Shortcomings of natural family planning methods
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5566 (Published 21 August 2012) Cite this as: BMJ 2012;345:e5566
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The issue of contraception has long been left off the global public health agenda with many national governments and NGOs proving reluctant to encourage any contraception methods apart from natural family planning.
As Dr Verkuyl explains in his letter, the evidence for the efficacy of fertility awareness based methods (FABMs) is lacking (1). Contraception provision is currently estimated to cause a 44% reduction in maternal deaths, and if all women who wanted access to contraception were given it then a further 29% could also be prevented (2). Contraception provision reduces maternal and infant mortality, improves maternal health and provides significant macroeconomic benefits. Smaller family sizes also confer benefits to wider society; reducing food instability, allowing more women to remain in education and improving living standards.
Some of these issues were finally addressed in the London Family Planning Summit on 11th July 2012 where the Bill and Melinda Gates Foundation pledged $560m to be spent on family planning services. Important pledges were made by governments of the developing world and donor countries to improve women’s access to a variety of methods of contraception, including LARCs (long-acting reversible contraception).
A Catholic, Melinda Gates, has stood up for some of the world’s poorest women, having the courage to go against the teachings of her faith.
As medics we must be prepared to question our moral convictions and follow where the evidence, and not personal belief, directs us.
1. Verkuyl, DA. Shortcomings of natural family planning methods. BMJ 2012;345:e5566 (21st Aug)
2. Ahmed S, Qingfeng L, Li L,Tsui A. Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet. 2012; 380: 111-125
Competing interests: No competing interests
Dr Verkuyl in his well referenced letter is to be congratulated in challenging the assertion made by Dr C Evans that natural family planning is effective and culturally acceptable and should be promoted in the developing world.
Natural Family Planning is of course the only type of contraception officially sanctioned by the Catholic Church.....
By not having effective contraception,millions of women around the world are facing the burden and risks of further unplanned/unwanted pregnancies and their existing children the hazards of a mother burdened by excessive multiparity. As Dr Verkuyl demonstrates in his clearly worded letter there are many better methods available, - if only there was more political will to make them available, and to educate women. NFP has a small place, as a niche and less reliable form of contraception for those who CHOSE to use it, rather than imposed.
Competing interests: hugely concerned about the ever increasing human population and man-made damage to the environment of our earth, and aware of the fact that over 40% of pregnancies are unplanned
A man and woman enter a fertility shop. "Yes please how can I help"? We would like to see what we can do about managing our fertility please. Lets see then how much did you want to spend? "Nothing at all if possible but show us the range". Ok, "absolutely no baby and sex galore" is top of the range but pricy and involves hysterectomy. This next option is called " no sex and absolutely no baby" and it does what it says on the tin and counselling may cost a little. Over here we have the pill/potion/injection department and these do cost, and have many unwanted side effects like blood clots and breast cancer but many take the risk. As regards babies yes they do occur at a rate similar to or not quite as good as the next option which is called "natural sex for intelligent self controlled adults". This is free has no side effects and is gaining in popularity. The idea is that you dont have sex when the female is fertile and you can tell this from several signs. It has been used very successfully in poorer countries and studies in several high profile journals published this, but it is ignored by those who want to push pills or implants or IUDs and who think sex is just an impulse and has nothing to do with responsibility and babies. So what will it be then?? We'd like the intelligent one please and so it won't cost anything and has absolutely no side efects and since we just married we would love a large family.
Competing interests: No competing interests
I apologise for introducing two errors into this letter while editing it for print.
Firstly, the second sentence of the penultimate paragraph should have read:
"Pills, condoms, FABMs, and even depot medroxyprogesterone acetate require continuing commitment" [not "Pills, condoms, FABMs, and even implants require continuing commitment"].
Secondly, the initials at the start of the competing interests statement should have been DAV [not DAK, as published].
Finally, I should also have included a link to the full rapid response
http://www.bmj.com/content/345/bmj.e4908/rr/596880
at the end of the letter.
Competing interests: No competing interests
Re: Shortcomings of natural family planning methods
Scientific theses should be argued scientifically.
The Verkuyl paper makes no less than 45 separate claims only 9 of which are referenced with 3 papers (1). Of these three references one records the prevalence of Natural Family Planning (NFP) (2), one the author’s opinion argued elsewhere (3) and one is irrelevant to NFP (4). Ironically, the two relevant papers (2, 3) actually support my position (5).
Regarding the first, the high rate of NFP usage in Poland (2, 6) suggests that NFP is an attractive option to women when they receive accurate and unbiased information on it. In a study of German and Polish women, Mikolajczyk et al found that 53% and 68% respectively would consider using modern NFP, with perceptions about accuracy being more influential than perceived difficulty with periodic abstinence (7).
The second paper discusses the ‘Failed Intention Rate’. This is a peculiar concept as it counts as failures women who say in a consultation they will use a particular form of family planning but actually decide against it, especially as the proposed solution for non-compliance is to bounce women into it “directly after the decision is made during a busy clinic” (3). Presumably women in the developing world will be similarly intimidated if they question what the drug companies tell them about their “unmet need for contraception”, the dogma of a study which included countries for which there was not a single datum on any woman (8).
Finally, NFP has been associated with reduction in the birth rates in Gurage, Ethiopia (9) and low unwanted pregnancy rates in Kolkata, India (10), the latter influenced by a woman who genuinely cared about the poorest of the poor.
Verkuyl’s thesis is on shaky ground.
1. Verkuyl DA. Shortcomings of natural family planning methods. BMJ. 2012;345:e5566.
2. United Nations DoEaSA, Population Division. World Contraceptive Use. 2009.
3. Verkuyl DA. Intention-to-treat studies crucial for contraception research. Contraception. 2009;80(3):234-6.
4. Cameron S, Glasier A, Chen Z, Johnstone A, Dunlop C, Heller R. Effect of contraception provided at termination of pregnancy and incidence of subsequent termination of pregnancy. BJOG : an international journal of obstetrics and gynaecology. 2012;119(9):1074-80.
5. Evans C. Natural family planning is effective and culturally acceptable. BMJ. 2012;345:e4908.
6. Mishtal J, Dannefer R. Reconciling religious identity and reproductive practices: the Church and contraception in Poland. The European journal of contraception & reproductive health care : the official journal of the European Society of Contraception. 2010;15(4):232-42.
7. Mikolajczyk RT, Stanford JB, Rauchfuss M. Factors influencing the choice to use modern natural family planning. Contraception. 2003;67(4):253-8.
8. Singh S, Darroch J. Adding It Up: Costs and Benefits of Contraceptive Services - Estimates for 2012. New York: Guttmacher Institute & United Nations Population Fund (UNFPA); 2012.
9. Kelly J. Audit of health services in Gurage. Journal of tropical pediatrics. 1992;38(4):206-7.
10. Ghosh AK SS, Chattergee G. Sympto-thermia vis a vis fertility control J Obstet Gynae India. 1982;32:5.
Competing interests: No competing interests