Archive for the 'Family Planning' 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

Recognize Family Planning as a Human Right

Tuesday, May 29th, 2018

PastedGraphic-3.tiff

Family planning was declared to be a basic human right fifty years ago this month. The right to family planning was included in the International Conference on Human Rights held in Tehran, May 1968.

The concept of universal human rights started after World War II with the United Nations. Its charter included the obligation “…to promote… universal respect for, and observance of, human rights and fundamental freedoms for all without discrimination….” The Tehran conference was held 23 years later to define what those rights are. One of several points states:

“The protection of the family and of the child remains the concern of the international community. Parents have a basic human right to determine freely and responsibly the number and the spacing of their children”

The 84 countries attending this Iranian conference agreed to be bound by the decisions, but the world has changed radically since then. For one thing, there are more than double that number of countries. Furthermore, global population has more than doubled from 3,600,000,000 to 7,500,000,000 people. On the good side, there are more, safer and more effective methods of contraception available. The right to family planning is supported by many programs, including FP2020 which works in many developing countries. Planned Parenthood and the federal Title X (ten) program in the USA are under jeopardy because of a proposed law limiting healthcare providers from mentioning the word “abortion”.

Unfortunately the right to family planning is being limited or taken away in many countries. Funding for many organizations working internationally has been barred by the Global Gag Rule. The GGR prevents the US from funding any foreign agency that provides abortion services anywhere—or even mentions the word “abortion”. Because of the lack of these services women will go without birth control and there will be millions of unplanned pregnancies, and thousands of women will die from complications of pregnancy—and, ironically, there will be more abortions!

The Tehran Proclamation has 9 standards to uphold the human right to family planning. These include non-discrimination, availability of information, accessibility of services and supplies, quality, autonomy of decision making, privacy and confidentiality. I am happy to report my experience has been that these standards are upheld everywhere I have worked,. 

It is difficult to envision a UN conference being held in Iran now—there have been many changes since 1968. The Shah was overthrown in 1979 and the country became an Islamic theocracy, lead by a “Supreme Leader”. A pleasant surprise came about a decade later.

High level government and university experts held a conference in 1988 to discuss Iran’s population, which was increasing rapidly at that time. Attendees agreed “…that the rate of population growth in the Islamic Republic of Iran was high and this would have a negative effect on the welfare of the people. Hence, the participants strongly urged the Government to set up a family planning programme and integrate population factors in policy-making.” (quoted from “A New Direction in Population Policy and Family Planning in the Islamic Republic of Iran”)

The High Judicial Council of Iran decided “family planning does not have any Islamic barrier” so long as abortion was not involved. New laws were passed to promote small families. Couples were required to take birth control classes before they could get a marriage license. Government clinics were set up offering a wide choice of methods, including vasectomy. In addition, the government discouraged childbearing before age 18 and after 35 and recommended that children be spaced 3 or 4 years apart. The family planning program urged couples to have no more than 3 children; government employees lost some of their benefits, such as maternity leave and food coupons, if the family had more than 3 children. 

The TFR (the average number of children that a woman bears in her lifetime) in Iran had been as high as 7.0, had decreased to 5.5 in 1988 and now is less than replacement at 1.8—the same as the USA. It doesn’t mean that population is shrinking—there are millions of children and teens whose reproductive years are still ahead of them—so it will take decades before the population stabilizes.

A dictatorship can use its influence to slow population growth. Although there are many dictators in the world today, I think Iran is the most successful in slowing its growth. That sort of heavy-handed governing wouldn’t work in the USA. Indeed, I believe that people should have the right “…to determine freely and responsibly the number and the spacing of their children.”

© Richard Grossman MD, 2018

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