Catholic Medical Quarterly Volume 68(2) May 2018
Discussion Paper on NFP in the UK
the Couple & the Church - Moving things forward
Dr John-Paul O’Sullivan
Fifty years have passed since Paul VI’s now famous encyclical Humanae Vitae but an open and honest discussion about NFP (Natural Family Planning), the real life application of this doctrine is urgently needed within the Church. Confidence in NFP is down. Couples lack confidence in using NFP methods, use of those methods is down and lack of users means stagnating progress for NFP teaching organisations. Declining confidence becomes contagious – new couples, Clerics and young people in particular are dismayed at a situation where a publically promoted Church doctrine is privately considered impractical by many. An uneasy silence then develops that doesn’t help anyone. Reports abound of some Catholic couples feeling unable to speak to their healthcare professionals about using NFP and healthcare organisations in the UK have become largely dismissive or ignorant of NFP altogether in the absence of any real patient demand for these services. Healthcare providers and patients can become set as opponents in situations where one of the parties is open to the inclusion of NFP in discussions about family planning. Chronically understaffed and underfunded NFP organisations are struggling and perhaps sensing the poor capacity in those organisations, healthcare professionals and Clerics feel reluctant to refer couples to them which reduces their referrals further still. The situation has been bad for some time but toxicity from this issue will become corrosive if left unchecked. We are at risk of losing vital resources and skills that future generations may wish to use. Perhaps most all we risk losing the central vision of Humanae Vitae - that fertility is not a disease which needs to be controlled but rather a normal human function in which humans participate in the awesome creative power of God.
Ironically all of this occurs in the UK as the tools and systems of NFP continue to evolve and advance. Using the Creighton System, Dr Tom Hilger’s work in the United States developed NaProTechnology which extended NFP into women’s healthcare and gynaecology providing hitherto unforeseen benefits in those fields. Whilst contraceptive technology continues to exert a collective form of amnesia on the medical understanding of fertility and menstrual disorders, Hilger’s work showed that cycle-timed interventions can be extremely advantageous and menstrual biomarkers are ignored at the physician’s peril. His colleague in the US, Prof Richard Fehring went on to develop a system of NFP system using the ClearBlue Hormone Monitor in association with natural signs of fertility. Prof Fehring’s ‘Marquette Method’ has innovated protocols for women across various stages in reproductive life. At the University of Utah, Prof Joe Stanford is undertaking pioneering research using the Creighton System to study how exposures around the time of conception affect later life and develop even further lines of study in NFP. Dr Petra Frank-Herrmann and her colleagues in Germany used the Symptothermal Method to develop an enormous database of user cycles showing excellent levels of user effectiveness from German couples using Symptothermal in a widely-acclaimed (and cited) prospective longitudinal cohort study1. Various groups from Scandinavia to North America and Australasia are using new technologies like video-conferencing, mobile phone apps and cycle-timed interventions to assisting NFP couples in ever new and creative ways.
Those of us who work in the field of women’s healthcare are aware of the enduring popularity of contraceptive technologies for both family planning and ‘menstrual regulation’ however this need not impede progress in NFP. Other methods of fertility regulation should naturally find a niche for women and couples of various motivations and only this month in an open letter to the editor of the New England Journal of Medicine one woman requested "..renewed research on new or better birth control products — ones that are safe and convenient, and more equitably incorporate men in pregnancy prevention"2. As ever one wonders if this lady, or her healthcare providers have heard of NFP.
I have read the CMQ articles and letters on this topic over the past year with interest. Surely the most pertinent questions going forwards are: How do we move things forward for NFP in the UK? Can we come any closer to realising the benefits of Humanae Vitae or will we fall further behind other countries in the next 50 years? What our legacy be to future generations of Catholics in the UK?
The Current Situation
Broadly speaking we currently have 3 Systems of NFP available in the UK: Sympto-thermal, Billings and Creighton. To the best of my knowledge none of these systems are available through NHS Clinics currently (although arguably they should be). All are run on a fully or semi-voluntary basis and various organisations exist to support their use – NFPTA (Natural Family Planning Teachers Association UK), Couple to Couple League UK, Billings groups include: Fertility Care Scotland & Billings South West. The Creighton System is facilitated through the Prolife organisation ‘Life’.
All the groups highlighted above are prolife in their approach and do not include artificial forms of family planning as part of their systems. A further groups called Fertility UK also support women and couples to learn about natural signs of fertility however they incorporate use of barrier methods and other forms of contraception as part of their approach. In association with the Faculty of Sexual and Reproductive Healthcare (part of RCOG), Fertility UK contributed to a recent Green top Guideline from FSRH in 2015 on ‘Fertility Awareness Methods’. The correct and modern term for NFP is Fertility Awareness Based Methods (‘FABMs’) & this term will be used synonymously with the term ‘NFP’ henceforth in this article.
Separating out the Main Stakeholders to assess their roles
The Principle stake-holders in NFP are users and teachers. That may seem like a straightforward point but it’s foundational in our understanding of the problems that NFP is facing. Users' main objectives are to learn a system that a. Is suitable for them & integrates easily into their lifestyle & b. Is effective in helping them to achieve the pregnancy intentions they set-out to achieve [and/or gain assistance / facilitation towards appropriate healthcare support if medical problems are identified].
It’s important for NFP supporters to be earnest in this field. Both experienced healthcare professionals and NFP Teachers are well aware that pregnancies do not always occur at times which couples identify as most ideal for them [as is the case with all behavioural methods of family planning including the contraceptive pill & condoms]. Nonetheless, NFP Organisations must take the pregnancy intentions of users very seriously indeed and I would suggest that they make this the standard upon which their Organisation’s success rates are judged. Not only do modern NFP users seek this but a full & adequate understanding on this point is essential towards effective consent also. Whilst Humanae Vitae provides guidance to spouses on how they may wish to plan their families, in NFP, those decisions should never be second guessed and teachers ought to make couple’s pregnancy intentions their primary aims and objectives during meetings with couples.
Considering pregnancy intentions also makes one cognisant of the increasing burden in our society from subfertility, miscarriage and stillbirth. There is a greater need for Christian support for these conditions in general and modern NFP Organisations are ideally placed to provide support for those conditions, especially to couples using NFP. Modern NFP organisations ought to have clear referral pathways for couples who are suffering from these conditions, ideally to a Restorative Reproductive Centres where further medical investigation can be undertaken as well as provision of appropriate guidance and advice to women / couples suffering from these conditions. Thus far only Creighton Method with NaPro Technology has extended medical protocols that assist NFP users with these type of problems. In many cases, addressing undiscovered underlying causes like PCOS, endometriosis & hormonal imbalances are vital to achieving conception and sustaining pregnancies.
The other main stake-holders are NFP Teaching Organisations. NFP Teaching Organisations train and equip individuals to become NFP teachers and NFP teachers are one of the most valuable assets we have in NFP. Couples who are NFP users themselves are often well placed to take their understanding further and train as teachers. More healthcare professionals are also needed to support the development of these organisations. It’s unfortunate indeed that understanding of natural fertility has fallen so low in the healthcare professions but also that the call for support from Catholic healthcare professionals in Humanae Vitae is not more widely addressed. NFP organisations must also monitor the performance of their teachers, update them on a regular basis and re-accredit them for ongoing practice. Given the nature of NFP which is relatively heavy on user-support in the early phases but lighter over the long-term, NFP organisations need to be flexible in their capacity & have the ability to welcome back existing users as problems crop-up as well as taking on new users. This matching process is difficult to manage as at any one time the pool of available NFP teachers fluctuates alongside the fluctuations in demand for NFP.
The Church, Environment groups and other organisations are secondary stake-holders. Whilst their promotion and participation are welcome to make progress going forward NFP needs to focus on the needs of NFP users and organisations foremost I think.
FABM (Fertility Awareness Based Methods) users need good quality teaching and access to an NFP teacher over the time. Ideally users are able to access teaching in their own location but technologies like Skype, video-conferencing & smartphone apps can facilitate access to teaching support, as could effective online learning resources. Access to teaching support is vital for users as their reproductive category changes over time e.g. not-pregnant avoiding or not-pregnant achieving, pregnant & receiving antenatal care, puerperal / breastfeeding phase, perimenopause etc. Users ought to be able to find support whatever their reproductive category and whatever their ongoing situation is. In all NFP consultations, the women’s general and reproductive health should be considered if not assessed formally in addition to her pregnancy intention and any concerning signs or symptoms which are identified. There is frequently a need to link in with Primary Care, Counselling groups &/or other organisations from NFP as necessary. This aspect of NFP, in and of itself makes FABMs a superior family planning system to several artificial methods and we don’t need to be bashful about this point. Artificial methods of family planning tend ablate or mask important pathologies like PCOS, ovarian cyst & endometriosis (and again in the interests of full consenting individual users may wish to discuss this possibility with their GP or Practice Nurse).
Whilst setting-out the needs of NFP users it’s equally important to set-out their responsibilities. Clearly no couple are tied to the use of any one particular family planning system and whilst couples are free to switch their method at any time it is vitally important that couples are completely honest with their teachers about
- What family planning systems they’re using at any one time & that
- NFP Organisations are notified immediately when a couple stop using an NFP system.
This is because historically, analysis of NFP effectiveness has been disenfranchised by couple’s who stop using their NFP system, neglect, forget or omit to tell their teacher that their method use has stopped and the couple’s time-in-use analysis remains included in effectiveness statistics which as highlighted above are of paramount importance to NFP groups.
In addition to this, NFP users in the UK have historically not been asked to fund their teaching but in the future this situation may need to change if NFP organisations are develop and indeed survive. The main beneficiary of NFP teaching is the couple themselves. In the absence of funding from healthcare groups users should therefore contribute directly towards the costs of NFP organisations allow them to maintain and develop their services. In a pluralistic society with a single healthcare provider (like the UK) there is certainly an argument that the healthcare provider should also contribute toward the costs of NFP-use for couples who request this service however strangely this point appears to go untested in the UK. As noted, FABM users require higher levels of teacher input at the beginning of their FABM use but if a couple sticks with an FABM system, high initial costs are recouped over the longer term. It’s possible that lower costs may be achieved in other ways also, especially in terms of couple harmony and family stability.
Some couples will wish to come and go between natural methods and artificial ones and NFP organisations need to be flexible in their capacity to accommodate these users back to charting and NFP use as situations change for couples.
Fertility Awareness Based Methods (FABM) Organisations
To be effective, FABM organisations need to be accessible and supportive. To address the concerns about efficacy they need to be research focused, open and transparent about their ongoing performance. Systems which monitor and publish local effectiveness statistics are to be encouraged. In the modern healthcare climate, NFP organisations should look to continually improve their success rates and capitalise on all means of doing this on an ongoing basis.
Fertility education is a far larger task than any singular NFP Group or Organisations could hope to undertake and discussion about fertility really need to begin in the home and the school. Users who come from a background of fertility awareness often find NFP relatively easy to understand & integrate into their lifestyle. Couples and individuals coming from a contraceptive background sometimes find fertility awareness more challenging.
All of this requires funding. In the absence of NHS funding, NFP organisations should both fund-raise and seek to recoup their costs from FABM users. Whilst fund-raising from secondary stakeholders is helpful, a shift in financing is needed to secure the future of NFP on a long-term basis. The current approach to running organisations on a voluntary basis may not be the best way to achieve that aim going forwards and further discussion on this point is needed. Groups which take-up opportunities to invest in Restorative Reproductive healthcare opportunities could presumably plough any profits from those enterprises back into the NFP-side of their business so to speak. Groups could operate as not-for-profit organisations. Teacher training, accreditation and re- accreditation are expensive activities and NFP Organisations may wish to start charging Teachers for these services also. Switching from voluntary to paid NFP Teachers might attract more individuals to the position of NFP Teacher and provide a further stimulus for growth. The Palliative Care movement in the UK has had similar challenges with fund raising over the years and has developed creative ways to address this problem.
NFP organisations have a real opportunity to assist couple’s in managing their fertility, to provide Christian support in times of suffering (subfertility, miscarriage etc) and to promote monitoring and improvement in couple’s reproductive health. It must always be clear however that NFP stands quite separately from contraceptive techniques and abortion services. Whether couples use artificial or natural family planning means, no system is 100% full-proof and all pregnancies achieved during NFP use are welcomed while sensitive enquiry pursued if any breakdown in teaching or method occurs (& this should be clear from the outset).
How can the Church can assist her Members and FABM Organisations?
The Church has been a stalwart supporter of married life for centuries and thank God for her concern and pastoral care in that regard. Care and concern for marriage is clearly a far bigger issue that family planning and NFP will only ever form part of the larger jigsaw puzzle.
In relation to family planning however, the Church’s position infers a need to directly support either NFP organisations or to assist her members in some other way with the directives of Humanae Vitae. Whilst support for NFP is welcome from all quarters, to grow and develop NFP organisations need to move more towards the healthcare world and to an extent stand apart from the Church in doing this. I would argue that the natural setting for NFP clinics should either be the healthcare clinic or the home and not the Church hall. NFP teachers currently are often inspired to work in this area as a result of their Catholic faith and whilst this inspiration is welcomed, NFP teachers must remain cognisant of their own background vis-à-vis the different backgrounds NFP users come from. It deserves to be said that Catholic parents and teachers (including Clerics) play an essential role in educating members of our Church about NFP and being able to appropriately signpost individuals towards these services. It is unhelpful when parents, teachers or Clerics signpost people towards artificial family planning services in a Church context.
Given her stance on family planning the Church should do all she can to ensure that members who are marrying in the faith are adequately informed about modern NFP methods and this has implications for marriage formation / preparation courses as well as organisations the Church supports directly in other ways. It is disheartening to hear about marriage preparation courses where the Church position on family planning is not articulated clearly. Whilst the use of a family planning method is entirely down to couples themselves it is certainly possible for the Church to support NFP and promote effective NFP teaching being available to all her members rather than the perennial refrain which all NFP Teachers in the UK will likely have heard a hundred times “..I wish someone had told me about this 20 years ago”.
A common comment on Humanae Vitae is that the doctrine hasn’t been tested and found wanting so much as effective knowledge, understanding and application of it has. If this is the case then we have urgent work to do. Healthcare professionals are needed to advance this work and Catholic lay people and healthcare workers have a role to play. Changes need to take place in the Church; within her lay members, her Clerics and within NFP organisations as well. Reforms in all these areas are overdue.
NFP organisations need to find ways to ways to grow and develop. They need to find ways to incorporate modern healthcare standards into their work whilst providing flexibility towards the needs of modern users. NFP organisations must be equally able to educate the enquirer who might never use the NFP system as well as the couple who are committed to using it and the whole spectrum of users in-between. It’s important to continue to naturalise NFP use but also to upskill NFP teachers so that important conditions are picked-up more efficiently in future and referred where appropriate. For couple’s who are healthy the aim remains to educate, facilitate (& measure) method use. NFP organisations need to think through and develop protocols for women and couples who are suffering from subfertility and recurrent miscarriage.
As Catholics, if we want these type of services to be available in the future I think the time has come to pay for them. We should pay for them both financially and in terms of our service. NFP in the UK needs new FABM teachers and healthcare personnel. It requires administrators, receptionists, people with expertise in website design, smartphone apps, accountancy, statistics and a whole host of other skills. As the FSRH Guideline commented in 2015, FABMs have a legitimate role to play in our healthcare system and Catholics should be able to speak to their GPs, their Practice Nurses, Health Visitors and others (honestly) about the family planning system they’re using. They should be able to seek support from those groups and find that support for using systems of family planning which are healthy, safe and promote reproductive health for both sexes. The past 50years have been a mixed bag for NFP in the UK and we’re drifting. Let’s make the next 50years better?
Dr J-P O’Sullivan is a GP practicing in Paisley
- The effectiveness of a fertility awareness based method to avoid pregnancy in relation to a couple's sexual behaviour during the fertile time: A prospective longitudinal study. PF Herrmann, J Heil, C Gnoth, E Toledo, S Baur, C Pyper, E Jenetzky, T Strowitzki, G Freundl. Hum Reprod. 2007 May;22(5):1310-9.