Chapter 11 / Behavioral Methods of Contraception 179 11 Behavioral Methods of Contraception Jennefer A. Russo, MD and Anita L. Nelson, MD CONTENTS INTRODUCTION CANDIDATES FOR NFP OF FAMS EFFICACY AND CONTINUATION RATES TRAINING OPTIONS: BEHAVIORAL METHODS OF CONTRACEPTION SUMMARY REFERENCES INTRODUCTION A surprising number of couples rely on behavioral methods of contraception, at least intermittently. Abstinence promotion usually targets adolescents, but abstinence is used by women of all ages. Natural family planning (NFP) and fertility awareness methods (FAMs) are critically important for many couples for whom this is the only religiously, culturally, or socially acceptable method. Coitus interruptus has a typical failure rate comparable with the more effective female barrier methods. This chapter provides information about the techniques found to enhance the success of each of these methods. CANDIDATES FOR NFP OR FAMS Only women with regular cycles are appropriate candidates for NFP techniques. This typically excludes women with polycystic ovary syndrome and women who have menstrual disruptions because of breastfeeding, as well as postpartum and perimenopausal women and those currently or recently using medications and herbs that affect their menstrual cycling. Success requires that both members of the couple agree to abstain or use protection during the data collection periods and during the at-risk days. In clinical trials, the greatest source of failures has been that couples decide to have intercourse despite clear indications of ovula- tion ( 1). Given such realities, NFP users should be extensively counseled about emergency contraception and offered kits by advance prescription. From: Current Clinical Practice: The Handbook of Contraception: A Guide for Practical Management Edited by: D. Shoupe and S. L. Kjos © Humana Press, Totowa, NJ 179 180 Russo and Nelson EFFICACY AND CONTINUATION RATES Typical use failure rates are reported to be 25%. The typical use failure rates vary little among the currently available NFP and FAM, mostly because of routine violation (2). However, failure rates associated with consistent and correct method use do vary, depending on whether pre-ovulation intercourse is permitted or excluded. The calendar method has a 9% failure rate with correct and consistent use, compared with 3% for ovulation detection, 2% for symptothermal method, and 1% for post-ovulation method (3). Continuation rates with NFP methods in well-supported programs after 1 year range between 52 and 74% (3). Advantages of NFP are wide-ranging: no exog- enous devices or drugs are routinely used, most couples learn a great deal about their own reproductive physiology, and NFP may be the only method accepted by various religions and cultural groups. The same techniques for identifying at-risk days can be used by couples seeking pregnancy to conceive. There are no direct medical side effects from use of the method, although the psychosocial implications of avoiding intercourse for significant periods of time should be taken into account by couples considering use of these methods. TRAINING With the exception of the standard days method with CycleBeads™, couples need extensive formal training to effectively practice periodic abstinence or fertility awareness. Because it is quite time-consuming to provide couples with all of the needed information in a busy office practice, it may be helpful to have available community resources to provide more detailed education. The organi- zations listed in Table 1 can provide advice, charts, and teaching plans. OPTIONS: BEHAVIORAL METHODS OF CONTRACEPTION Abstinence Worldwide, it has been estimated that 200 million reproductive-aged women use abstinence as their method of birth control, where abstinence is defined as the avoidance of penile-insertive vaginal intercourse. For some women, this is a permanent choice, but for others it may be a temporary one. This latter situation accounts for the variable success rate of abstinence. If practiced, abstinence should be 100% effective, but when declared as a method at one point of time (such as an annual visit) but not practiced consistently until the next visit, “abstinence” carries with it a measurable risk of pregnancy. Much effort has been invested in developing programs to encourage absti- nence among adolescent men and women. The benefits are obvious: abstinence provides the only truly effective way to prevent pregnancy and sexually transmit- ted infections (STIs). It can help promote self-esteem and maintain a young Chapter 11 / Behavioral Methods of Contraception 181 Table 1 Natural Family Planning Resources for Advice, Charts, Teaching Plans, and Referrals Billings Ovulation Method Association, NFP Office 316-N 7th Avenue St. Cloud, MN 56303 Phone no.: (888) 867-6371 Calgary Billings Centre of Natural Family Planning Room 1 1247 Bel-Aire Dr SW Calgary, AB T2V 2C1 Phone no.: (403) 252-3929 Website: www.billings-centre.ab.ca California Association of Natural Family Planning 1010 11th Street Suite 200 Sacramento, CA 95814 Phone no.: (877) 332-2637 Website: www.canfp.org The Couple to Couple League International PO Box 111184 Cincinnati, OH 45211-1184 Phone no.: (513) 471-2000 Website: www.ccli.org Institute for Reproductive Health Georgetown University Medical Center 3 PHC, Room 300r 3800 Reservoir Road NW Washington, DC 20007 Phone no.: (202) 687-1392 Website: www.dml.georgetown.edu/depts/irh National Center for Women’s Health Pope Paul VI Institute 6901 Mercy Road Omaha, NE 68106-2604 Phone no.: (402) 390-6600 Website: www.popepaulvi.com Family of the Americas Foundation, Inc. PO Box 1170 Dunkirk, MD 20754-1170 Phone no.: (800) 443-3395 Website: www.familyplanning.net (continued) 182 Russo and Nelson Table 1 (Continued) Natural Family Planning Resources for Advice, Charts, Teaching Plans, and Referrals Natural Family Planning Center of Washington DC 8514 Bradmoor Drive Bethesda, MD 20817-3810 Phone no.: (301) 897-9323 Northwest Family Services 4805 NE Glisan Street Portland, OR 97213 Phone no.: (503) 230-6377 Website: www.nwfs.org Twin Cities NFP Center HealthEast, St. Joseph’s Hospital 69 W Exchange Street St. Paul, MN 55102 Phone no.: (651) 232-3088 Website: www.tcnfp.org woman’s options for self-growth and financial self-sufficiency. In the United States, however, only about half of all adolescents choose this method. In a 2004 review of data from the 2002 National Survey of Family Growth, Abma et al. found that 47% of female adolescents and 46% of male adolescents reported that they had engaged in sexual intercourse at least once in their lives. For the age group of 15–17, there was a decrease in sexual behavior from 1995 to 2002, with 30% of girls and 31% of boys reporting sexual activity in 2002 versus 38% of girls and 43% of boys in 1995 (4). Risk factors for early and/or unprotected intercourse among adolescents have been identified. Low income, poor school performance, siblings with teen pregnancies, early puberty, and other risk-taking behaviors have all been demon- strated to be associated with an adolescent’s risk for unintended pregnancy. However, teen sexual activity and adolescent pregnancy are not restricted to these high-risk groups; adolescent pregnancy is an epidemic that cuts across all socioeconomic and ethnic groups. Even parent–family connectedness and perceived school connectedness were not found to protect against pregnancy (5). Abstinence-promoting programs must be broad-based. They must also recog- nize that, for many adolescents, the risk of an unintended pregnancy is minor compared with other risks that they face on a daily basis. For example, in 2004, the Center for Disease Control and Prevention estimated that 33% of adolescents had been in a physical fight in the last 12 months and 17% had carried a weapon in the last 30 days (6). Experience with a wide variety of abstinence-promoting programs has pro- vided important insights. Programs based on a “just say no” approach or that Chapter 11 / Behavioral Methods of Contraception 183 threatened young women with STIs or unintended pregnancies if they engage in sexual activity (“scare them straight” approach) have been shown to have no effect on either sexual behavior or contraceptive use. Analysis of the “Postpon- ing Sexual Involvement” curriculum used in 31 California counties showed no effect on sexual behavior of 7340 students participating in the program. Such programs do not delay the onset of sexual activity, but they do result in higher pregnancy rates than controls (7,8). A didactic program that only discussed human sexuality and encouraged young people to seek family planning services if they needed them did not change sexual behavior (9). This is consistent with other research showing that knowl- edge-based approaches are not effective in reducing adolescent negative health behaviors (10,11). Programs that strongly encourage abstinence but also provide information about available methods for birth control and STD protection have been shown to increase contraceptive utilization by 70–80% (12,13). Providing teen women with concrete examples of how to decline sexual advances is also important; translating abstinence principles into action in different situations is not a skill most adolescents have mastered. The realities of adolescent life involve the rejection of adult authority, relatively low self-esteem, and foreshortened time frames. In addition to the limited future alternatives many teens anticipate for themselves and the short-term gains many