Archive for the 'Contraception' Category

Consider Natural Family Planning

Monday, 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

Give Thanks

Saturday, November 24th, 2018

 

Map of Total Fertility Rates courtesy of M. Tracy Hunter

At the risk of seeming overly optimistic, I would like to make a list of good things that are happening in the world of family planning and demography. Here goes:

My perception is that people are starting to realize the advantages of having small families. Their motivation is two-fold. Many people are realizing that it is possible to be married and have a good life with just one child, or with no children at all. In the USA and in many other rich countries this is practical because we have old age benefits, but more difficult where these benefits don’t exist so people have to rely on their children. There is another, altruistic reason a few are limiting their fertility. They see that the world is already overpopulated and don’t want to contribute further to the problems we are causing.

There are better, safer and more effective contraceptive methods than 52 years ago when Gail and I got married. The number of women using highly effective methods is rising, and (thanks to some good people running altruistic organizations) some are more affordable. An example is Medicines 360 which makes the Liletta™ IUD available to nonprofit clinics for just $50.

Colorado was chosen several years ago for a 5 year experiment. Women were able to receive LARCs (Long Acting Reversible Contraceptives, such as IUDs and implants) at no cost, even if they didn’t have insurance. The result was phenomenal—the unplanned pregnancy rate in our state dropped dramatically, and so did the abortion rate. I like to think of all the young people who were able to finish high school and go on to college because of this experiment. That experiment is over, but funding has continued thanks to private and state funding.

Emergency Contraceptive pills are now available without a prescription. This medication is so safe that there are essentially no cases of serious harm from taking it. It is not the best solution, because it is used after a failure—failure of a man to respect a woman, failure of a couple to use contraception or failure of a condom. Nevertheless, EC pills have prevented thousands of unplanned pregnancies.

There is also a movement to make birth control pills available without prescription (www.freethepill.org), or with a prescription from a pharmacist. Now a woman can purchase “the pill” over the internet, and in some states (including Colorado and New Mexico) pharmacists can prescribe hormonal contraceptives by following a protocol. Planned Parenthood has been doing something similar for years. A woman can purchase pills there, if all is ok, after answering a health questionnaire and having her blood pressure checked.

Although the need for abortion is decreasing, there are still all-too-many unplanned pregnancies. Access to abortion services is being curtailed in many parts of this country, causing women to have unsafe abortions. This is similar to what happened before Roe v. Wade in the USA, and is common in countries where abortion is illegal. The good news is that mifepristone and misoprostol, the pills used for a medical abortion, are available over the internet.

There are problems with internet-aided abortions. Most of these pills come from India, are expensive, some are of low quality, and they can take weeks to arrive. Unfortunately, medical care by internet has some inherent issues that will be difficult to resolve. It lacks the personal support that is so important when making an important decision. Also, there are two possible complications. Unless a woman has an ultrasound she might not know that the pregnancy is ectopic. These medications won’t cure a tubal pregnancy, which can rupture and cause serious internal bleeding. And the medications aren’t always effective in ending a pregnancy, so follow-up pregnancy tests are important.

Many countries now have Total Fertility Rates (TFRs) below the replacement rate—the number of children needed to replace the two parents. Replacement rate is slightly more than 2 because some kids die before they reach the age of parenting. This means that the countries’ populations will eventually decrease. Don’t be fooled, however—with few exceptions, all countries have increasing populations due to population momentum and increasing longevity. Of the CIA’s list of countries, only 105 have a TFR above 2.1, and 119 are less. The average TFR for the world is 2.4. We are getting closer to slowing population growth, but still adding about 80 million people to the already overcrowded planet each year.

I’ll be attending the International Conference on Family Planning this month and hopefully will have more good news for you soon!

© Richard Grossman MD, 2018

Reduce Barriers to Family Planning

Sunday, December 24th, 2017

There’s no good news about male contraceptives yet, but there is much progress in the field of family planning for women. This column will touch on some of the high points.

Perhaps the best news is that, globally, more women who want to avoid pregnancy are using an effective contraceptive method. The number who weren’t using modern contraception was estimated to be 225 millionin 2014but is 214 million now. The decrease is partly due to huge efforts from Family Planning 2020 to make better family planning available in developing countries. With local support as well as funding from rich countries and foundations, FP2020 has provided over 30million women with effective contraception.

The goal of FP2020 is to reach 120 million previously unserved women with effective family planning by the year 2020. In many places couples only had access to one or two methods, such as condoms or tubal ligation. FP2020’s strategy includes avoiding coercion and offering a choice of several methods.

Please remember that it is not just developing countries that wrestle with unintended fertility. In 2008 in the USA 51% of pregnancies were unintended. There is good news here, too; it is now just 45%. This decrease, and the significant decrease in abortions, is thought to be due to Long Acting Reversible Contraception—LARCs. These methods include IUDs, implants and the 3-month shot. One in 7 women in the USA is now using these most reliable types of birth control.

LARCs have two shortcomings, however. In general they are expensive—but remember that dollar-for-dollar, contraception saves more than any other health intervention!

The other problem with LARCs is convenience, since most require a health care professional. An exception is the 3-month shot, “Depo” or DMPA. This has been in use for birth control for almost 50 years, but requires a clinic visit 4 times a year.

Sayana Press® is an innovative solution that is accepted very well. It is a small plastic bubble filled with the medication and a short attached needle. The woman just punctures her skin, squeezes the bulb and she is protected against pregnancy for 90 days.

Malawi, a small East African country with large families, compared women who went to the clinic to get their shots with women who injected the medicine themselves. They found that women who were given the first shot at the clinic then took home 3 Sayana Presses® were much more likely to use the medication for a full year.

Birth control pills are available without prescription in many countries, and the USA will be following suit if Daniel Grossman has any say. Grossman and I may be distantly related, and we are very close in our belief that “the pill” is amazingly safe and there should be minimal barriers to its access. Grossman has started the “Free the Pill” campaign. This would follow the way Emergency Contraceptive (EC) pills have gone over the counter; Amazon.com now sells EC pills!

Another physician named Grossman—Jessica—heads up Medicines 360. This organization has as its mission “…to expand access to medicines for women regardless of their socioeconomic status, insurance coverage, or geographic location.” Their first product is a big success! Liletta® is an IUD that releases a hormone over 4 years, is safe and very effective, and decreases menstrual bleeding and cramping. It is primarily sold to clinics and is significantly less expensive than similar IUDs.Recently there is good news about all IUDs; they reduce the risk of a woman getting cervical cancer.

When Trump reinstated and expanded the Global Gag Rule, the Dutch started “SheDecides” to replace essential funding for reproductive health. More countries, foundations and individuals have stepped up to pledge $200 million! This amazing organization’s goal is to make it possible for “…girls and women to decide freely and for themselves about their sexual lives, including whether, when, with whom and how many children they have.”

Most couples in the USA use contraception at some time in their lives, even if their religion opposes birth control. In much of the global south, however, this is not the case. There the Roman Catholic hierarchy turns most women away from birth control. This might change, however. The Pontifical Gregorian University in Rome will be holding a series of talks on the 50th anniversary of Humanae Vitae, according to the National Catholic Register.

Despite political forces in this country that are trying to erect barriers around access to family planning, there is a lot of good news about contraception for women.

© Richard Grossman MD, 2017

Creative Commons Attribution 3.0 United States
This work is licensed under a Creative Commons Attribution 3.0 United States.