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Tuesday Dec 12, 2017

Make Fertility Awareness Part of Family Planning Toolbox

The past few months have seen a whirlwind of discourse regarding our health care system, including issues related to reproductive health. In the midst of these discussions, there have been items in the news(www.newsweek.com) about fertility awareness-based methods (FABMs) that are often confused with the rhythm method and dismissed as ineffective by commentators and medical professionals alike.

[natural family planning chart or calendar]

There have been claims that FABMs carry a 24 percent failure rate(www.cdc.gov) in preventing pregnancy. This figure would seem to be a daunting condemnation of these methods, but this is a grossly misleading statistic, and it's not accurate to equate fertility awareness methods with the rhythm method.

The 24 percent failure rate stems from data pulled from the National Survey of Family Growth (NSFG) conducted in 1995 and the NSFG survey performed in 2002, which were then summarized in a 2011 study.(www.ncbi.nlm.nih.gov) In those surveys, women who became pregnant in a 12-month period were asked what method of birth control they were using when they became pregnant. Any answers that included "rhythm," "calendar," "mucus" or "temperature" methods, "periodic abstinence" or "natural family planning" were combined, and the resulting data led to the conclusion that women who used these methods had approximately a 24 percent unintended pregnancy rate. The trouble is, the overwhelming majority of FABM users in the study said their primary form of contraception was the calendar rhythm method, which does not accurately represent modern FABMs.

Unlike the rhythm method, which was developed in the 1920s-30s, modern FABMs, including the cervical fluid (such as the Creighton model(www.creightonmodel.com)), symptothermal(sympto.org), symptohormonal (such as the Marquette model(nfp.marquette.edu)) and Standard Days(www.cyclebeads.com) methods, are based on scientific research. Each of these methods has a different efficacy, and each has been evaluated in prospective cohort studies(www.factsaboutfertility.org) that support the fact that these methods are more effective than the 24 percent failure rate reported in the 2011 NSFG-based study.

Thankfully, in the past few years, many organizations, including Planned Parenthood(www.plannedparenthood.org) and the American College of Obstetricians and Gynecologists,(www.acog.org) have begun to distinguish between the different types of FABMs and provide more up-to-date data on efficacy. In one of the best studies(www.factsaboutfertility.org) to date, the authors looked at all the research about efficacy rates available for each method published since 1980 and ranked the level of evidence based on Strength of Recommendation Taxonomy criteria. In 2012, American Family Physician published a review of the methods, which shows 92 percent to 98 percent efficacy in avoiding pregnancy with typical use for some of them. When compared with other methods that require a behavioral change, such as birth control pills or condoms, the evidence shows that FABMs are just as effective, and in some cases, more effective.

So why is this important? The simple reason is that patients are interested. In one survey,(www.ncbi.nlm.nih.gov) 22 percent of women were interested in learning more about FABMs to avoid getting pregnant, and 37 percent were interested in learning about them to help achieve pregnancy. In another survey(www.ncbi.nlm.nih.gov) of mostly Hispanic women, 61 percent of respondents said they would be interested in using these methods to avoid pregnancy, and 50 percent would like to use them to achieve pregnancy.

Some women are concerned with the potential adverse effects(www.nytimes.com) of hormonal contraceptives, and others may want to use FABMs for personal, environmental(www.sciencedaily.com) or religious reasons.

When a patient is interested in family planning, I list all the different methods that are available, but whenever I mention fertility awareness, nearly all women are curious and want to learn more. Some choose an artificial method, but many others are eager to try something that won't give them the negative side effects they've experienced from other methods. At this point, I typically refer them to a local instructor or have them return to my office, where, as a trained instructor, I can provide the appropriate education for them to learn a method of fertility awareness and use it effectively to meet their family planning goals. Since these methods require behavioral change (i.e., daily observation of fertility signs and periodic abstinence), it's important for our patients to learn how to use them from trained instructors and not simply from a pamphlet, book, website or app.(www.jabfm.org)

Having this skill set as part of my patient care toolbox has been incredibly rewarding. In my first year of practice out of residency, three women who had struggled for years to get pregnant were able to achieve pregnancy by learning an FABM. Other women have learned a great deal about their bodies and are able to better understand mood changes and changes in vaginal/cervical secretions. In some cases, abnormalities in the charting of their cycles has helped in diagnosing polycystic ovary syndrome or endometriosis.

Too often, our focus on FABMs is their efficacy in avoiding pregnancy, and we forget about their versatility. Couples can use these methods to avoid or achieve pregnancy, women can use them to better understand their cycles, and medical professionals can use the information gathered from cycle charting to aid in management of a woman's reproductive health. In fact, doctors and scientists have studied women who use the Creighton method and have developed an individualized approach to women's health called NaPro Technology.(www.naprotechnology.com) Family physicians trained in this science have been successful in helping women with infertility.(www.ncbi.nlm.nih.gov)  

So what can we do to prepare for the patients who are interested in FABMs? First, we can educate ourselves on how these methods work and the evidence that supports them to dispel the tired report of the 24 percent failure rate.

Second, why not learn how to use or teach one of these methods ourselves? Thanks to fertility awareness, my wife and I have two beautiful daughters who may not have been conceived without the understanding of her irregular cycles and the expertise of the NaPro doctors who treated her.

Last year, the AAFP sent a letter to the CDC, which conducts the NSFG, asking the agency to "review the evidence for avoiding pregnancy among different fertility awareness-based methods and update the effectiveness rates" so family physicians can help patients make decisions based on accurate data. Whether women are trying to avoid or achieve pregnancy, they need to know their options, and as family physicians, we need evidence-based information to help patients make the decision that is right for them.

Luis Garcia, M.D., is a family physician in York, Pa., working at Family First Health, a federally qualified health center. He focuses on caring for the Spanish-speaking community and spending time with his wife and two daughters.

Posted at 02:44PM Dec 12, 2017 by Luis Garcia, M.D.

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