Remember Simple Family Planning

The United Nations predicted 7 million additional unintended pregnancies would occur if the coronavirus lockdown lasted 6 months. It is already more than a half year since the pandemic started, but we won’t know the effects on reproductive health services for months to come.

            Part of the problem accessing care in developing countries is what are called “stock-outs”. Where the supply chain is long, supplies often run out. An example of the impact of this problem is that a woman may spend a day and money for the bus to go to the family planning clinic for her 3-monthly shot of DepoProvera, and find out that the clinic has run out of the medicine.

            One solution for this has been explored. Another form of Depo has been developed which also lasts 3 months, is highly effective, but is given under the skin rather than into the muscle. An “appropriate technology” way to package this subcutaneous shot. Sayana® Press is a single-use syringe that contains the medication in a small plastic capsule attached to the short needle. All the woman needs to do after placing the needle is to squeeze the capsule.

            Women in Malawi are first taught how to give themselves the injection, then supervised as they actually do it. Then they are given 3 syringes to take home. It was found that self-injection works well and was more popular with women than having to make 4 trips each year. As a consequence, the continuation rate was higher among women who only visited the clinic annually.

            With the pandemic there are many other reasons than stock-outs that can make it impossible for people to get the most effective, modern family planning. The clinic may be closed, the bus driver sick or the family has run out of money. Many providers, myself included, have disparaged traditional methods of contraception because of their lack of effectiveness. However, during a time of emergency such as the pandemic, any family planning method is better than none for a couple who wants to postpone pregnancy. Knowledge of traditional contraception helps to prepare for disruptive events.

            Many societies have ways of controlling fertility. These include breastfeeding, prolonged abstinence from intercourse after childbirth, abstinence during the fertile time in a woman’s cycle (often called “natural family planning” or “the rhythm method”), and withdrawal.

            It has been known for centuries that nursing a baby makes the mother relatively infertile; the Lactational Amenorrhea Method (LAM) formalizes this knowledge. LAM is 96% effective if: the baby is less than 6 months old, is nursing with little supplementation and the woman hasn’t started to menstruate yet. The reduction of fertility is less, but still significant, if only 1 or 2 of the criteria are met.

            The effectiveness of periodic abstinence is debated. What is not debated, however, is that instruction in the method is helpful, and that a cooperating partner is essential. Some studies report almost 100% effectiveness, while others cite much lower figures. There are many ways of tracking when a woman is fertile, and each has its own success rate—but most are in the range of 80%. This means that about 20 out of 100 women will get pregnant when using periodic abstinence.

            There are two ways of increasing effectiveness of periodic abstinence. Users of the Standard Days Method® (formalized by using CycleBeads®) report an effectiveness approaching that of modern contraception, but it is limited to women who have 26 to 32-day cycles.      The other is with a smartphone app. CycleBeads has one, and there are many others. One, Natural Cycles, is FDA approved and claims to be over 90% effective in preventing pregnancy.

            Withdrawal (“pulling out”) has the distinction of being so old that it is mentioned in Genesis. It is a family planning method that needs no medication or supplies, just perception and willpower on the man’s part. He needs to perceive when ejaculation is imminent and withdraw his penis before it occurs. Overall, withdrawal is about 80% effective. However, for a man who uses this method perfectly, his partner only has a 4% risk of conceiving each year. As I found out in Puerto Rico where many of my patients used withdrawal, in certain populations it may be very effective.

            An article in The Economist “The pandemic may be leading to fewer babies in rich countries” brings no surprise—the birth rate seems to be down in rich countries, but people in poor countries are probably having more babies. Covid is increasing problems for the poor.

© Richard Grossman MD, 2020



We camped by Butler Wash, west of Bluff, Utah, October 16-18, 2020. The goal was to climb on the slick rock of Comb Ridge, on the other side of the Wash.

I am amazed at how life exists even in very harsh conditions. There is evidence that this area is in a state of severe drought, yet some life persists.

Although they may not be as exciting as plants, the mosses and lichens are colorful. We try to avoid walking on the cryptobiotic soil, which helps to hold the water and binds the soil together–and even make new soil.

I have been intrigued by these little potholes which contain small samples of life.

There are limits to what can live without water. The people who lived in this area, the Ancestral Puebloans (formerly called Anasazi) left during a severe drought and moved south, along the Rio Grande.Their numbers had risen during moist years to a level that the land couldn’t support them during a drought.

Some of the potholes are larger and support multiple species of plants. The larger ones may even have vertebrate animals living in them!

Many potholes are barren. The rock slopes down to the left in this picture; the little surviving life lives where the water lasts the longest.

It has been a long time since the last rain. We’re amazed that anything is still alive; some of the plants are barely holding on in the drought.

Even the prickly pear cactus is shriveled.

A recent article states that human activity is responsible for about half of the drought. For more information, see below.

Although most of the colors are muted deserty, there are a few bright spots.

Having spread its seed, a dried yucca stands on the horizon.

A “megadrought” is defined as a drought lasting 20 years or longer. For comparison, the Dust Bowl of the midwest, although it was terrible, did not qualify as a megadrought. Although the duration of the current drought hasn’t reached 20 years yet, it shows no sign of relenting.

There isn’t much sign of animal life; we strain to find as much as we can. Gail sees a rabbit, but it’s gone before I turn.

We debate if this comes from big horn sheep or cow,

and wonder if this is deer or sheep, but saw neither animal.

However, we found deer skat in one of the larger pothole gardens.

This tiny fly rested on my thumb after a lizard lunged at it, but missed.

We are amazed to see water in a series of potholes down low. Ty, our old black dog, takes a dip and a drink. The water came down from the rock above when it rained and was collected in a series of little pools. The last rain was September 7th; we were there 40 days since that rain. is a convenient source of information. This map shows the Four Corners Region; the blue pointer aims at Bluff. Rose color is D3 (Extreme Drought) while the brown is D4 (Exceptional Drought–the driest level). Bluff is D3 while the Durango area is D4.

When I asked Jim Hook of Recapture Lodge (in Bluff) when the last rain before October 17th was, he wrote: “The last rain I recorded was on September 7 when we received 0.5 inch. September ends the water year so we ended the last 12 months with 4.57 inches of moisture. Average over the last 100 years is 7.76 inches which isn’t much but it means Bluff only received 59% of “Normal” precip. October actually is our wettest month 🙁 “

The figure above is from the article “Large contribution from anthropogenic warming to an Emerging North American megadrought” by Williams et al., Science, May 2020.

The graph shows soil moisture with the straight line being average, and the red line departure from average, by year. The yellow square on the map is the area of interest–southwest North America. Brown shading denotes the local degree of drought.

The summary of this article states: “Anthropogenic trends in temperature, relative humidity and precipitation from 31 climate models account for 47%… of the 2000-2018 drought severity….” That means that human activity is responsible for about half of the drought that we are facing.

Thank you for reading. Although I have written about drought in my monthly essays, our visit to Comb Ridge made the current drought visible in a way that I wanted to share.


P.S.: While this photoessay talks about drought in an abstract way, there is an excellent article that speaks to the problems that the drought is causing people, animals and plants: I strongly recommend the video that is embedded in the article.

© Richard Grossman MD, 2020