1 Winter/Spring 2001 ● Vol. 12, Nos. 1 and 2 Richard J. Fehring, DNSc, RN, Marquette University College of Nursing In this issue Natural Family Planning ………………………………………… 2 Fertility ……………………………………………………………. 5 Contraception …………………………………………………….. 8 Research Briefs …………………………………………………… 9 Under the Microscope ……………………………………………. 14 Predicting the Fertile Window Current Medical Research is a publication of the Natural Family Planning Program of the United States Conference of Catholic Bishops.© Washington, DC: USCCB, 2011. The managing editor is Theresa Notare, PhD, Assistant Director. Permission is granted to reproduce in whole or in part, in print and/or electronically, with the following statement: Current Medical Research, NFPP/US Conference of Catholic Bishops, Washington, DC, volume # (year): page#. Used with permission. 2 Natural Family Planning Compliance and Natural Family Planning The importance of user compliance on the effectiveness of natural family planning programs is the topic of a review published by a research group from the University of Federico II of Naples, School of Medicine.(1) The main cause of NFP method failure, according to the authors, is either a conscious departure from the rules of the various NFP methods or the erroneous application of the rules. In addition, they also stated that methods of NFP have relatively high discontinuation rates. A reason for discontinuation and lack of compliance they postulate is that the rules of NFP might be too demanding (i.e., rules for pregnancy avoidance can average 14-15 days each cycle). Continuation rates reviewed from 13 published studies (1981-1997) ranged from a low of 4.2% over a 12 month period to a high of 73.7%. The reasons provided for discontinuation of NFP methods, included lack of interest, dissatisfaction with the method, unplanned pregnancy, difficulty in recognizing biological indicators (i.e., the mucus sign), a desire for pregnancy or separation from spouse. The authors speculated that lifestyles, belief patterns, cultures, and the availability of contraceptives might affect the decision to use NFP as a method of family planning. Potential users in developing countries that live a hectic fast paced lifestyle and that have many contraceptive choices might not be readily open to NFP methods that have complex rules, self-observation of biological signs and sexual abstinence. However, if couples in developing countries use NFP methods they probably will be compliant users because their interests are based on strong personal beliefs. The authors provided a number of suggestions to increase the use, satisfaction and compliance with NFP rules of instruction. These suggestions include the use of urinary home test kits for monitoring ovulation. They believe that these kits are easy to use and could be targeted to a larger part of the population. Besides urinary hormonal test kits they also suggest fertility monitoring devices such as the CUE monitor that provides a digital measure of salivary and vaginal secretions (see CMR, Winter/Spring 1998, pages 5-7, for a review of the CUE monitor). The authors also suggested simplifying or decreasing the rules in the use of NFP and using simple monitoring devices such as beads and necklaces (see next article on the simplified rhythm calendar method). Finally, the authors also mention (with a religious caution) the use of barriers during the fertile time. They believe that the use of barriers might increase the number of potential users who are doubtful of the effectiveness of NFP methods and who do not wish to practice periodic abstinence. 3 Comments Compliance in NFP use is an important topic. Understanding why users of NFP discontinue, are unsatisfied with the methods, or are unable to use them will help NFP teachers to address this problem in client instruction. Certainly, simplifying instructions, using accurate and objective fertility monitoring aids, decreasing the amount of periodic abstinence and adapting methods to various cultural groups and contexts are some possible ways of increasing compliance. However, as the authors point out, the group that comply the most are users who have a strong personal belief system. For example, a 1997 New Zealand study showed that Catholic women with strong religious motivations were more likely to continue in the use of NFP (2) and a 2000 United States study showed that those couples who were more likely to continue instruction in NFP were Catholic, white and college educated. (4) For a number of reasons it is doubtful that the use of barriers would increase the use, compliance and satisfaction with NFP methods. Research has indicated that couples often report barrier sex to be unsatisfactory. In addition, Catholic teachings reveal that such behavior is contradictory to the true nature of the conjugal relationship. It would be helpful for NFP teachers and researchers to look to other models that have addressed the problem of compliance and apply them to NFP. Social support, self-efficacy, behavioral control, contracting and health belief models are some examples of approaches that have been developed and researched in other disciplines that could be applied to NFP to address the complex problem of compliance. Innovative solutions are required not condoms. 1. Tommaselli, G. A., Guida, M., Palomba, S. et al., The importance of user compliance on the effectiveness of natural family planning programs. Gynecological Endocrinology 14 (2000): 81-89. 2. France, M., France, J. and Townend, K. Natural family planning in New Zealand: a study of continuation rates and characteristics of users. Advances in Contraception. 13 (1997): 191-198. 3. Stanford, J. B. and Smith, K. R. Characteristics of women associated with continuing instruction in the Creighton Model Fertility Care System. Contraception 61 (February, 2000): 121-129. ____________ High Satisfaction with a Fixed Day Calendar Rhythm Method Reported Among Mayan Couples in Guatemala Over the past 30-40 years the calendar rhythm method of family planning has been denigrated among the health professions and public at large as being ineffective and harmful to 4 relationships. A renewed interest in the calendar rhythm method however has recently been initiated by a number of groups in the United States and abroad. One of the strengths of the rhythm method is in its simplicity. Recent re-formulations of the rhythm method have made it even easier. With the old formulation of the rhythm method the days of periodic abstinence in a given menstrual cycle varied according to the lengths of the previous 6 to 12 cycles. In order to determine those days a simple mathematical formula was used to calculate those days. An even simpler method would be to have a fixed-day period of abstinence in each cycle. The two current fixed day formulas that are being tested are the 11 and 12-day formulas, with days 9-19 or 8-19 of each cycle constituting the fertile time. Both of these fixed day methods and the studies they are related to have been discussed and reviewed in previous issues of CMR. (1,2) An 11 day (9-19) fixed day formula of the calendar rhythm method was recently tested among the Mayan population of Guatemala.(3) The method was implemented with the use of calendars and a beaded necklace system. The calendars were used to record the beginning and end of each menstrual cycle as indicated by the woman's menses. The beads were used to track the days of fertility and infertility. To begin the cycle the first bead was colored red, the 11 fixed days of fertility from day 9-19 were colored green, and the rest of the beads were colored brown. The green and brown colors coincided with the dry (brown earth and foliage) and the rainy fertile (green foliage) times of the countryside in Guatemala. Each beaded necklace has 30 beads and a marker that is moved from bead to bead. The fixed formula is intended for women who have 26- 30 day cycle lengths. The fixed day formula bead method of calendar rhythm was tested among 301 couples (women between the ages of 18-39 years) living in the Guatemalan highlands. A team of one supervisor and three instructors at 5 centers taught the method. Instructors visited each couple and completed follow-up forms after the first three cycles and every three months until the end of the 12 -month study period. Suspected pregnancies were confirmed by pregnancy tests. About 51% of the 301 couples were Catholic (41% Evangelical), about 31% desired more children and only 16% of the women had more than 7 years of a formal education. Almost 89% of the sample had never used a method of family planning. After 12 months of use, 79% of the couples were still using the method. The reasons that the 32 couples who discontinued gave for stopping were personal (45%), migration (22.6%), or desiring a pregnancy (16.1%). After 12 months of use 32 couples were pregnant giving a 11% pregnancy rate. However, only 34% of these couples were sure that they did not have sexual relations during the fertile period. At 1, 3, and 12 months, 100% of the women reported satisfaction with the method but 5 of the men reported being dissatisfied due to the periodic abstinence. The authors concluded that a bead necklace fixed day system of calendar rhythm was highly acceptable and potentially effective among the Mayan population of Guatemala. 5 Comments The authors of this study pointed out that the level of attention received by the instructors might have contributed to the high satisfaction, high continuation and low pregnancy rate. They plan on a one-year follow-up study to determine if the satisfaction, continuation, and low pregnancy rates continue. The authors also speculated that male dissatisfaction with periodic abstinence should send up a red flag and the instructors should then encourage couples to keep a barrier handy.