- The Wisdom of Pope Paul VI , Bishop James T. McHugh
- "Of Human Life--A Pastoral Letter on the Truth and Meaning of Married Love"--Selections, Archbishop Charles Chaput
- Lowey Amendment: No Catholics Need Apply, Catherine Deeds
- "Effectiveness"--What's it All About? A Dialogue Between Two Scientists, Robert T. Kambic, MSH & Joseph Stanford, MD
- NFP and the National Council of Catholic Women, Bertha Moreno, RN, NFPP
- NFP AROUND THE WORLD
"NFP Government Supported Services in the UK", Jane Knight
- NEWS BRIEFS
Bishop James T. McHugh
July 25, 1998, marks the thirtieth anniversary of Pope Paul VI's encyclical Humanae vitae--On the Regulation of Birth. The encyclical was met in 1968 with a barrage of ridicule and rejection and a highly publicized dissent by Catholic theologians. Most who rebelled immediately and stridently had not read the encyclical. It was not that the document's reasoning was flawed or incomplete; it was simply that its conclusions were unacceptable, if not unimaginable, to the world of the late 1960's. This was the decade of the sexual revolution in which sexual intercourse was torn from its moorings of marital love and mutual responsibility and looked upon as little more than a customary pleasurable encounter with no commitments. The contraceptive pill had arrived, the most effective method of birth control for married and unmarried alike.
There was little receptivity for the carefully reasoned papal document that reviewed the Church's teaching on sexuality in the context of conjugal love, responsible parenthood, the sanctity of human life and the virtue of sexual self-restraint.
Three decades later we are reminded that Humanae vitae was motivated, in Paul VI's words, by the "attacks inflicted by civil legislation on the indissoluble sanctity of the marriage bond and the inviolability of human life even while still in the mother's womb." Today we live in a world of throwaway marriages, out of wedlock pregnancies, dangerously low birth rates, the highest divorce rates on the globe, sexual promiscuity that has brought us AIDS and the abortion deaths of more than one million children a year. At the highest levels of government in the United States, we find those who continue to foster and promote this program of sexual permissiveness and free choice.
Nonetheless we are beginning to see a new atmosphere of acceptance for faithful, stable and enduring marriages, and an openness to childbearing and parenting. In this context especially, we should reexamine Humanae vitae.
Paul VI told us that every human problem must be seen in the light of an integral vision of the human person and his or her vocation--not only the natural earthy vocation, but also the supernatural and eternal. We are not lost souls floundering about on planet earth. We are men and women created in the image of God, redeemed by Jesus Christ and called to eternal glory.
Humanae vitae speaks of Christian marriage. Marriage, says Paul VI, is "the wise institution of the creator to realize in mankind His design of love." Christian marriage exists in the order of grace: it is a Christian sacrament. The sacramental grace of marriage empowers the couple to carry God's grace to their children, their families, friends and even to the entire world.
The foundations of Paul VI's teaching on marital morality were conjugal love and responsible parenthood. Paul VI went on to speak of conjugal love as fully human, total--that is to say, a very special form of personal friendship, faithful and exclusive and directed toward the begetting and educating of children.
The companion principle, responsible parenthood, involves the following elements:
- A free, informed, mutual decision by the couple...
- regarding the frequency of birth and size of the family...
- based on their conscientious assessment of their responsibilities...
- to God, themselves, their children and family and the society of which they are a part...
- and enlightened by the authentic teaching of the Church regarding the objective moral order and the licit methods of spacing or limiting pregnancies.
- regarding the frequency of birth and size of the family...
In light of these principles, Paul VI concluded that there is an inseparable connection between conjugal love and the transmission of life, and thus in the conjugal act one may not reject or deliberately frustrate either purpose.
In a homily on the Feast of Sts. Peter and Paul in June, 1978, Paul VI said that while the reaction to Humanae vitae caused him much suffering, the encyclical was motivated by his commitment "to defend life in all the forms in which it can be threatened, disturbed or even suppressed." Thirty years later the Church remains committed to the legacy of Paul VI, and to building a culture of life in which every human being is protected and sustained at every moment of life from conception to natural death.
Bishop James T. McHugh is Bishop of Camden, Director of the Diocesan Development Program for NFP and a member of the NCCB Committee for Pro-Life Activities.
"Of Human Life--A Pastoral Letter on the Truth and Meaning of Married Love"--
Archbishop Charles Chaput
The following are excerpts from the Archbishop of Denver's pastoral letter written to commemorate the thirtieth anniversary of Pope Paul VI's encyclical Humanae vitae. This pastoral has received widespread positive publicity. A copy of the complete text is enclosed with this mailing. The document was written for general distribution. You do not need permission to copy it (simply cite the archdiocese). We recommend that you include this letter in your informational program resources. Multiple copies can be obtained from the Archdiocese of Denver, Office of Marriage and Family Life, 1300 South Steele St., Denver, CO 80210; 303-715-3259. It is also available on the internet at <<http://www.archden.org/archden/documents/human_life.htm>>
1. Thirty years ago this week, Pope Paul VI issued his encyclical letter Humanae Vitae (On Human Life), which reaffirmed the Church's constant teaching on the regulation of births. It is certainly the most misunderstood papal intervention of this century. It was the spark which led to three decades of doubt and dissent among many Catholics, especially in the developed countries. With the passage of time, however, it has also proven prophetic. It teaches the truth. My purpose in this pastoral letter, therefore, is simple. I believe the message of Humanae Vitae is not a burden but a joy. I believe this encyclical offers a key to deeper, richer marriages. And so what I seek from the family of our local Church is not just a respectful nod toward a document which critics dismiss as irrelevant, but an active and sustained effort to study Humanae Vitae; to teach it faithfully in our parishes; and to encourage our married couples to live it.
II. WHAT HUMANAE VITAE REALLY SAYS
10. Perhaps one of the flaws in communicating the message of Humanae Vitae over the last 30 years has been the language used in teaching it. The duties and responsibilities of married life are numerous. They're also serious. They need to be considered carefully, and prayerfully, in advance. But few couples understand their love in terms of academic theology. Rather, they fall in love. That's the vocabulary they use. It's that simple and revealing. They surrender to each other. They give themselves to each other. They fall into each other in order to fully possess, and be possessed by, each other. And rightly so. In married love, God intends that spouses should find joy and delight, hope and abundant life, in and through each other -- all ordered in a way which draws husband and wife, their children, and all who know them, deeper into God's embrace.
11. As a result, in presenting the nature of Christian marriage to a new generation, we need to articulate its fulfilling satisfactions at least as well as its duties. The Catholic attitude toward sexuality is anything but puritanical, repressive or anti-carnal. God created the world and fashioned the human person in His own image. Therefore the body is good. In fact, it's often been a source of great humor for me to listen incognito as people simultaneously complain about the alleged "bottled-up sexuality" of Catholic moral doctrine, and the size of many good Catholic families. (From where, one might ask, do they think the babies come?) Catholic marriage -- exactly like Jesus Himself -- is not about scarcity but abundance. It's not about sterility, but rather the fruitfulness which flows from unitive, procreative love. Catholic married love always implies the possibility of new life; and because it does, it drives out loneliness and affirms the future. And because it affirms the future, it becomes a furnace of hope in a world prone to despair. In effect, Catholic marriage is attractive because it is true. It's designed for the creatures we are: persons meant for communion. Spouses complete each other. . . . .
12. But why can't a married couple simply choose the unitive aspect of marriage and temporarily block or even permanently prevent its procreative nature? The answer is as simple and radical as the Gospel itself. When spouses give themselves honestly and entirely to each other, as the nature of married love implies and even demands, that must include their whole selves -- and the most intimate, powerful part of each person is his or her fertility. Contraception not only denies this fertility and attacks procreation; in doing so, it necessarily damages unity as well. It is the equivalent of spouses saying: "I'll give you all I am -- except my fertility; I'll accept all you are -- except your fertility." This withholding of self inevitably works to isolate and divide the spouses, and unravel the holy friendship between them . . . maybe not immediately and overtly, but deeply, and in the long run often fatally for the marriage.
13. This is why the Church is not against "artificial" contraception. She is against all contraception. The notion of "artificial" has nothing to do with the issue. In fact, it tends to confuse discussion by implying that the debate is about a mechanical intrusion into the body's organic system. It is not. . . .
The Church teaches that all contraception is morally wrong; and not only wrong, but seriously wrong. The covenant which husband and wife enter at marriage requires that all intercourse remain open to the transmission of new life. This is what becoming "one flesh" implies: complete self-giving, without reservation or exception, just as Christ withheld nothing of Himself from His bride, the Church, by dying for her on the cross. Any intentional interference with the procreative nature of intercourse necessarily involves spouses' withholding themselves from each other and from God, who is their partner in sacramental love. In effect, they steal something infinitely precious -- themselves -- from each other and from their Creator.
14. And this is why natural family planning (NFP) differs not merely in style but in moral substance from contraception as a means of regulating family size. NFP is not contraception. Rather, it is a method of fertility awareness and appreciation. It is an entirely different approach to regulating birth. NFP does nothing to attack fertility, withhold the gift of oneself from one's spouse, or block the procreative nature of intercourse. The marriage covenant requires that each act of intercourse be fully an act of self-giving, and therefore open to the possibility of new life. But when, for good reasons, a husband and wife limit their intercourse to the wife's natural periods of infertility during a month, they are simply observing a cycle which God Himself created in the woman. They are not subverting it. And so they are living within the law of God's love.
Archbishop Chaput is a member of the NCCB Committee for Pro-Life Activities.
Lowey Amendment: No Catholics Need Apply
On July 16 the U.S. House of Representatives passed a dangerous and unprecedented amendment that would require health plans serving federal employees to provide contraceptive drug coverage, including abortifacients. The Senate passed a similar but broader amendment on July 29. Such a mandate, if it becomes law would be a threat to both religious freedom and developing human life.
In June, Rep. Nita Lowey (D-NY) succeeded narrowly in having her amendment accepted by the House Appropriations Committee as part of the 1999 Treasury/Postal Appropriations bill, (H.R. 4104). The amendment required health plans that participate in the Federal Employee Health Benefits Program (FEHBP) and that provide prescription drug coverage or "outpatient services" to provide coverage for all FDA-approved drugs and devices "intended for preventing pregnancy." Drugs such as Norplant, Depo-Provera and the low-estrogen Pill would sometimes act not by preventing ovulation or fertilization, but by preventing implantation of the developing embryo in the womb are included. For the abortifacient drug known as the "morning after pill," approved by the FDA as "emergency contraception," this is the primary mode of action.
The Lowey amendment contained no exemption for these abortifacient methods and no conscience protection for Catholic or other plans or federal employees who object to such coverage. (Surgical abortion coverage has been excluded from 1984-1993 and again since 1996.) Although most FEHBP plans already pay for a range of artificial contraceptive methods, Rep. Lowey claimed that "only 19 percent of federal health plans now cover all five methods of prescription contraceptives [Pill, IUD, diaphragm, Norplant and Depo Provera] and that 10% cover none."
Arguments on and off the House floor ranged from debate about whether the Pill is an abortifacient, to claims by proponents that pro-lifers want to ban the Pill and all contraceptives, to arguments over whether contraception reduces the need for abortion.
House passes modified Lowey amendment
During the first round of contentious House floor consideration of the Treasury/Postal bill on June 25, the entire bill was sent back to the Rules Committee for several reasons -- including the objection by many members to the Lowey amendment. When the bill was brought up a second time on July 16, with a different rule governing debate, Rep.Todd Tiahrt (R-KS) was able to strike the Lowey provision from the bill, without a vote, on a "point of order," claiming that it wrongly made legislative policy on an appropriations bill. However, Rep. Lowey then redrafted her amendment to withstand this procedural motion and offered it on the floor.
After this was approved, an amendment by Rep. Chris Smith (R-NJ) to exclude abortifacients, failed on the House floor. The modified Lowey amendment passed on a vote of 224-198. The Smith amendment failed by nearly the same margin, 198-222.
On July 17, the House passed the Treasury/Postal Appropriations bill (H.R. 4104) with the modified Lowey provision. The modified amendment differs slightly from the original amendment, in that it does not define "contraceptive" and it applies only to health plans that offer prescription drug benefits. It includes a religious exemption for five specific religious plans (SelectCare, PersonalCaresHMO, Care Choices, OSF Health Plans, Yellowstone Community Health Plan) that currently participate under the FEHBP. Without a broader conscience protection clause, other Catholic and any other health plans which object to providing such coverage will be effectively precluded from participating in the FEHBP.
Push for "emergency contraception" coverage
This effort by Rep. Lowey and others is the third step in a well-planned campaign to make "morning-after" abortifacients an accepted part of routine medical care, and to force private health plans to provide it. This method has been defined by the Food and Drug Administration (FDA) as "emergency contraception," though it can be used up to three days after fertilization to ensure that the embryo dies.
The Wall Street Journal reported on June 26 about the FDA's active encouragement to drug companies to market "emergency contraception" to women. The article spoke of the FDA's frustration that companies were resisting its "pressure" to market drugs for this purpose, due to fear of liability and the controversial nature of this abortion-inducing regimen.
Last month, Navy physicians received a new order requiring them to offer "emergency contraception" to female patients; even conscientiously opposed physicians were ordered to make referrals to physicians who were willing to prescribe the abortion drugs. After military chaplains protested, the order was reviewed and rescinded.
The Lowey amendment is the abortion movement's third and last chance this year to exploit the power of the federal government to force Americans to accept abortifacient drugs as a form of "contraception."
Catherine Deeds is the Public Policy Analyst at the NCCB's Secretariat for Pro-Life Activities.
"NFP Effectiveness"--What's it All About? A Dialogue Between Two Scientists
Robert T. Kambic, MSH & Joseph Stanford, MD
The following dialogue took place over the internet through the NFP Discussion Group. The Group, consisting of NFP promoters, scientists, and teachers, had raised the question: "Is the concept of unplanned pregnancy, as used in contraceptive studies, applicable to Natural Family Planning?" Here two leading NFP researchers, Robert T. Kambic, MSH of Johns Hopkins University, School of Public Health and Joseph Stanford, M.D., of the University of Utah, Department of Family and Preventive Medicine, carefully articulate their thinking.
Robert T. Kambic, MSH:
There are a number of people interested is the effectiveness of NFP when used to avoid pregnancy. The first is the couple. Informed consent means we give the new learning couple proper information about NFP effectiveness. This is fundamental to any kind of health care, of which NFP is a part. Physicians and health care providers are also interested in accurate and understandable pregnancy rates on all methods of family planning including NFP. Finally, health administrators and policy makers need to have pregnancy rates of family planning methods when establishing population policy within their jurisdiction.
When NFP is used without error, to avoid pregnancy ("perfect use" as defined by Trussell & Grummer-Strawn) it is highly effective with rates in the neighborhood of 1 to 3 pregnancies per 100 women per year. We also know that when a couple who wants to avoid pregnancy has genital contact or intercourse on a day of fertility ("imperfect use," Trussell & Grummer-Strawn), the chances of a pregnancy are very high. Trussell and Grummer-Strawn have clearly shown that the more imperfect NFP users in a population, the higher the pregnancy rate. This means that if everyone using NFP perfectly for pregnancy avoidance, at the end of year there would be from one to three pregnancies out of 100 couples using NFP. If everyone used NFP imperfectly, that is, everyone broke the rules all the time, there would be 70 or 80 pregnancies in 100 couples at the end of one year.
We know that any group will be composed of a mix of couples, both perfect and imperfect users, and, as a result, the pregnancy rate of any particular group using NFP for one year will fall between one and 80. We know that from 1970 to the present, there have been 38 studies of NFP and the pregnancy rates of these studies have averaged 10 to 15 pregnancies per 100 couples per year.
But what do scientists mean when they say a pregnancy is unplanned? Beginning in 1966, population scientists at Princeton University published three books dealing with exactly the issue of fertility and its biological and social determinants. These books are:
1) Whelpton, Campbell, & Patterson. Fertility and Family Planning in the United States, (1966).
2) Ryder & Westoff. Reproduction in the United States, (1965).
3) Westoff & Ryder. The Contraceptive Revolution, (1977).
A review of the issues discussed in these books will confirm that the features and components of unplanned pregnancy have been extensively reviewed.
Let us look at the special case of the validity of measuring 'unplanned pregnancy' in NFP users. I prefer to use an operational definition which can be applied to the 38 NFP studies referenced above. An operational definition is, 'The sequence of steps you take to obtain a measurement. The sequence must be repeatable, so that you can instruct someone else to obtain the same measurement.' (Selltiz, Wrightsman, & Cook. Research Methods in Social Relations. Holt Rinehart & Winston, 1981). An operational definition of unplanned pregnancy in NFP is, 'Couples using NFP who tell us verbally or in writing that they do not plan to become pregnant for a specified period (three, six, twelve months, or no more pregnancies etc.).' Can they change their mind at any time? Yes. But, when conducting a study, we ask them to inform us of this change prior to becoming pregnant. This allows couples to really change their minds, but does not allow spur-of-the-moment imperfect use to be qualified as a planned pregnancy.
I note that Selltiz (1981) lists measures of validity including, face validity, concurrent validity, predictive validity, and construct validity. The definition of unplanned pregnancies in NFP meets all of these criteria. Face Validity - agreement by groups of experts that the construct measures what it claims to measure. In 1981 a group of 22 NFP physician-providers met in Los Angeles to discuss the classification of unplanned pregnancy in NFP. The resulting paper (Brennan and Klaus. Terminology and core curricula in NFP. Fertility and Sterility, July 1982) is sufficient evidence that the requirement of face validity is met. This meeting used the term 'informed choice pregnancies' for those pregnancies which result from a conscious decision to have intercourse on fertile days without previous indication of planning a pregnancy. They clearly distinguish planning a pregnancy from not planning a pregnancy. Additional evidence is in the breast-feeding consensus statement (The Lancet, Saturday 19 November 1988) where breast-feeding experts use language such as 'protection from pregnancy' in the first six months if a woman is fully breast-feeding.
Concurrent Validity - the ability of a test to distinguish between individuals who are known to differ. The definition of unplanned pregnancy would certainly distinguish between those who are planning and those who are not planning a pregnancy. Predictive Validity - the ability of a test to identify future differences. We know that those couples who indicate that they want no more children will have fewer pregnancies than those who indicate a desire for more children but not now. This means that the question about pregnancy intention can discriminate these two kinds of NFP users.
Construct Validity - the agreement between scores obtained from different instruments and different raters. Do observers agree that an unplanned pregnancy is an unplanned pregnancy by the definition? In general, effectiveness studies have several experts review pregnancy charts and face sheets to come to a determination of unplanned pregnancy. For example, in our African studies the teacher and the supervisor reviewed the pregnancy charts. Most studies of NFP effectiveness have more than one pregnancy reviewer, as should a good program.
I conclude from this evidence, that unplanned pregnancy, as defined for the purposes of an NFP effectiveness study, meets all applicable criteria for a valid definition and data collection instrument. If NFP is different in fundamental and important ways from artificial contraceptives- ways that need to be paid attention to, is it still possible to make comparisons between NFP and other methods? NFP is different. Now how should we evaluate it? Let me make an analogy to heart disease, another health care issue. (NFP is health care.) Heart disease is the number one killer of adults in the U.S.A. How do we stop it? There are many ways. We can change our diets, quit smoking, live a less stressful life. We can have a bypass operation, take medication to reduce cholesterol, have a pacemaker implanted, or in dire cases have a heart transplant. How are these vastly different interventions evaluated? We evaluate the result of these interventions by studying the years lived and reduction in mortality after the intervention. The point is, different interventions may have the same outcome. The intervention may be educational, medicinal, or surgical, but what we are looking for is extended life expectancy. Similarly, with NFP we want to know, how many couples who do not want to become pregnant for a while, or want no more pregnancies, will become pregnant if they are using NFP. Certainly the methods are different than contraceptives, but the desired outcome is the same. The reasonable way to do this is to use a similar evaluation methodology so that results can be compared.
Let me write a little scenario to illustrate this. The players are a Minister of Health and an NFP advocate who wants the Minister to adopt NFP as a method to use in his/her country.
Minister: "You know that the population issue is of concern to us. In the olden days our families had from 4 to 7 children, but today the families know that their children will live. Both the husband and wife have a job and they want to be able to start a small business so they want only two or three children. Now if I introduce NFP as a method of family planning into my country, what can I tell my people about how many children they will have?"
Answer 1: "Well Minister, NFP is a very special method of family planning. We are not able to compare it with other methods because couples who use it are quite different from other couples. They are more likely to stay married and to have strong families. They may want more children than other couples but they will be good citizens."
Answer 2: "Well Minister, we have studied NFP for many years now and have found that it is at least as effective as barrier methods. We know that you have a large barrier method program in this country, and we think that this offers the effectiveness of barriers with some advantages over the barrier methods. "
Answer 3: "Well Minister, NFP is 99% effective. People do not get pregnant using NFP if they do not want any more pregnancies. "
Answer 4: "Well Minister, rhythm is not effective. I was sent to tell you about it, but it just doesn't work. I suggest that you have everyone sterilized."
Joseph Stanford, MD:
There is no question that most women/couples will have a serious desire to avoid pregnancy through much of their reproductive life. For those who use NFP, I believe that NFP teachers should meet them where they are at by teaching them how to use it effectively to avoid pregnancy.
It is possible to define a construct of "unplanned" pregnancy that by its very definition is measurable. As Mr. Kambic stated, does the couple state in advance at predetermined intervals (three, six, twelve months, or lifetime) that they do or do not "plan" to become pregnant during that coming time. But what have you really measured and what does it really mean? Does this dichotomous outcome take into account the wide spectrum of motivation that may occur and the relevant cognitive, emotional, and spiritual processes that go into achieving a pregnancy? That, I submit, is very questionable. Further, does the nature of the decision to plan to not get pregnant differ fundamentally and qualitatively between groups that decide to get sterilized and those that decide to use NFP or to use barriers? I think the answer to this is often going to be yes. The category of "unplanned" is so heterogenous as to make its conceptual value highly questionable. There is research that strongly suggests that degrees of motivation (such as can be measured by "receptivity to unplanned pregnancy") have a powerful influence. (For example, see Labbok, M.H., Klaus, H., & Perez, A. "Efficacy studies in natural family planning: issues and management implications illustrated with data from five studies." American Journal of Obstetricts & Gynecology 1991; 165:2048-2051) Asking couples to be sure to tell you every month (or three months or whatever) whether they plan to get pregnant the next month may reduce this substantial heterogeneity of underlying motivation, but it by no means eliminates it. It will still be a substantial confounder if you are trying to compare pregnancy rates of various NFP methods to contraceptive methods.
My main concern with the "unplanned pregnancy" concept is that it is actually a final outcome that depends on a mixed input of four factors: 1) the nature and level and strength (and duration) of the "commitment" to avoid pregnancy; 2) the difficulty or challenges the couple experiences in using the method; 3) the quality of teaching of the method; 4) the biological (method effectiveness) of the method. Of these four factors, #4 can be separated out by calculating a separate method pregnancy rate ("perfect use" pregnancy rate). But there is no way to separate #1, #2, and #3 if you use "unplanned pregnancy" as your sole outcome. The result is that if an unplanned pregnancy rate varies between NFP studies, or between contraceptive studies for that matter, you can't know to what extent it is due to factors #1, #2, or #3. For NFP, #3 is a particularly critical variable. It is the crux of whether you have a good instructional system in place or not- which in NFP is half the issue for potential effectiveness, the other half being the NFP method itself. (Whether #2 would be substantially different between NFP methods could be a matter for another discussion.)
To address #3, NFP researchers have split out "unplanned pregnancies" into categories that differentiate between knowing use of a fertile day for whatever reason (e.g. "informed choice") or which are due to some error on the part of the teacher or user (e.g. "teaching related"). I think that at least for NFP (and perhaps also for some methods of contraception) this is a highly clinically significant distinction that needs to be examined.
Perhaps another approach to this whole issue is to look at this as an issue of the "ideal efficacy study," which I would suggest is Mr. Kambic's approach, vs. a "real world/service delivery study" which I would suggest is what I am talking about.
Ideal/Efficacy Study: If indeed you could assemble a group of couples using NFP who were extremely motivated to avoid pregnancy and would remain uniformly so for the entire study period (say one year), that would be the ideal group to eliminate factor #1 above, and just measure factors #2, 3, and 4 all together under the rubric of "unplanned pregnancy." Moreover, if these couples all were as motivated to avoid pregnancy as women/couples who were using, say oral contraceptives in another study, you could indeed compare them validly to the oral contraceptive study by means of the "unplanned pregnancy" rate.
Real World/Service Delivery Study: I question whether most NFP studies have selected couples who are reasonably homogeneous in a strong enduring "commitment" to avoid pregnancy that is truly comparable to that of, for example, oral contraceptive studies. Thus I question whether most NFP studies are really able to live up to this ideal of the efficacy study. I would state that another approach is to simply measure how they actually use the method over time and apply descriptive terminology to that use.
Further, while Trussell has made some key contributions to the evaluation of contraception and NFP, the contraceptive terminology of "perfect" and "imperfect" use implies that the only use of NFP is to avoid pregnancy. If a couple consciously chooses to "achieve" pregnancy, then they are by this definition using NFP "imperfectly." If they "plan" a pregnancy by telling you in advance that they want to get pregnant, then you either have to say they are "planning imperfect use," or drop them from the study as no longer using NFP. However, if they use NFP to define when they can get pregnant, they are of course still using NFP. Therefore, I would prefer that NFP studies report all pregnancies that occur during use of NFP, including "planned" pregnancies, to give a more accurate picture of the use of NFP. Further, I suggest that in order to fully describe the use of NFP, terms be used that indicate whether the couple is knowingly having intercourse only on days of infertility (as defined by the method), or is knowingly sometimes having intercourse on days of fertility. This is objectively measurable and in my opinion correlates more directly to what really happens when most couples use NFP. "Informed choice" pregnancy or pregnancy resulting from "achieving-related behavior" (the key concept here is behavior, not intention) approaches this much better than "imperfect use" does. I do not suggest that "spur of the moment" intercourse on a fertile day (one type of "imperfect use") should be classified as a "planned" pregnancy. It is clearly not that. But again, I question the conceptual foundations of the concepts of "planned" pregnancy as well as "unplanned" pregnancy, and the assumption prevalent among population scientists that "unplanned" always denotes an undesirable outcome.
The term "planned," as commonly used, carries all sorts of additional assumptions with it. "Planned" is presumed to automatically mean wanted, and "unintended" (a related term) is presumed by researchers to mean either mistimed or unwanted. (This latter is the conceptual scheme used by previous versions of the National Survey of Family Growth.) However, recent research has suggested that the methods used by the National Survey of Family Growth to characterize pregnancies as "mistimed" vs. "unwanted" have serious measurement problems. (See, for example, Kaufmann, R.B. et al. "Comparison of two question sequences for assessing pregnancy intentions." American Journal of Epidemiology 145 (1997): 810-816; see also Pedersen, R. & Moos, M.K. "Defining and measuring unintended pregnancy: issues and concerns." Women's Health Issues 6 (1997): 234-240.
In our own small qualitative study (not yet published), and in at least one other qualitative study (Moos, M.K., Pedersen, R., Meadows, K., Melvin, C.L., & Spitz, A.M. "Pregnant women's perspectives on intendedness of pregnancy." Women's Health Issues 1997; 7:385-392) it was found that terms such as "planned," "intended," and "wanted," have sometimes widely different meanings for different women. As far as the response to and care for the pregnancy, "wanted" seems to be much more relevant than "planned." To illustrate, consider: 1) the couple who says this pregnancy is unplanned, because they wanted to wait a few more months but they are delighted with the pregnancy; and 2) the woman who says this pregnancy was unplanned because her contraceptive failed, who has no support from the father of the baby or her family, and who is planning an abortion. Are these two scenarios (and many other possible ones) reasonably categorized into the same category of "unplanned"? I think not.
Recognizing these issues, the 1995 National Survey of Family Growth, for the first time, has used more sophisticated measures to look at a spectrum of pregnancy "intendedness" rather than an overly simplified questionable dichotomy of "intended" and "unintended." Whether they have done this adequately remains to be seen, but it is laudable that they are looking at this issue.
For the couple considering the use of NFP, I think that they need to know in advance that:
1) NFP is highly effective when learned from a competent instructor and used exactly as directed to avoid pregnancy.
2) NFP is highly effective when used to achieve pregnancy, and genital contact on days of fertility is highly likely to result in pregnancy .
3) Most studies of NFP use have shown that around 10-25% of couples have become pregnant in a year's time, with the vast majority of those pregnancies resulting from a couple choosing to have intercourse on a day they knew to be fertile, whether or not they "planned" in advance to become pregnant.
4) Using NFP may encourage a couple to have more children than they currently think they want to have, especially if they are "receptive to unplanned pregnancy."
5) Many couples report benefits in their relationship from using NFP.
6) NFP has obvious health benefits with its lack of side effects.
Finally, I think Mr. Kambic's scenario with the Minister of Health is very well illustrated. I think answers 1, 2, and 3 all contain some element of the truth. For a conversation with a policy maker who is interested in population issues, I would emphasize my points #1, 3, 5, and 6 immediately above. I would add one more benefit for policy makers: the low cost of NFP.
Reply by Kambic:
Let me reiterate what my audience is. I am speaking to couples who want to know about NFP and who may want to use it, physicians and providers who may want to use NFP either as their only family planning method or as one method in a mix of methods, and policy makers. The information I give to them has to be clear, simple, and easy to understand and assimilate. An executive briefing paper or an informed consent form is rarely more than one page long. Thus, I want to speak to these people in a language and manner to which they can relate. They understand when I tell them that NFP is between 10% and 20% effective in the general population, and that it can be used very effectively by motivated people. Couples, doctors, and government leaders understand these terms.
From a research perspective Dr. Stanford's points are well taken. If we want to delve into the motivations, rationales, emotional state, economic behavior of couples his questions are appropriate. But, in the final analysis, even these kinds of studies will come down to the number of couples in one category and the number in another. We do this all of the time. Men, women, black, white, rich, poor, those who live in a particular geographic area; we constantly simplify and categorize knowledge in order to make it accessible, understandable, and usable. I suggest that, in the final analysis, the presentation of information to those who do not know and may not care that much about NFP is what matters. Because only though the presentation of this information to them in way they can understand will we move NFP forward.
Reply by Stanford:
For policy makers who places their highest priority on population control, you may well be able to convince them (based on the data of overall pregnancy rates) that NFP is as effective as barriers, but they will still consider it second rate to "more effective" methods such as hormonal contraception and sterilization. The fact is that it is significantly easier for couples who are using NFP to get pregnant than couples who are using most methods of artificial contraception. But this is a bad thing only if you accept the underlying premise that population control is in and of itself the highest priority. It is very important that we are clear on what our desired outcomes are (which may differ significantly from the desired outcomes of some policy makers), and most importantly, what the desired outcome is for the couple using NFP. In my opinion, the most relevant outcome is the degree to which a couple loves and can care for the children they have. Unfortunately, this is not an outcome which has been measured by studies of contraception or of NFP--though perhaps it could be in the future.
I think that NFP does encourage couples to have as many children as they can care for, while still giving them a highly effective approach to limiting or spacing when necessary. Contraceptive methods, especially hormonal methods and sterilization, do not inherently encourage couples to have as many children as they can. Thus, NFP will always be somewhat suspect to those who place their highest priority on population control. This is a fundamental ideologic issue which, in my opinion, is at the heart of many debates over NFP effectiveness, but which is rarely explicitly voiced.
If you have questions or comments about the above discussion, please write us. We will ask Mr. Kambic and Dr. Stanford to respond in the next issue.
NFP and the National Council of Catholic Women
Bertha Moreno, RN, NFPP
For as long as I can remember, and it has been some, the National Council of Catholic Women (NCCW) has been of service to women. Our Mission statement is clear:
The NCCW acts through it's affiliated organizations to support, empower and educate all Catholic women in spirituality, leadership, and service. NCCW programs respond with Gospel values to the needs of the Church and society in the modern world.
With the motto "For God and country . . . faith and service," how could we not be expected to offer the best of service to women?
That said, during our national convention in October 1997, it was resolved that:
Whereas the NCCW recognizes, because of contemporary scientific research, that Natural Family Planning (NFP) is in the best interest of women's health and well being, and
Whereas NFP enables men and women to meet their mutual responsibility for fertility in natural ways while preserving the sacred integrity of marriage and the family as the basic cell of society and sharing respect for all human life, and
Whereas, NFP is in accordance with the magisterial teaching of the Church specifically: Humanae vitae, Gaudium et spes, Familiaris consortio, and Evangelium vitae,
Be it resolved: that NCCW engage in communication and cooperation with other agencies and organizations, both public and private and at a local, regional, national and international level, for the advancement of NFP, and
Be it further resolved: that the NCCW network with the Diocesan Development Program of the NCCB in Washington, D.C. for the purpose of disseminating information and educational resources on NFP.
In light of the above, our NCCW chapter provided NFP materials to the participants of the Province of San Antonio's 6th Biennial Convention, Dallas, TX (Spring 1998). An exhibit was set up with NFP materials including the National Directory of Diocesan NFP Coordinators and a listing of programs available in the Dallas area. We found that the most popular brochure was "Sexuality . . . God's Gift," a Pastoral Letter by the most Rev. Francis J. Mugavero, former Bishop of Brooklyn. The next most popular was "NFP? Down to earth replies to the most common reasons people give for not using NFP." Many of us at this convention lived during the "Rhythm era." These women expressed a loving concern for their children and grandchildren in wanting them to have access to NFP information. They saw how these new, modern, well researched methods give life and will carry our young Catholic couples into the new millennium. We know that love and truth is the only way into the future!
NFP Around the World
"Government Supported NFP Services in the UK"
Fertility UK is an independent service of Marriage Care (a registered charity of the Catholic Church, formerly called Catholic Marriage Advisory Council). Although Fertility UK has connections with a religious organization, many of our teachers are not Catholic, and are in fact, from diverse religious groups and non-religious backgrounds.
Fertility UK's complete name is National Fertility Awareness and Natural Family Planning Service, UK. It is funded by the Department of Health to provide the following services:
- Evidence-based natural family planning information.
- Educational materials about fertility awareness and natural family planning (NFP).
- A referral service to accredited natural family planning teachers.
- Comprehensive training for health professionals in fertility awareness and NFP. (Validated by the University of Greenwich--30 credit points at level 3).
We have found that NFP services are of particular significance for couples in the following groups:
Cultural and ethnic communities. Many people from different cultures depend on knowledge about fertility for their method of family planning. This knowledge is often passed down from older members of the community and is frequently inaccurate.
Religious: NFP is chosen by couples with a conscientious objection to using artificial methods. Catholics, members of other Christian Churches and also Islamic groups who wish to plan their families in accordance with their religious beliefs, may choose natural family planning.
Ecological: Many couples who are ecologically aware prefer to use natural family planning.
Media hype: Since the 'Pill Scare,' of 1997, the Family Planning Association (FPA) reported a marked increase in the number of requests about NFP in the UK. According to a national opinion poll for Schering Health Care (a major British health insurance company), the overall use of NFP has increased from 1% to 3%. In addition, through media coverage of the fertility indicator, Persona, in Autumn 1996, further interest in NFP has been fueled. A recent BBC Health program, "Trust Me I'm a Doctor" highlighted the fact that natural methods, if taught by experienced teachers, are more effective than Persona. This has increased the demand for information and teachers within the NHS.
Medical: The minority of women / couples for whom other methods of contraception are contraindicated on medical grounds.
Our national office deals with nearly 3,000 enquiries annually from the general public and health professionals. Our web-site has been running for two years and is further increasing the demand for UK services. The requests are generally, for support with fertility awareness to plan and to avoid pregnancy. In the UK, fertility awareness education is increasingly seen as the basis for understanding how all methods of family planning work. In the Spring of 1999, the Family Planning Association UK will be launching a demonstration kit to support health professionals in their work with clients. This will include a fertility awareness consultation sheet and a resource showing how male and female fertility works and is the basis of fertility awareness methods. Basic education is also included in all professional courses. NFP is taught along with other methods in increasing numbers of general practice and family planning clinics in the UK. NFP is still taught from some Marriage Care centres by non-health professionals who have completed the required training. Additional support is available through a correspondence service and telephone, Fax, or E-Mail help-line service.
We are the only government-funded organization teaching NFP in the UK. The other large sympto-thermal group is the National Association NFP Teachers (founded by Dr. Anna Flynn of Birmingham). Other smaller organizations include: a Billings group; Couple to Couple League; and the Creighton Model.
Jane Knight is the Director of Fertility UK--The National Fertility Awareness & NFP Service UK. She can be reached at: <email@example.com> Web-site is http://www.fertilityUK.org
August 12-16, 1998. Billings Ovulation Method Association, USA is holding a teacher training and continuing education conference in Denver, CO. With the theme "Celebrating the 30th Anniversary of Humanae vitae," the conference will feature such noted speakers as: Eric Odeblad, M.D., Ph.D., Richard Fehring, D.N.Sc, R.N., and Hanna Klaus, M.D. Archbishop Charles Chaput, OFM.Cap. will celebrate Mass. Contact: BOMA Conference, 316 North 7th Ave., St. Cloud, MN 56303-3631; 301-252-2100; 1-888-637-6371; E-Mail, <<firstname.lastname@example.org>>.
August 21-22, 1998. CANFP is sponsoring a chastity educators' training in Salinas, CA. Funded by a grant from the Monterey County Health Department, Northwest Family Services (of Portland, OR), will conduct the training. The training will prepare 12 educators to teach courses utilizing the FACTS curriculum, enabling them to reach over 450 people (junior high school students and their parents). It will be offered in both English and Spanish. Contact: Sheila St. John, CANFP, 1217 Tyler Street, Salinas, CA 93906; 408-443-3743.
October 9-17, 1998. Creighton Model NaProEducation Technology training will be held in Omaha, NE. Contact: Pope Paul VI Institute, NFP Education Dept., 6901 Mercy Road, Omaha, NE 68106-2604; 402-390-9168; FAX 402-390-9851.
October 12-16, 1998. Pope Paul VI Institute will hold a Catholic Leadership Conference in Omaha, NE. The conference will explore the philosophical, theological and practical aspects of NFP. Contact: Pope Paul VI Institute, (address as above); 402-390-9168; FAX 402-390-9851.
February 23-27, 1999. Northwest Family Services will hold a NFP teacher training in Portland, OR. The NWFS system is based on the research of Dr. Josef Roetzer. This program provides necessary skills enabling participants to teach the Sympto-thermal system of NFP. Fees include tuition, books and materials. Spanish materials are also available. Contact: NWFS, 4805 N.E. Gilsan St., Portland, OR 97213; 503-215-6377; FAX 503-215-6940.
August 5-7, 1999. The National Leadership Summit on Abstinence will meet in San Antonio, TX. Sponsored by the Medical Institute for Sexual Health (MISH), this Summit should prove to be an excellent resource for those who teach and promote chastity. This will be the second Summit, the first was held in Washington, DC, July 1997. Contact: MISH, 3810 Medical Parkway #221, Austin, TX 78756; 512-451-7599; 512-328-6269 FAX.
CALL FOR ABSTRACTS
The American Academy of Natural Family Planning (AANFP) invites you to submit an abstract for presentation at its annual meeting, to be held July 20-24, 1999, in Lowell, Massachussetts (Boston area). Abstracts are welcome in the following topic areas:
* fertility awareness
* applications of fertility awareness to women's health
* natural family planning
* vaginal discharge
* reproductive anatomy and physiology
*anatomy and physiology of the cervix
* psychosocial dimensions of family planning
* prevention of adolescent pregnancy
* demography of natural fertility regulation
* other topics relevant to natural family planning
Abstracts may be of original research (clinical or basic science),
literature reviews, theoretical development, or demonstration projects.
All abstracts must be received by December 7, 1998. Notification of
acceptance will be sent by January 5, 1999.
Contact: Richard Fehring, DNSc, RN, CNFPE, Chairman, AANFP Science and Research Committee, Marquette University, College of Nursing, P.O. Box 1881, Milwaukee, WI 53201-1881; 414-288-3838; FAX 414-288-1939; E-MAIL: Richard.Fehring@Marquette.Edu
Quentin Publication Limited has published a new book entitled: What Every Woman and Girl Should Know About Herself. The book extolls the benefits of NFP as the result of scientific development of the Billings Ovulation Method. The book includes topics such as Breast Care and Problems; Sexually Transmitted Diseases; Artificial Methods of Contraception; and Choosing the Sex of Your Child. Contact: Quentin Publications, Ltd., Provincial House, Solly Street, Sheffield S1 4BA England or phone 0114 235-0517.
The Archdiocese of St. Louis has just produced a new video. "The Truth About NFP," tells the stories of how several couples came to choose NFP for their married lives. Only eleven minutes in length, this very good NFP witness film can be used with both engaged and the married. Quantity discounts are available when more than ten are purchased. Contact: The Office of Laity and Family Life, 7800 Kenrick Road, St. Louis, MO 63119-5041; 314-961-4320, ext.120.