Catholic Medical Quarterly Volume 66(1) February 2016
Recognition for Natural Family Planning: A Real Step Forward
Dr Olive Duddy MB CHB MRCGP,
Tutor of The Natural Family Planning
In June 2015 the Clinical Effectiveness Unit, CEU, of the Faculty of Sexual and Reproductive Healthcare (FSRH)published “Clinical Guidelines for Fertility Awareness Methods.” This document can be accessed by clicking on this link. It is interesting and well worth reading.
In 2014 the FSRH declared that the Diploma of Sexual Healthcare would not be given to those who would not prescribe contraceptives. We were all very worried about this unjust exclusion as it excludes those with a moral objection to prescribing contraception. I wrote to Dr Richmond, President of the Royal College of Obstetricians and Gynaecologists saying,
“that the decision was contrary to the human rights of those Doctors and Nurses, and that the medical profession would recoil with horror if they could be accused of racial discrimination but that they were acting as though they were above accusations of discrimination on religious grounds. That at one time, those Consultants who had a religious objection to certain procedures were appointed to posts where there were several consultants, and the religious requirements of all religions were accommodated, even to the Jewish Sabbath and the Muslim Holydays being respected among the group of Consultants.
“That now only one group is suffering discrimination. It is unreasonable. It is unlawful. Freedom of Conscience is enshrined in European Law.
“That there are many women unwilling to take hormonal contraception. There are some who will not take it for religious reasons but there are also an increasing number of women who do not want to alter their menstrual cycles, their HPO axis, nor to alter their psyche, nor run the risk of the hormonal effect on themselves, their existing reserves of ova or on their husband’s fertility.
That a better physiological understanding of fertility, improved pedagogy and technology has resulted in highly efficacious natural methods. Concomitantly, a certain malaise with the complications of current family planning methods and an increase interest in ecology has promoted a return to natural methods (including breastfeeding) for medical rather than moral reasons.
That the depth of the moral conviction of people against contraception may not be fully understood. We believe that at conception, the very fusion of the sperm and the ovum is accompanied by the very breath of God. Each person’s life is therefore sacred. The act of sexual intercourse has its sacred dimension which is negated by contraception.”
It was asked that the unjust and unlawful decision to deny the Diploma to some Doctors and Nurses be reversed and secondly that, included in the Diploma is a requirement to be able to teach Natural Family Planning to World Health Organisation standards.
It was a bold letter but sent with a prayer. The reply was to the effect that they do not stop anyone teaching Natural Methods. I have written to congratulate them on the comprehensive document.
New guidance: A step forward for Natural Family Planning
The new guidance sets out in a positive document in which Natural Family Planning is referred to as Fertility Awareness Methods.
The guidance makes a number of key recommendations including those in Table 1 (below)
Table 1. Key recommendations with which we would agree
- Women wishing to use fertility indicators for contraceptive purposes should receive support and instruction on the method from a trained practitioner.
- Women should be informed that combining fertility indicators is considered more effective than using single fertility indicators alone.
- Sexual intercourse on days when cervical secretions are present increases the likelihood of pregnancy.
- Over 1 year, fewer than 1 in 100 women would be expected to fall pregnant with perfect use of the symptothermal method (monitoring of cervical secretions and basal body temperature (BBT) used with a calendar calculation).
- Women may be advised that if they are 6 months postpartum, amenorrhoeic and fully breastfeeding, the lactational amenorrhoea method (LAM) is over 98% effective at preventing pregnancy.
- Women using LAM should be advised that the likelihood of pregnancy is increased if the frequency of breast-feeding decreases (stopping night feeds, supplementary feeding, use of pacifiers/dummies), when menstruation returns or when >6 months postpartum.
Those recommendations, made by a national body, are a real step forward. Together with the Introduction and the final Questions for Continuing Professional Development, the Guidelines are only 26 pages long, not too long to read easily. The list of Fertility Awareness Methods is comprehensive, including coitus interruptus.
Problems with the document
But there are also major concerns about this document. It soon becomes apparent, that the effectiveness statistics given are inconsistent.
Firstly, there is inconsistency in the reported efficiency of the Basal Body Temperature, BBT, in the post-ovulatory phase. In one place (page ii)= 6.6% and in another (p2) it states “In the post-ovulatory phase there is an extremely low risk of pregnancy” In another place the report correctly states that “over 1 year, fewer than 1 in 100 women would be expected to experience a pregnancy with perfect use of the Symptothermal Method”.
Secondly, the document gives a view that the Calendar Method is popular. In fact many years ago it was discredited as Vatican Roulette, having been superseded by the Billings Ovulation Method and the Symptothermal Method. Many of the references are very old. The marvellous work in Australia and China of Dr James Brown and Dr and Mrs Billings are neglected, as is the work of Professor Odeblad in Sweden and as is the very useful recent research done in Germany.
The formula for the Standard Days Method (Calendar) is doubtfully useful even for women with cycles 26-32 days, because 21 -35 day cycles can be seen in the same woman. Each individual woman’s pattern is better tracked by her own Fertility Indicators. The Two Dry Days Method (Mucus) is useful for teaching women in remote areas when teaching time is very limited and also when women stop hormonal methods, of whom only 56% have immediate return of fertility and others have to wait a long time for resumption of their fertility, some over a year.
On page 13 there is an interesting comparison of the pregnancy rate for use of condoms (forbidden by the Catholic Church) against total abstinence in the fertile phase. For the calendar Standard Days Method (SDM), the comparison rates are 4.8% for abstinence against 5.7% with ‘protected intercourse’ i.e.barrier methods, condoms or diaphragm. For the Symptothermal Method the comparison rates are 0.34% abstinence and 0.59% using condoms. Why use the less effective method when abstinence is better. The failure rate of condom usage is variably reported from 2% to 20%
Thirdly, no guidance is given as to the teaching method of NFP, which
needs a different timescale from that needed for oral contraception,
hormonal implants or fitting a IUS. For NFP the main teaching is at the
beginning with little need for follow up. The first consultation is long,
depending on how much the couple remember about the menstrual cycle (if
they ever had any instruction), and how they understand the fertility
indicators. The second, third and fourth consultations are much shorter
but after that the couple are autonomous. They are freed from years of
follow ups by Nurses and Doctors. In my estimation the average total time
needed to help them become autonomous is 3 hours; a huge saving of NHS
time and money.
In the document, p16 the section ‘Planning a Pregnancy’ more space is given to ultrasonography and LH dipsticks than to the presence of fertile cervical mucus. All natural methods report a pregnancy success of 33% in sub-fertile couples when they are taught to recognise the fertile signs, and it is free. But the RCOG has recommended that couples not be taught this simple knowledge as it would cause anxiety.
Disagreements with the guidance
There are several key recommendations with which we substantially would disagree. These are set out in Table 2 below.
Table 2. Key statements in the document with which we disagree include
- Barrier methods can be considered as an alternative to sexual abstinence during the fertile window of the menstrual cycle in women, provided couples have been properly instructed in their use and accept a potentially higher failure rate if using barrier contraception around the time of ovulation (peak fertile time).
- Women stopping hormonal contraception should not rely on fertility indicators until regular menstrual cycles have been established and they have had a minimum of three cycles after stopping.
- Women using drugs that are known to have a teratogenic effect should not rely solely on fertility indicators for prevention of pregnancy.
- In women for whom pregnancy poses a significant health risk, the reliance on fertility indicators for the prevention of pregnancy is not recommended. Contraceptive options should be discussed with the woman and specialists involved in the management of the condition.
- Women wishing to avoid pregnancy should not have sexual intercourse, or they should use an additional contraceptive method until three consecutive dry days are noted.
- Withdrawal is not advised as a method of contraception on its own or as an alternative to condom use or abstinence in women using fertility indictors to avoid pregnancy.
- When sexual intercourse only occurs in the identified post-ovulatory phase, the failure rate of BBT as a single indicator is estimated to be approximately 6.6 %.
- The effectiveness of changes to the cervix as a sole indicator for contraceptive purposes is unknown and therefore is not recommended.
- Women may be informed that the effect of expressing breast milk on the efficacy of LAM is not known but it may potentially be reduced.
Our core concerns are, therefore, that NFP can be used reliably by those for whom the avoidance of pregnancy is very important (for health reasons etc) and also that the recommendation to substitute other methods (such as a condom) at the fertile time merely increases the likelihood of pregnancy. We think therefore that points 1 to 5 show that the Guideline Development Group have failed to really understand that well taught and used well, NFP is reliable and in fact more reliable than other methods of avoid pregnancy. They have also ignored their own data as set out above, which shows that condoms (5.7%)are less reliable than even the standard Calendar Days method (4.8%). As stated above, why use the least effective method when abstinence is better.
Rather, it is surely better to use the substantially more reliable Symptothermal Method and to counsel couples that if they do have intercourse during the fertile phase, even with a condom, that is the most likely way in which a conception will occur.
We disagree with the effectiveness data set out in point 7, and also have concerns about points 8 and 9.
A separate worry
A second concern in the recognition of NFP is that some hierarchy within the Church have said that that NFP should not be taught as it can be used for identifying the best time for harvesting ova for IVF. This is like saying that we should not have knives as they can be used for killing, or that we should not prescribe medication as it can be used for euthanasia. The alternating fertile and infertile phases in the woman’s hormonal cycles are designed by the Creator for His purpose. We have only recently in the last 100 years discovered the knowledge of these phases to regulate our fertility and so have the privilege of planning our family according to our means and talents.
The first humans were given ‘stewardship’, including being the guardians of fertility in our own generation and that of future generations. It was very recently reported that one in 20 schoolgirls under the age of 16 years, are on hormonal contraception. This, for many of them is before their Hypothalamic/Pituitary/Ovarian Axis has established itself, running the risk of future infertility.
We should welcome the document produced by the FSRH and follow its recommendation to undertake full and proper training in Natural Methods of Family Planning. But the Review Date is needs to be brought forward. June 2020 is too long a gap.
Dr Olive Duddy adds: I was a user of NFP and have been a teacher of Natural Family Planning for over 50 years moving from the calendar methods (Vatican Roulette) to the highly effective Symptothermal Method. I am Tutor for the Natural Family Planning Teachers’ Association NFPTA for 10 years. We (NFPTA) have run courses in Birmingham, Manchester and London. We have a twelve week distance learning course with pupils from Russia, California and Africa, as well as the UK.
World Health Organisation 1986 Definition of Natural Family Planning
NFP is defined by the WHO as a method of planning and avoiding pregnancy by observation of the naturally occurring signs and symptoms of the fertile and infertile phases of the menstrual cycle.
It is implicit in the definition of Natural Family Planning that:
- Drugs, devices and surgical procedures are not used
- There is abstinence from sexual intercourse during the fertile phase of the menstrual cycle
- The act of intercourse when occurring is complete
The attentive reader may well remember that in 2014 the Faculty for Sexual and Reproductive Health (FSRH) caused controversy when it stated that medics wishing to qualify in their speciality would have to fit IUDs and perform other practical acts to do so. As a result the CMA wrote to the FSRH to protest. As you can see Dr Olive Duddy from the Natural Family Planning Teachers Association did better still with wonderful results.
The document is very welcome, although we share concerns that the reliability data are inconsistent along with pleasure at some of it being reported as positively as it is.
Finally, do consider joining one of the NFTPA courses and become an NFP teacher.There are many people out there who need NFP teaching.