still using it after six months. How- Mayan women commonly breastfeed 11 None 6.6 4.3 ever, an urban Brazilian population is cul- until the next pregnancy, we considered turally quite different from rural Mayans, it important to include those who were Age despite their shared religious affiliations, lactating if there was evidence of a likely 18Ð19 2.0 3.7 20Ð24 12.6 25.9 and the relevance of these results for the return to fertility; consequently, women 25Ð29 32.2 29.6 Guatemalan Mayans is doubtful. who were breastfeeding but had had at 30Ð34 23.3 21.6 In addition to the necklace, study par- least three regular menstrual cycles also 35Ð39 21.3 19.3 ticipants were given a calendar for mark- were eligible. ≥ 40 8.6 0.0 ing the initiation of each menses. The cal- For men, the only inclusion criteria were Education (yrs.) endar served as a research aid for that they be interested in using the method 0 22.9 34.6 verifying the end of a cycle in which a and willing to participate in at least one 1Ð3 21.6 21.9 pregnancy did not occur and as a backup instruction session. 4Ð6 31.9 27.6 for couples who might have forgotten to Finally, for couples to be included, they ≥7 23.6 15.9 move the marker on the necklace. By had to be married or in union and had to Literate counting the number of days since initia- have lived together for at least one year; Yes 80.7 67.8 tion of last menses as marked on the cal- both partners had to be willing to abstain No 19.3 32.2 endar, a couple could position the mark- from vaginal intercourse for 11 days dur- Desire more children er on the corresponding bead. ing each cycle. Couples were ineligible if Yes 33.9 35.2 either partner had had a sterilization pro- No 64.1 63.1 Methods cedure. If a woman’s cycle was found not Undecided 2.0 1.7 Study Design and Sample Selection to be between 26 and 32 days, the couple Total 100.0 100.0 The study was a noncomparative, multi- was informed that this method might not center prospective clinical trial conduct- be the most effective for them; they could ed among couples from two departments then choose whether to remain in the search has demonstrated that rural pop- of the Guatemalan highlands. It was car- study. Potential participants had to be ulations with low or no literacy easily un- ried out in five collaborating centers run willing to meet with study staff for follow- derstand this link,7 and focus-group dis- by small, indigenous nongovernmental up visits; provide basic demographic data; cussions with Mayan men and women in organizations (NGOs) that are dedicated keep track of the first day of menses on a the preparatory phase of the study con- to improving the health and well-being of firmed this finding. In Guatemala, the year their communities. The centers’ staff and Table 2. Percentage distribution of couples, by begins with the dry season; at that time, volunteers are Mayans who speak the number of living children and ever-use of con- the countryside is brown and crops are not local Mayan languages. At each center, a traceptives planted. In May, the rainy season begins, supervisor and three instructors in use of Measure % the countryside turns green and seeds the method were trained in the protocol. No. of living children bear fruit. At the end of the year, the dry La Asociación Pro Salud Preventiva para 115.0 season arrives again, the earth turns la Mujer Vivamos Mejor (APROVIME), a 221.9 brown and again no crops are sown. Guatemalan NGO based in the capital city, 322.9 415.6 Therefore, the first bead on the necklace coordinated the study with technical as- 5 7.6 is red, to indicate the first day of menses; sistance from the Population Council. 6 7.0 beads 2–8 are brown, indicating infertili- Assuming a confidence coefficient of 7 6.0 8 3.0 ty; beads 9–19 are green, to indicate fer- .95, an expected 40% dropout rate, a 20% 9 1.0 pregnancy rate, a five-point confidence in- *No cycle history was taken prior to enrollment, but Ever-use terval and a one-tailed t-test, the study re- No method 88.7 women were asked if they had regular cycles. Women quired enrollment of 288 couples in order Traditional/natural method 4.7 were considered to have regular cycles if they reported Modern method 6.6 a cycle length of 26–32 days or, since most women had to have 173 completing 12 months of fol- never kept track of their cycle length, if they reported hav- low-up. Participants were enrolled be- Total 100.0 ing a monthly bleed. tween mid-March and early July 1998.

132 International Family Planning Perspectives ly responsible for the choice of a natural Table 3. Number of couples with various outcomes and life-table continuation rate, by interval method; alternatively, natural methods Interval No. of couples Cumulative SE may be considered more compatible with (days) % continuing Mayan culture, which attaches great im- Entered Con- Discon- Lost to Contin- 14 ceived tinued follow-up ued portance to land and nature. Two-thirds of the women were breast- 0Ð90 301 11 6 1 283 94.3 .0133 feeding when they enrolled in the study, 91Ð180 283 7 12 0 264 88.0 .0187 181Ð270 264 10 10 0 244 81.3 .0225 and a quarter had given birth within the 271Ð365 244 4 3 1 236 79.0 .0235 past 10.5 months, the national median for postpartum amenorrhea.15 Note: SE=standard error. Continuation and Discontinuation calendar; inform the instructor if a preg- intended to avoid pregnancy for a year, The one-year life-table method continua- nancy occurred; and use only periodic ab- the potential existed for them to change tion rate was 79% (Table 3). A total of 32 stinence, but inform the instructor during their minds. At each visit, they were asked couples stopped using the method be- follow-up visits if they used an addition- if they intended to continue use; if they cause the woman became pregnant, an ad- al method during the fertile time. said that they did not because they wished ditional 31 discontinued for other reasons to conceive, they were classified as dis- and two were lost to follow-up. Data Collection and Analysis continuing. Among couples who discontinued Instruction took place during a woman’s Data were input into a database in SPSS method use for reasons other than the oc- menses; if a woman was not bleeding at and analyzed using life-table techniques, currence of a pregnancy, the largest pro- the time of enrollment, the couple was the method now commonly used in ef- portion—45%—cited personal factors scheduled to receive instruction during fectiveness studies.12 (Table 4). Eight of the 14 couples who dis- her next menses. At the time of instruc- continued for personal reasons wanted to tion, the couple were asked about their de- Results switch to a modern method, as did the two mographic characteristics, reproductive Participants’ Characteristics who discontinued after their doctors ad- history and childbearing plans for the next A total of 301 couples enrolled in the vised them that a pregnancy could en- 12 months, and the instructor recorded study. Nearly all of the participants were danger the woman’s health. According to these data on an admission form. The in- Mayan, and more than half reported that the instructors, some couples decided to structor explained how to use the neck- the primary language spoken in their use a more effective method when they re- lace and to keep track of the start of the home was one of three indigenous lan- alized that the woman’s cycles were not woman’s cycles on a calendar, and gave guages (Table 1). Roughly half were as regular as they had believed prior to the couple a necklace and a calendar. Cou- Catholic, and two-fifths were Evangelical, entry in the study. ples generally received this instruction, reflecting the rapid spread of Protestant Neither the woman’s educational level, which lasted approximately two hours, religions in Guatemala. The largest five- her literacy status nor her breastfeeding in their home and, if they did not speak year age-group for both men and women status was statistically associated with Spanish, in their Mayan language; the was 25–29. continuation (Table 5, page 134). Howev- necklace and calendar were the only vi- In Guatemala, education and literacy er, the proportion of couples who com- sual aids. rates are higher for men than for women, pleted a full year of successful use rose Instructors visited participants and and this pattern was evident among the steadily from 46% to 90% as the woman’s completed a follow-up form once during participants. Roughly two-thirds of the age increased from younger than 20 to menses after the first three cycles of women had attended school, while about 35–39, and this correlation was highly sig- method use and every two or three three-quarters of the men had some nificant. The pattern for discontinuation months thereafter, depending on the cou- schooling. Similarly, two-thirds of the was equally consistent, but in the oppo- ple’s mastery of the method. The last women were literate, compared with four- site direction. Interestingly, the pattern scheduled follow-up visit was at the end fifths of the men. was less consistent and the differences of the 12-month study period; if a Almost two-thirds of both men and were not statistically significant when woman’s cycle was open-ended (i.e., she women wanted no more children. This completion rates were analyzed accord- was not menstruating) at that time, the in- finding is surprising, given that about the ing to the woman’s number of living chil- structor made an additional visit to de- same proportion of couples had three or dren, although women with five or more termine the outcome of that cycle. During fewer children (Table 2) and the total fer- follow-up visits, the instructor noted tility rate for Mayan women is 6.8 lifetime Table 4. Percentage distribution of couples whether the couple were continuing or births per woman.13 Although natural who discontinued method use, by reason for had discontinued the method and family planning methods are generally discontinuation (N=31) whether a pregnancy was suspected (i.e., considered inappropriate for couples Reason % 42 days or more had passed since the wishing to limit their families, the study Personal 45.2 woman’s last menses). participants chose a natural method after Migration 22.6 Instructors referred all women with a being informed about the availability and Desire a pregnancy 16.1 suspected pregnancy for confirmatory the comparative effectiveness of other Separation/death of spouse 9.7 Medical condition 6.5 testing. If a woman resumed menses with- methods. Few couples in the study had Total 100.0 out a positive pregnancy test, her status previously used a contraceptive, and only Note: Excludes those who discontinued use because they con- was changed to continuing. Although 7% had used a modern method. Inexpe- ceived. couples stated before enrollment that they rience with modern methods may be part-

Volume 26, Number 3, September 2000 133 Effectiveness of a Standard-Rule Method of Calendar Rhythm

who were breastfeeding the method to others. Furthermore, they Table 5. Percentage distribution of couples, by outcome of method use, according to selected characteristics of women at the start of the study all reported that they would continue and those who were not using the method, although three stated Characteristic Discontinued Conceived Continued Total (Table 5). that they currently desired a pregnancy. Education (yrs.) There were large dif- 0 9.6 8.7 81.7 100.0 ferences in the numbers Correct Use 1Ð3 13.6 18.2 68.2 100.0 4Ð6 9.6 8.4 81.9 100.0 of pregnancies among Although remembering to move the ≥7 8.7 8.7 82.6 100.0 women in the various marker presented difficulties for the great- collaborating centers. est number of couples, instructors noted Literate Yes 10.4 12.4 77.2 100.0 Although each center only a few misplaced markers during fol- No 10.3 7.2 82.5 100.0 had essentially the same low-up visits. After comparing the day in number of participating the cycle with the bead marked, and al- Age* <20 18.2 36.4 45.5 100.0 couples, the number of lowing for the possibility that the couple 20Ð24 14.3 15.6 70.1 100.0 pregnancies per center had not yet moved the marker on the day 25Ð29 13.5 7.9 78.7 100.0 ranged from three to 10. of the visit, instructors found that 95% of 30Ð34 6.3 7.8 85.9 100.0 35Ð39 3.4 6.9 89.7 100.0 The center with the couples had the marker on the correct largest number of preg- bead after one month, and 96% at the fifth Breastfeeding nancies experienced follow-up visit (i.e., after approximately Yes 10.4 11.5 78.1 100.0 No 10.3 9.3 80.4 100.0 management problems seven months). The results were similar during the study, which for marking the calendar on the first day *Differences within the category are statistically significant at p=.000, using analysis of vari- ance. Note: Excludes two couples who were lost to follow-up. may have contributed to of menses. At one month and seven difficulties among the months, 98–99% of couples had the first instructors. Instructors’ day marked correctly on the calendar. children had fewer pregnancies and dis- experience, however, was not a factor: Moving the marker daily and marking continuations than those with 1–4 children Roughly equal numbers of pregnancies the calendar on the first day of menses (not shown). occurred among the first half of the cou- were responsibilities that fell principally ples trained by each instructor as among but not uniquely to the woman. Among Pregnancies the second half. 73% of couples who successfully com- Of the 32 women who became pregnant pleted a year in the study, the woman during the study, 34% were sure that they Satisfaction moved the marker; in 18%, the couple had not had relations during the fertile pe- At one, three and 12 months, 100% of the moved it together, and in about 10%, the riod, while the rest were not sure. A total women reported being satisfied with the man did it. One couple reported that they of 78% of pregnancies were confirmed by method and with the time of abstinence. required the instructor to move the mark- testing. The probability of pregnancy over However, five of the men reported being er on the necklace. Men played a greater 12 months of typical method use was 11% dissatisfied with the time of abstinence after role, however, in marking the calendar: (Table 6). Pregnancy rates were not sta- three months; two of these men completed Twenty percent of couples reported that tistically associated with any demographic the study, but the other three discontinued the man did this, 12% the couple togeth- characteristic except age. Like the dis- because their partners became pregnant. er and 56% the woman alone; the re- continuation rate, the pregnancy rate de- In the final follow-up visit, couples or maining 12% required the assistance of the creased with rising age (Table 5). (because 48% of men were not present for instructor to record the first day of menses A woman’s cycles may be less regular this visit) women were asked whether on the calendar. when she is breastfeeding than when she they had had any difficulty with the three is not. However, breastfeeding may have key components of the method: moving Discussion some protective effect against pregnancy the marker, abstaining from intercourse This study was open to women 18–39 even after the resumption of menses. Nev- for 11 days and marking the calendar. Half years of age. We excluded older women ertheless, the one-year pregnancy rate did reported that at the beginning, they had because they may experience disturbances not differ significantly between women had trouble remembering to mark the cal- in the menstrual cycle related to the onset endar on the first day of menses or re- of menopause. Some studies admit Table 6. Cumulative pregnancy rate among fraining from intercourse for 11 days (51% women only through age 35, since after couples using a standard-rule natural family for each); 67% said that at first, they had this age, natural fertility declines. One-fifth planning method, by months of use had problems remembering to move the of women in our study were 35–39 years Months No. of Cumulative SE marker on the necklace. Only 2% had had old, and this age-group had the lowest couples* pregnancy difficulty remembering to move the mark- pregnancy and discontinuation rates. Be- rate (%) er other than at the beginning of the study. cause the success and continuation rates 3 297.5 3.7 (1.6Ð5.8) 1.1 Some 47–48% had had no difficulty with display a steady pattern according to age, 6 277.0 6.1 (3.4Ð8.9) 1.4 abstaining or with marking the calendar, we conclude that older women, at least 9 259.0 9.8 (6.3Ð13.2) 1.8 and 31% had had none with moving the through age 39, are probably good candi- 12 242.0 11.2 (7.6Ð14.9) 1.9 necklace marker. It should be borne in dates for the method. However, the *Number exposed to the risk of pregnancy, taking into account cou- mind that only couples who successfully youngest couples had the poorest success ples who discontinued or were lost to follow-up and not exposed to the risk of pregnancy for the entire three-month interval. For these completed a year of using the method rates and probably are not suitable can- cases, we assign an exposure time equal to one-half the length of were asked about difficulty. didates for this method. The only charac- the interval. Notes: Figures in parentheses are 95% confidence intervals. SE=standard error. All of the couples who completed a year teristic that was significantly associated of use said that they would recommend with pregnancy was younger age.

134 International Family Planning Perspectives Breastfeeding has a protective effect cles were important for providing reas- 12. Kambic R and Lamprecht V, Calendar rhythm effi- against pregnancy, although it is difficult surance to the woman. This level of at- cacy: a review, Advances in Contraception, 1996, 12(2): 123–128. to quantify unless the woman is fully tention should be feasible for NGOs that breastfeeding, amenorrheic and less than provide health services to this population 13. Instituto Nacional de Estadística et al., 1999, op. cit. (see reference 1). six months postpartum. Two-thirds of or others that are equally underserved and women admitted to this study were prefer a natural method. The level of at- 14. Menchu R, Rigoberta: La Nieta de los Mayas, Mexico City: Aguilar, Altea, Taurus, Alfaguara, 1998; and Ward breastfeeding (but had had at least three tention couples received from instructors V, Bertrand J and Puac F, 1992, op. cit. (see reference 4). regular menstrual cycles) at enrollment; may have contributed to the low rates of a similar proportion were not breastfeed- pregnancy and discontinuation observed 15. Instituto Nacional de Estadística et al., 1999, op. cit. (see reference 1). ing at the end of the study. In the high- in the study. A one-year follow-up study lands of Guatemala, a large proportion of will research this issue. 16. Burkhart MC et al., Incidence of irregular cycles among Mayan women who reported having regular cy- all Mayan women who are in need of pro- Although studies of natural methods cles: implications for fertility awareness methods, Con- tection against a pregnancy are lactating are usually conducted among better- traception, 1999, 59(4):271–275. at any point in time. Because rural Mayan educated couples, the effectiveness and women were the population of interest in continuation rates among this population Resumen this study, we wanted to capture the ex- are quite high. Our findings demonstrate Contexto: Las parejas mayas en Guatemala perience of a population that closely re- the potential for effective use of a fairly presentan tasas muy bajas de uso de anticon- sembled the women who were likely to simple natural method and its high lev- ceptivos, aunque desde hace mucho tiempo in- use the method, rather than limit the study els of acceptability among the Mayan pop- dican que tienen interés en usar métodos na- to the small part of that population who ulation of Guatemala. turales de planificación familiar. were ideal candidates for the method. Métodos: Se probó un método de planifica- The requirement of regular cycles is par- References ción familiar simple mediante el uso del ca- ticularly challenging for rural Mayan pop- 1. Instituto Nacional de Estadística et al., Guatemala: En- lendario y el ritmo, entre 301 parejas residen- ulations. While all women admitted to the cuesta Nacional de Salud Materno-Infantil 1998–9, tes en dos departamentos ubicados en la zona Guatemala City: Instituto Nacional de Estadística, 1999. study reported having regular cycles, they montañosa de Guatemala. Este método re- had not kept a record of cycle length prior 2. Pineda MA et al., Estudio de Base de Percepciones y Ac- quiere que las parejas hagan un control del ciclo titudes Masculinas sobre Salud Reproductiva en Cuatro Mu- to enrollment, and when participants nicipios del Departamento de El Quiché, Guatemala City: menstrual de la mujer, mediante el uso de un began to chart their cycles on a calendar, Population Council, 1995; Méndez-Domínguez A, Study calendario y un collar de 30 cuentas coloradas many discovered that their cycles were not of Cognition and Speech Patterns of Urban and Rural In- que sirven como recordatorio de los días, y que regular.16 Although we did not eliminate digenous Community Residents About Reproductive Health se abstuvieran de mantener relaciones sexua- any women from the study if their cycle in the Department of Quetzaltenango, Guatemala City: Pop- les entre los días 9–19 de cada ciclo. Los par- ulation Council, 1995; and Bertrand J et al., Promoting Birth varied from the 26–32-day limit for ad- Spacing Among the Maya-Quiché of Guatemala, New Or- ticipantes—quienes en su mayoría eran mayas, mission, these women and their partners leans, LA, USA: Tulane University School of Public tenían bajos niveles de educación y alfabeti- were counseled about other methods. Health, 1998. zación y nunca habían usado un método an- Couples who require the assistance of 3. Hatcher R et al., The Essentials of Contraceptive Tech- ticonceptivo—recibieron instrucciones preci- the instructor to move the marker or mark nology, Baltimore, MD, USA: Population Information Pro- sas de cómo usar el método y eran sujetas de the calendar may face difficulties in gram, Johns Hopkins School of Public Health, 1997. un seguimiento durante un año. Los datos ob- achieving autonomy in their use of the 4. Ward V, Bertrand J and Puac F, Exploring sociocultural tenidos fueron analizados mediante el uso de method. On the other hand, if the in- barriers to family planning among the Mayans in tablas de vida. structor lives near the couple, she may Guatemala, International Family Planning Perspectives, Resultados: El 79% de las parejas completó 1992, 18(2):59–65; and Pineda MA et al., 1995, op. cit. (see continue to provide this service; alterna- reference 2). con éxito un año de uso. Las dificultades que pu- tively, the couple may seek assistance from dieron haber encontrado con el método (por 5. Ward V, Bertrand J and Puac F, 1992, op. cit. (see ref- a relative or friend. Autonomy of practice erence 4). ejemplo, con el uso del calendario o del collar, o will be studied in a one-year follow-up con abstenerse de mantener relaciones sexua- 6. Lamprecht V and Grummer-Strawn L, Development study. of new formulas to identify the fertile time of the men- les durante un período de 11 días cada mes) ocu- As is common in natural family plan- strual cycle, Contraception, 1996, 54(6):339–343. rrieron durante la primera etapa del estudio, y ning studies, couples reported high de- 7. Mayorga C and Solórzano J, Project report: integrat- después de un año, las parejas estaban muy sa- grees of satisfaction with the method. Part- ed obstetric, family planning and STD training for TBAs, tisfechas con el método. El 11% de las parejas ners of men who reported dissatisfaction Guatemala City: Population Council, 1997. concibieron durante el período de estudio y la with the length of the abstinence period 8. Lamprecht V and Pyper C, Opinión: la conciencia de tercera parte de este grupo indicó que no habí- had an excess number of pregnancies, but la propia fertilidad y la planificación familiar natural, Net- an mantenido relaciones sexuales durante el pe- the numbers are too small to be definitive. work en Español, Vol. 17, No. 1, 1996. ríodo fecundo de la mujer. Entre las 31 parejas Nonetheless, male dissatisfaction may 9. Schenkel P, Puac F and Vernon R, Testing the fertility que no continuaron utilizando el método por serve as a red flag for the instructor to en- necklace in rural Guatemala, Mexico City: Population otras razones que no fueran el embarazo, la prin- courage the couple to keep a barrier Council, 1992. cipal razón esgrimida fueron cuestiones perso- method handy. 10. Faúndes A et al., Evaluation of the use of the “col- nales. La edad fue la única característica de- Study participants received more vis- lar” as a natural method of family planning, final report, mográfica que estuvo significativamente its from the instructor than is feasible in Campinas, Brazil: Research Center for Maternal-Child relacionada con las tasas de continuación de uso Diseases of Campinas, 1997. many large-scale programs. Visits after the del método y con las tasas de embarazo. third cycle of use were for data collection 11. de Maza I, de Oliva M and Burkhart M, Testing the Conclusiones: Un método anticonceptivo re- formation of La Leche League support groups with in- purposes and are unnecessary outside a digenous populations in Guatemala: final report of an lativamente simple puede resultar eficaz y muy research context. Instructors reported in- operations research project, Guatemala City: Population aceptable entre la población maya de Guate- formally that the visits in the first three cy- Council, 1998. mala.

Volume 26, Number 3, September 2000 135 Effectiveness of a Standard-Rule Method of Calendar Rhythm

Résumé part étaient mayas, présentaient de faibles ni- satisfaits de la méthode. Onze pour cent ont Contexte: Les couples mayas du Guatemala veaux de scolarisation et d’alphabétisme et conçu pendant l’année de l’étude. Un tiers présentent de très faibles taux de pratique n’avaient jamais pratiqué de méthode contra- d’entre eux ont déclaré n’avoir eu aucun rap- contraceptive mais expriment depuis long- ceptive—ont été instruits sur la manière de port durant la période féconde de la femme. Des temps un intérêt pour les méthodes naturelles. pratiquer la méthode, puis suivis pendant une 31 couples ayant abandonné la méthode pour Méthodes: Une simple méthode de planning année. Les données ont été analysées sur la base des raisons autres que la grossesse, le motif te- familial, basée sur la continence périodique, a des tables de mortalité. nait à des facteurs personnels. L’âge s’est avéré été testée parmi 301 couples vivant dans deux Résultats: Soixante-dix-neuf pour cent des la seule caractéristique démographique signi- départements des montagnes du Guatemala. couples ont achevé l’année de pratique avec ficativement associée aux taux de continua- La méthode invitait les couples à suivre le cycle succès. Les difficultés éventuelles de la méthode tion et de grossesse. menstruel de la femme, avec l’aide d’un ca- (utilisation du calendrier ou du collier, ou Conclusions: Une méthode naturelle relati- lendrier et d’un collier, et à s’abstenir de tous continence sexuelle pendant 11 jours de chaque vement simple semble potentiellement effica- rapports sexuels durant les jours 9 à 19 de mois) sont apparues vers le début de l’étude ce et largement acceptable parmi la population chaque cycle. Les participants—dont la plu- et, au terme d’un an, les couples étaient fort maya du Guatemala.