All forms of birth control require some motivation, and motivation calls for understanding. If a woman learns to interpret her own cycles, her understanding of her body will be enhanced, and this could have benefits in all aspects of her fertility control. Professional nurses and health visitors are frequently expected to explain the intrigues of the menstrual cycle whether it be in family planning clinics, on gynecology wards, or in a client's home. When information about the monthly cycle is linked with the signs women observe in their own bodies, knowledge will result. With accurate knowledge about the span of the fertile phase, it should be within most women's grasp to control their own fertility, whether they use this knowledge alone or together with some mechanical contraceptive method. The endocrine hormones which control each menstrual cycle come from the pituitary gland and the ovaries, and they work in a feedback system, triggering each other. The start of the cycle is day 1 of the period when the pituitary gland starts the production of follicle stimulating hormone (FSH). This is taken in the bloodstream to the ovary where, as its name implies, it stimulates the ripening of follicles, each of which contains an egg cell. Operating in a feedback system, estrogen is carried back to the pituitary gland where it then causes a lessening in the production of FSH and stimulates the release of the luteinizing hormone (LH). LH proceeds back to the ovary and together with estrogen suppresses the growth of all the follicles except one, which then matures to release an egg at ovulation. If the egg is not fertilized, the pituitary gland detects the high level of progesterone and ceases production of LH, which causes the corpus luteum to die away. The 1st phase of the cycle leading up to ovulation is known as the follicular phase, and its length can vary considerably from month to month. The 2nd phase, leading up to menstruation, is the luteal phase, and its length does not vary more than 12-16 days, normally 14. There are 3 main observations that women can make each month: daily temperature; the cervical mucus; and a "calendar" assessment, and after a few months the likely course of the cycle is evident. Each of these 3 ways of interpreting cycles are reviewed in detail. If the motivation and understanding is there, most women can become adept at reading the signs each month. While still learning, it is important to seek advice from those who understand the methods and can ensure accurate interpretation. Encouraging women to discover how their bodies work is not aimed at discouraging the use of mechanical or chemical contraceptive methods. It is simply a way to enhance a woman's understanding of her body which could bring her positive physical and emotional benefits. Practically, if more women could read their body cycles, there would most likely be an increase in motivation to use contraception and an associated reduction in unwanted pregnancies.
There has been an increase in interest in natural family planning (NFP) in recent years. The Roman Catholic Church and other groups sympathetic to NFP philosophy have pressured the US Agency for International Development (AID) to increase emphasis on NFP, and AID has responded by increasing funding devoted to NFP from US$0.8 to US$7.8 million from 1981-85. In 1985, AID exempted NFP providers from the requirement of providing direct or referral services for other methods, but repealed the exemption in 1986. Several methods rhythm, the estimation of ovulation time by the counting of days elapsed in relation to menstruation; and the more precise cervical musus; basal body temperature; and sympto-thermal methods. Because NFP requires considerable training, recording, and willingness to abstain, recruitment is difficult and dropout rates high. A 5-country World Health Organization study found that 17% of women dropped out during training, and 36% discontinued during the following year. At the 4th International Congress of the International Federation for Family Life Promotion (IFFLP), it was stressed that data on NFP prevalence classed by type of NFP are lacking. Questions raised included whether populations of countries that have achieved or hope to achieve a low birth rate will be interested in NFP; whether NFP can increase the risks of birth defects through fertilization by "aged gametes;" and whether NFP is capable of helping couples to select the sex of the child. The implications of the contraceptive effects of breastfeeding were reviewed. Some problems arise concerning NFP advocates often do not consider couples who "break the rules" as acceptors, and when these couples are excluded from data the method appears much more effective. Traditionalists emphasize the increased quality that NFP brings to a marital relationship. Some participants maintained that rigid moral advocacy would deter many couples.
Fertility AwarenessBillings Ovulation MethodSympto-Thermal MethodClinician Role
Despite skepticism on the part of the health care delivery system, increasing numbers of women and couples are relying on natural family planning methods to avoid or achieve pregnancy. Most clients require 2-4 cycles to become familiar with the delineation of the fertile phase. Both the ovulation and the sympto-thermal methods are considered to have a method effectiveness of at least 98%. Teaching-related unplanned pregnancies fall below 5%. Use of the Billings ovulation method requires the couple to abstain from intercourse from the beginning of mucus until the 4th day after peak. The sympto-thermal method is preferred by those desiring a multiple-index approach. 75-80% of users of this method can detect cervical softening and dilatation, and 50% are aware of the change of position of the cervix. Knowledge of mucus buildup patterns can be expecially important for adolescents, lactating women, and premenopausal women in helping them to determine whether cycles are ovulatory. Instruction in interpretation of the mucus cycle is further advised in cases of infertility. Unwillingness of the partners to practice it constitutes the only contraindication to natural family planning. However, couples are advised to wait for the postovulatory infertile phase of the cycle to have intercourse in cases where prgnancy would pose a serious threat to the life of the mother or fetus. Although some groups recommend the use of a barrier method rather than abstinence during fertile periods, this practice makes mucus recognition more difficult and impedes confidence in the method. Attainment of couple autonomy in natural family planning involves 2 1) correct recognition of the signs of fertility and 2) comfort with periodic asbsinence. Successful autonomy is reflected in the high continuation rates found in programs that offer adequate counseling support.
This review of natural family planning (NFP) components of the fertile phase; sympto-thermal methods; the history and methodology of NFP (calendar rhythm, basal body temperature, cervical mucus--the Billings Ovulation method); special circumstances--periods of erratic ovulation (puberty, lactation, premenopause, discontinuation of ovulation suppression, cervicitis and vaginitis, ovulation suppression by stress and pharmaceuticals); effectiveness of natural family planning; achieving pregnancy; achieving couple autonomy (confidence in the method, periodic abstinence, dynamics of the learning process, and support systems); problem areas; and delivery systems. The number of users of NFP methods increased from 2.8% of currently married couples in 1973 to 3.4% in 1976. In 1979, 75,000 new clients received training in contemporary NFP, while the number increased to over 100,000 in 1980. NFP is planning for achieving or preventing a pregnancy by the timing of intercourse. A couple can, by observing and recording certain natural symptoms and bodily changes that occur in a woman's menstrual cycle and using the information as a guide, learn to identify fertile and infertile phases in the menstrual cycle. Precise prediction of ovulation forms one of the components of delineation of the fertile phase. Billings pioneered the use of cervical mucus as a single parameter for the prediction of ovulation and its application to NFP. Women are instructed to observe their mucus patterns at the vulva, relying primarily on the sensation of wetness and lubrication, the use of the Kegel exercise, palpation with the finger, a "wipe-through" with toilet paper, or a combination of these observations. In the absence of ovulation, the usual changing mucus pattern is also absent. NFP can be used either to achieve or to avoid pregnancy. When NFP is used to avoid pregnancy, one will encounter method-related pregnancies, teaching-related pregnancies due either to poor teaching or poor learning or both. The major use effectiveness studies are listed in table form, and the results are shown under new headings. To achieve pregnancy, it is the general practice of NFP instructors to teach women to recognize and record their fertility signs and to suggest some months of merely concentrating coitus at the time of maximum fertility. Mastery of NFP calls for both identification of the fertile phase and integration of that knowledge into the couple's sexual decision making and behaviors. Studies are reviewed in terms of the spectre of genetically damaged offspring. NFP instruction is available in nearly every country outside the Soviet bloc.