Consider Natural Family Planning

April 29th, 2019

            In 1965 I visited a medical meeting where an Australian couple, both physicians, advocated a new natural family planning method. The Doctors Billings claimed their method was very effective, could be used easily by any couple and was approved by the Catholic Church.

            Natural family planning makes use of the fact that women are not fertile every day. A woman can have intercourse certain days of her cycle with little risk of conceiving, but the problem is knowing when the infertile days are. Fortunately, there are several clues.

            Normally a woman bleeds for 4 to 7 days and is most fertile for several days around the middle of the month. When the bleeding stops, but before ovulation occurs, her ovaries make more estrogen. Estrogen causes cervical glands to secrete egg-white-like mucus to facilitate sperm swimming into the uterus. Ovaries increase progesterone secretion when ovulation occurs, usually in the middle of the cycle. This hormone causes cervical mucus to become thick and tacky. The Billings Method teaches women to observe these cervical mucus changes to discover when they are fertile.      

            It is difficult to study the success rate of any family planning method, but especially of natural family planning. Let’s look at how birth control effectiveness is computed. With an IUD, women are infertile as long as it is in place. The couple doesn’t have to do anything for the IUD to prevent pregnancy, so typical use is the same as ideal use. On the other hand, if a woman is using “the pill”, she must remember to take it about the same time every day. It is easy to forget a pill now and then, resulting in failure. The pill’s ideal failure rate is quite low, but the typical failure rate is significantly higher.

            Because natural family planning requires a couple to abstain from unprotected intercourse when the woman is fertile, the pregnancy rate is typically higher than ideal. After all, we are human! That is why some couples will use condoms or other barrier method if they have intercourse during the fertile time.

            Unfortunately, recent figures don’t bear out the Billings’ claim of effectiveness; the typical failure rate is about 20%. One in five women will conceive a pregnancy using periodic abstinence based on cervical mucus. When a woman does get pregnant while in a study of natural family planning, it is easy for her to rationalize that she really wanted to conceive. This a factor why some studies report very low pregnancy rates. Asking about pregnancy intention in advance is important when doing a study of any contraceptive method. 

            Natural family planning has moved into the 21st century! Now there are almost 100 software apps for smartphones, tablets and computers that can help women determine when they are fertile. None of them is perfect, of course, and some are pretty poor. Two have been evaluated scientifically and risen to the top.

           In order to predict when an individual is most likely to be fertile, Natural Cycles uses the duration of several menstrual cycles. Although the calendar method of natural family planning has been used for decades, this app “learns” from several months of data to make it more accurate. In addition, Natural Cycles uses the rise in woman’s temperature that occurs with ovulation which requires a special thermometer, adding cost. 

            The Dot fertility app has been examined stringently. It relies on menstrual cycle length to determine the fertile days and uses a sophisticated formula to adapt to the individual woman’s cycle. The study enrolled over 700 women and followed them for 13 cycles. The women reported each day if they were bleeding, if they had intercourse, if they used protection such as a condom—and if they wanted to conceive or not. If a pregnancy was suspected, the women were mailed a pregnancy test.

            The “perfect use” pregnancy rate for both these natural family planning methods was only 1%–ranking the them along with birth control pills! As you can expect, not all couples paid attention to the recommendations of their app. Therefore the typical user failure rate was higher. However unintended pregnancy rates of 8% for Natural Cycles and 5% for Dot are still quite good.

           Natural family planning isn’t for everyone. It doesn’t protect against AIDS, chlamydia or other sexually transmitted infections. Some couples may have difficulty abstaining or using a barrier method for several days each menstrual cycle. For couples in this era of computers and smartphones it offers an option that is quite effective and has no side effects.

©Richard Grossman MD, 2019

See how Rwanda has Changed

March 25th, 2019

     A friend told me about the International Conference on Family Planning to be held in Rwanda, and asked if I planned to go. I responded: “I am ambivalent about Rwanda; the country has a bad emotional feeling for me, despite what the Rwandans have done to deal with their genocide.”

     Nevertheless, Gail and I found ourselves in Kigali last November. We had a pleasant stay at a modest hotel near the beautiful modern convention center. The city’s lack of litter amazed us! While most cities we have visited have trash in the streets, there was none in Kigali. We learned about one of the reasons for this: the government has mandated that every Rwandan donate their labor to the country on the last Saturday morning of each month. After the community work there is a community meeting with community leaders to discuss problems. This service is called “Umuganda”.            Umuganda dates back hundreds of years but has been resurrected to become a tool for reconciliation. In the local Kinyarwanda language this word means “coming together in common purpose” and is just one way the Rwandan government promotes peace in the country. Another policy was a benefit to us. Whereas French used to be the prevailing European language (the country was a Belgian colony), now English is the primary language of instruction.            The article “Remember Rwanda” was one of the reasons that I had not felt good about visiting Rwanda. It suggests that one of the causes of the genocide there was overpopulation. People in many parts of the country in 1994 had too little ground to grow food and too little to eat. They became violent because they were starving.
            The Rwandans have made an amazing turn-around! People are no longer labeled as either by ethnicity (largely artificial distinctions)—they are all Rwandans. School children visit the Kigali Genocide Memorial to learn about their country’s history and ways to promote peace—so did we.
The healthcare system has improved markedly. Recall how important it is for a country to have a low under-five mortality rate if it is trying to slow its growth. Well, this important measure of child health in Rwanda is just a fifth of what it was just 15 years ago! As Rwanda’s Minister of Health, Dr. Diane Gashumba said “Investing in Universal Health Coverage (UHC) is one of the smartest investments a country can make.” The number of doctors in the country is low, but they are well distributed. Each village has a small clinic which is often attended by a nurse or community health worker. Almost all Rwandans have inexpensive health insurance, making it easy for the people to access primary health care. Unexpectedly, Rwanda has a unique system to deliver family planning.
            Notice that the Minister of Health is a woman! There are many women in the Rwandan government, including half of the cabinet ministers. Their parliament is also dominantly female, with 60% of the seats of the lower house held by women—the highest percentage in the world! People in the government are young, with the youngest cabinet minister just 31 years old.
            Education has taken a turn for the better, too. Whereas most African countries charge tuition for even elementary students, Rwanda abolished school fees for basic education in 2003. Enrollment soared! Recall that education of girls and women is one of the best ways of empowering women and increasing the use of family planning.
About half of Rwandans are Roman Catholic and are supposed to not use “artificial” contraception. The Church runs many of the Rwandan hospitals and clinics, so they cannot distribute contraception. However, the government has found a way around this limitation. Near each Catholic facility is a small family planning clinic that compliments the care of the Catholic facility.
            FamilyPlanning2020, the organization that is delivering family planning care in 69 countries, collaborates with the Rwandan governmental programs. They have provided an additional quarter million men and women with contraception since 2012. The most popular method is the “Depo” shot that is quite effective and lasts 3 months. Unfortunately, few men participate—only 1 in 12 couples uses condoms and vasectomy is rare.
            People in Rwanda are still poor—the average annual per capita income is less than $2000. However the government is making great strides to improve the lives of its people. They are strengthening the 3 most important things to help slow population growth: increase access to family planning, educate and empower girls and women, and promote the heath of children.

© Richard Grossman MD, 2019

Combat Overpopulation Denial

February 23rd, 2019

“Most economic fallacies derive from the tendency to assume that there is a fixed pie, that one party can gain only at the expense of another.” 

           Milton Friedman

            I first met people who denied the population problem in 1994 at the International Conference on Population and Development. They supported their claim that there was no population problem with the statement that all the world’s people could fit into Texas.

            Well, they are correct, however there are problems with this contention. If everybody crowded into Texas we would each have almost a thousand square feet! That’s plenty of room, wouldn’t you say?

            What about food? where would food come from, and how would it get distributed to all those people? What about drinking water? How would we stay warm in the winter? And what would happen to all the waste? Clearly people require more than just a thousand square feet.

            How much land does each person currently use? The best way of calculating this seems to be the Ecological Footprint. The EF has been calculated for people in many countries, and combines the land needed to live on, grow our food on, the area needed to develop natural resources and also the land to dispose of our waste. It is a comprehensive method of evaluating a person’s impact on Earth, although it does leave out one factor. More about that factor below.

            The area of land in square feet, and the world population, are both very large numbers, of course. The EF only includes what is called “bioproductive” land—leaving out mountains and deserts. It turns out that an average citizen of the world is using about 291,000 square feet of land, or about 6 2/3 acres. This is more than 290 times the area allotted if we all squeezed into Texas! The people who deny overpopulation use an argument that is based on drastic misinformation.

            Indeed, not only could we all not fit into Texas for any period of time, but also we don’t really fit into Earth. To be sustainable, with our current population and level of consumption, we would need 1.7 times the land area available to us. We have overdrawn on our global savings account in order to enjoy our consumptive lifestyle.

            We can already see the effects of overpopulation and overconsumption. Perhaps most evident is climate change. Land is eroding, fisheries are depleted and toxic chemicals are ubiquitous. Furthermore, we are killing off other species at terrifying rates—at least 1000 timesnormal. Although the Ecological Footprint is an excellent tool for comparing what people are using with what is available, it has a major limitation. It does not leave any resources for other species.

            I haven’t read the book “Empty Planet: The Shock of Global Population Decline”, but I’ve read reviews. The authors, neither of whom is a demographer, maintain that the world is not overpopulated and, indeed, needs more people. They are concerned that the birth rate is falling more rapidly than the UN and other demographers realize. I wish they were correct, but I disagree!

            The Wall Street Journal review of the book uses the term “global population collapse”—but there is little reason to believe that this will happen this century; we’re still adding 80 million people to the planet each year. The review is concerned that the growth of the economy will slow. Only a madman or an economist can believe that perpetual economic growth is possible. 

            What is wrong with this book? There seem to be many errors. The authors don’t focus on subSaharan Africa, where the average woman still has almost 5 children, and parents want large families. The authors seem to ignore demographic momentum, which causes growth to continue for several decades even after a country reaches replacement family size.

            The major problem with “Empty Planet” is that nowhere (in reviews I’ve read) do the authors compare the resources we humans are using with what is available. The Ecological Footprint does that, and the result is not pretty. Unfortunately that book is not alone in not considering the finiteness of our planet. Even though Milton Friedman won a Nobel Prize for economics, he was not thinking globally when he wrote the quote at the beginning of this column. Our global “pie” is fixed in size. We in rich countries are endangering people in other countries with our growing population and extravagant lifestyle. We are also endangering our progeny.

© Richard Grossman 2019
Creative Commons Attribution 3.0 United States
This work is licensed under a Creative Commons Attribution 3.0 United States.