I’m currently in a country in southern Africa helping a non-governmental organization improve its capacity to provide family planning services. Because so many women in the developing world die due to pregnancy-related causes, family planning is a vital component in any strategy to decrease maternal mortality.
There are four key problems faced by women in developing countries: giving birth too early, too late, too many times, or too soon. Women who give birth before they turn 18 are at higher risk of death from pregnancy-related causes, as are women over 35. Women who have too many children are also at risk; women who have a child too soon after giving birth to a previous child are themselves at risk, as are their newborns.
Birth spacing is a critical component of family planning: Children born more than 2 years after their closest sibling are nearly 2.5 times more likely to survive to age 5 than those born 18 months or less after their closest sibling. (Rutstein et al, 2005) With fewer births, further between, their mothers are also much more likely to survive childbirth. (Davanzo et al, 2004) Although these risks exist for women in developed countries, they are orders of magnitude higher in countries where women face malnutrition, lack of access to clean water, lack of access to appropriate medical care, and other prevalent illnesses like HIV infections and malaria.
Given how much family planning could improve and save lives here, it’s disappointing to find that less than a quarter of women of reproductive age use any family planning method at all, and that of those who use a method the majority use “natural” methods. These methods are known as fertility awareness methods, and the premise is that women can predict their ovulatory cycles and abstain from intercourse (or use barrier methods) on those days when they are most likely to become pregnant. These are different from the “rhythm method,” in that they have been better studied and, when used perfectly, are much more effective.
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The method most frequently used in the developing world is known as the Standard Days method. The other two modern fertility awareness methods, the Two-Day method and the Ovulation method, require more understanding of anatomy, charting, and monitoring of cervical secretions.
Women using the Standard Days method are to use a string of beads with different colors. On the first day of her period, a woman places a ring around a red bead. Each day she moves to another bead. When she reaches day eight of her cycle, the beads change color (to a conveniently glow-in-the-dark white for those who have no electricity), indicating that she is likely to get pregnant if she has sex on that day. Days eight to 19 are white, then the color changes back to dark brown, indicating a return to a non-fertile part of the cycle.
When used perfectly (that is, either through abstinence from penile-vaginal intercourse or use of barrier methods during fertile days), the method will result in about five pregnancies per year for every 100 couples using the method. When used typically, this method will lead to about 25 of every 100 couples becoming pregnant in a year. These statistics have been criticized (Grimes 2005), however, due to methodological problems with many of the studies, including their dependence on small sample sizes, very high attrition rates (participants dropped out of the study before their outcomes could be assessed), and inappropriate randomization of participants.
In addition to the methodological flaws of these studies, I have many concerns about use of this method in developing countries, where women experience high rates of malnutrition and may have irregular menses, making this method ineffective. The high rate of breastfeeding and relatively long duration of breastfeeding when compared with developed countries also can contribute to irregular cycles due to the inhibition of ovulation. While exclusive breastfeeding proves to be an excellent contraceptive method for the first six months after birth, fertility rapidly returns after this, even if regular periods haven’t yet resumed.
Also of particular concern in countries where women enjoy limited autonomy is the requirement of a partner’s participation and willingness to respect the use of barrier methods or abstinence during fertile periods. Where I am now, over 70 percent of women report at least one kind of intimate partner violence (emotional, physical, or sexual) and nearly half of women believe it is appropriate for a man to hit his wife if she refuses to have sex with him. More than 20 percent of women here don’t even get to choose what groceries they will buy on any given day, and less than half of women have a say in personal medical decisions.
So in the best-case scenario (that is, among committed couples who are able to perfectly continue this method for a year), 5 percent of women will become pregnant in the space of a year. In a typical-use scenario (that is, among committed couples taught to use the method who continue this method for a year), 15 to 25 percent of women will become pregnant in the space of a year. In a more realistic scenario (that is, couples are taught the method and then left to their own devices for a year), the pregnancy rates are presumably much higher, but as noted above, methodological flaws in the studies that have been carried out do not permit us to know what they are.
I’m not saying women here shouldn’t have children, but they deserve to choose the timing of their pregnancies to maximize the probability of a healthy mother, baby, and family. In this part of the world, an unintended pregnancy has nothing but negative outcomes: a risky trip to an unqualified abortion provider, or a dangerous pregnancy producing another child who won’t have enough to eat, another child who won’t be able to afford to go to school, another child condemned to a life in poverty. One woman in twenty here will die from pregnancy-related causes. Faced with these dire statistics, running even a 5 percent risk of an unintended pregnancy seems reckless; running a 15 to 25 percent chance of unintended pregnancy is engaging in a dangerous game of Russian roulette. To me, this probability of method failure is unacceptably high, especially since we have many safe and highly effective methods available.
Not surprisingly, “natural” family planning is a project of religious groups. The Institute for Reproductive Health at Georgetown University is an international leader in studying and promoting fertility awareness methods. (I’m sure many of you will be pleased to know that your tax dollars are supporting their projects through USAID in multiple developing countries. I am heartened that some religious leaders recognize the health benefits of birth spacing and limiting. I also recognize the right of all couples to choose a family planning method consistent with their beliefs. However, I find their promotion of these less-effective methods to the exclusion of highly effective methods to be as problematic as their promotion of abstinence-only sex education.
They rely on the world existing as they wish it to be, rather than as it is.
Abstinence-only education relies on a non-existent world where there are no STIs, where teenagers aren’t naturally compelled to explore their sexuality, and where sex is always consensual. Similarly, fertility awareness methods rely on a world where women have autonomy; where terrible STIs like HIV don’t exist; where everyone has enough to eat, clean water, and access to basic medical care; and where the news of a pregnancy is not met with the knowledge that a woman has placed her life at risk.
So can we learn to love “natural” family planning? Not in Africa. Yes, it is better than nothing, but families here deserve the best medical care we can offer, and that includes education about all the contraceptive methods available to them, accompanied by a realistic explanation of the failure rates of each method.
Rutstein S. Effects of preceding birth intervals on neonatal, infant and under five years mortality and nutritional status in developing countries: evidence from the demographic and health surveys. International Journal of Gynecology and Obstetrics: 89 (2005): S7-S24.
Grimes D, et al. Fertility awareness-based methods for contraception: a systematic review of randomized controlled trials. Contraception: 72 (2005) 85-90.
Davanzo J, et al. The effects of birth spacing on infant and child mortality, pregnancy outcomes, and maternal morbidity and mortality in Matlab, Bangladesh. Working Paper WR-198, Rand Corporation, 2004.