NFP update: researcher cites need to improve instruction

In the Philippines more and more couples are practicing natural family planning (NFP), but there is a need to improve instruction on this method to increase its effectiveness. Calendar rhythm has been the most popular technique of NFP, but failure rates have been high. This could be changed by improved calendar rythm instruction and the introduction of newer, more effective natural techniques like the basal body temperature, cervical mucus, and symptothermal methods. Dr. John E. Laing, in a paper entitled "research on Natural Family Planning in the Philippines," examines the trends in NFP and summarizes major findings of past research related to NFP and the status of current research. It also discusses the implications of such findings for the National Population Program and the needs for current research. Cting World Fertility Survey (WFS) data on 19 developing countries, Laing states that the Philippines is second only to Peru in current and past use of the rhythm method. He also indicates that since the start of the National Population Program in 1971, rhythm has been offered as an official program method. Yet, in the early years of the program rhythm was not promoted as actively as the other family planning methods. In the last few years, program, officials have become more interested in NFP. 1976 National Acceptor Survey (NAS) data showed that rhythm reduced fertility by 78% compared to the condom's 79%, oral contraceptive's 94%, and the IUD's 98%. A comparison of data from the 1972, 1974, and 1976 NAS indicated a decline in continuation rates and an increase in overall pregnancy rates for all methods except rhythm. The overall pregnancy rate of rhythm declined, but there was no significant change in continuation rate. Laing suggests that probably, while the national population program was increasingly recruiting less motivated couples to try other methods, the rhythm acceptors, who were largely self initiated, mantained earlier levels of motivaton. Evidence points to the widespread use of crude formulas that do not take into account individual variations in cycle length. Many users do not even fully understand the mechanism by which rhythm affects fertility. There is also little knowledge among acceptors of the new and more reliable techniques of NFP for identifying the safe and unsafe periods. Despite problems, a considerable number of acceptors still prefer rhythm to other methods. The commission on population has embarked on a solution to some of the problems by committing itself to the training of volunteers of community-based organizations, particlarly lay leaders. 3 large scale projects are planned for this purpose.     

Upholding the freedom of couples to use a method of their choice

A recent review of the Philippine Population Program's 5-year plan, ended in December 1982, showed that in 1980, natural family planning (NFP) users were only about 12.5% of couples practicing family planning. This figure doubled by 1982. Based on these responses the decision was made to intensify the NFP program as early as 1982. The 1st step was to put more money into the NFP program. The program includes the modern scientific techniques such as cervical mucus, basal body temperature, and sympto-thermal. The program also will fund the training of doctors and other clinic personnel and the production and distribution of appropriate training and information material. Other family planning methods, such as sterilization, oral contraception (OC) and the condom, also will be promoted. Promotion of NFP will depend on the choice of the family planning practitioners themselves. The program's community based services are being intensified. NFP, together with the other family planning methods such as sterilization and OC, will always be made available to couples in the community based services. All agencies in the population and family planning program will be promoting NFP. Knights of Columbus doctors have been invited to assist the program and share their own training modules for the training of trainers. An agreement has been entered into with the Gabriel M. Reyes Memorial Foundation based in Aklan. The goal is for trainers who need further knowledge and skills in NFP to learn from the foundation's wealth of organized orientation and training techniques in NFP. NFP is emphasized at this time because it is acceptable to a great number of couples.     

NFP promotion in the Philippines: all program components covered

At least 50 of the 105 agencies in the Philippines listed in the "Directory of Agencies with Population Activities" are actively participating in the promotion of natural family planning (NFP). Of these, 40 offer instruction on its use, 22 provide training to clinic personnel or field workers, 19 conduct information/education/communication (IEC) activities, and 6 undertake research. The Population Center Foundation's (PCF's) Information Support to Population Projects (ISP) has prepared a preliminary inventory of programs and projects on NFP, covering some of those that were done in recent years, are being implemented, or have been proposed. Some projects described in the inventory are reviewed. Recent research or research proposals are showhow related, all leading to how the method can be effectively promoted and how couples can be taught its proper use. Instruction on NFP appears in all training activities of Popcom's regional offices, particularly in their refresher courses. Program managers are being trained in managing and monitoring activities to promote the method. In 1980 outreach workers, doctors, nurses, and midwives were trained by Popcom to motivate couples to practice the method and to teach them how to use it correctly. That same year, Popcom's office in the Ilocos region introduced the rhythm dial calendar, a simplified version of the rhythm slide rule. The Ministry of Health National Family Planning Office incorporates natural family planning instruction in its training seminars for the Ministry's health personnel in the regions. As in training, all regional offices of Popcom promote NFP along with other methods that they make available to prospective acceptors. This is in keeping with the program's "cafeteria approach" to family planning. In 1982 Popcom began intensifying the provision of services in NFP, allocating around 4 million pesos to preparations for its effective promotion. In support of service delivery efforts are IEC activities such as the development, production, and distribution of brochures and other reading material on NFP, schoolroom instruction, and lectures. The intensification of IEC efforts in the private sector to promote the modern and scientific techniques of NFP is most clearly evident in a fairly recent seminar sponsored by the Communication Foundation for Asia. Program agencies with activities in natural family planning are listed.     

The population program shifts to 'high-scenario' targets

The Philippine Population Program would like to achieve a replacement level of 1 daughter per childbearing woman by the year 2000 to reduce the population growth rate to 2% by 1992. Laing projected that high performance by the National Population Program would mean continued increase of sterilization prevalence at an average 1978-1983 rate. Strategies have been adopted to strengthen information-education-communication efforts, to attain higher contraceptive prevalence rates and use-effectiveness, to develop manpower, to achieve self-reliance, and to effect better program coordination, monitoring, research use. Effective service delivery will be a key to achieving the high-scenario targets. Effective use of natural family planning (NFP), will help in achieving the high-scenario goals. Apart from the heavy demand on NFP follow-up, need for prompt delivery of supplies, and lack of doctors and nurses, other factors may impede the high-scenario targets. Saniel believes that program workers should be allowed to insert IUDs and to dispense pills. Under the cost-recovery and cost-sharing schemes of the high-scenario targets, only sterilization will be done for free. It might affect the campaign for increased acceptors, but the start for self-reliance must happen now.     

The seasonality of conception

Individual data on menstrual cycles of noncontracepting women living in Western countries were used in order to verify whether the biological seasonality of conception persists after sexual behavior is controlled for. Episodes of intercourse were recorded daily, and the time of ovulation was detected by a marker We find that the seasonality of conception changes with woman's age and frequency of episodes of sexual intercourse. In particular; for women aged 27-31 having only one act of intercourse during the six most fertile days of the menstrual cycle, the seasonality of fecundability is stronger In this age group in the Northern Hemisphere, if seasonality of acts of sexual intercourse is controlled, the monthly distribution of probability of conception is bimodal, with two maxima (September and January) and two minima (December and March). When unobserved characteristics of the couples are considered, this seasonal pattern of conception persists.     

Understanding calendar rhythm

Rhythm has been among the family planning methods endorsed since the start of the National Population Program in the Philippines, but it has not been given as much emphasis as the other methods such as oral contraception (OC), the IUD, and sterilization. For several years, no systematic effort was made to promote the effective use of rhythm. The 1978 Community Outreach Survey (COS) tried to determine the extent to which contraceptive methods were being used in the Outreach Project areas. The project covered 2,000 barangay service points (BSPs) with 1.76 million married couples of reproductive age (MCRA), representing 32% of the estimated total MCRA in the Philippines. The COS findings revealed that, of the total sexually active married women aged 15-49, 48% were using contraceptive methods. Of these, only 11.4% were using modern methods, 20% were using other program methods (rhythm, condom, and combination of rhythm and condom); and 16.7% were using nonprogram methods (withdrawal, abstinence, and others). When used in combination with other methods, rhythm had a monthly continuation rate of 96%; when used alone, 94%. The COS data showed that the rhythm method is practiced by a large number of Filipino couples. With the renewed interest in rhythm, it became imperative for the program to help rhythm acceptors use the method more effectively and thus reduce user failure. There continues to be need for data on the "product image" of rhythm. These include the emotions that come into play in the acceptance or rejection of rhythm, the perceived side effects as well as advantages of the method, the ways women communicate their "safe" and "unsafe" days to their husbands, the manner in which couples prevent sexual contact during "unsafe" days, and the attitude of couples toward abstinence. Among important study findings were the following: couples choose rhythm because it does not disturb the sexual act, has no side effects, and poses no religious objections; 1 of the problems of rhythm users is that they get varied explanations and instructions from service delivery personnel on the correct way to practice rhythm; and many rural women do not have a clear understanding of the menstrual cycle. Requirements of successful rhythm practice include cooperation, regular cycle, and the couple's age.     

The risk of conception on different days of the menstrual cycle

Abstract Data on 1898 menstrual cycles, for 241 married women, were analysed by means of a quantal regression programme. The locations of the day of ovulation was determined by the basal body temperature method. Estimates were obtained of the risk of conception from an act of coitus on each day, as measured from the day of ovulation. The relationship between fecundability and coital frequency was also examined.     

The Philippine population program under the Aquino administration

3 views of the Philippine Population Program under the Aquino government are presented: the first states the government's position on population programs and the next 2 criticize that position. Issued by the Commission on Population (POPCOM) in early 1987, the first statement establishes the government's stance on population programs. It explains that the 1987 Philippine Constitution reaffirms the government's commitment to the ultimate goal of the Population Program: the improvement of the quality of life in a just and humane society. The statement explains the constitutional guarantees, policy principles, and policy strategies concerning population. The next view presented is an excerpt from Alejandro N. Herrin's paper entitled "Population, Health and Education: Policy Initiatives Under the Aquino Administration." In it, Herrin explains that after 1 year of silence, POPCOM finally issued a policy statement. The statement, however, is marked by ambiguity, avoiding an explicit mention of a policy to moderate fertility. Furthermore, the statement fails to clarify the government's position on 2 basic issues: whether or not an acceptable economic and social development can be achieved within a reasonable time without a moderation of the current high fertility and population growth, and whether or not the government is justified in sponsoring a program to moderate fertility and population growth. The 3rd view presented in the document is that of Virginia A. Miralao. In her essay "Population Policies, Family Planning Programs, and Women's Reproductive Rights," Miralao explains that the current population program -- which directly affects the lives of women -- has virtually excluded women in its planning. Moreover, since Aquino came into power, the Catholic church has gained great influence and has opposed family planning programs.     

Fecundability and coital frequency

Abstract The analysis previouslyreported (Population Studies, 23, 1969) of the risk of conceptionon different days of the menstrual cycleis extended so as to take someaccount of the agesof wives. The risks are estimated from data (basal body temperatures and occurrences of coitus) recorded by 241 married couples not using any contraceptives, to whom at least one child had previously been born. A mathematical formula relating natural fecundability to coital frequency is proposed and considered.     

The Mathematics of the menstrual cycle

Abstract Attempts have been made to rebut criticisms by Professor Potter of a rhythm method of contraception described by the author. There is a correlation between the lengths of adjacent cycles within the menstrual histories of some women.     

Family planning operations research in the Philippines

This essay introduces an issue of the Philippine Population Journal dedicated to the presentation of the results of operations research (OR) studies undertaken for the Philippine Family Planning (FP) Program as part of a program coordinated by the Population Council which seeks to improve FP services. The concept of OR was introduced to program managers and researchers at two workshops held in 1992. Five of the seven diagnostic proposals developed during these workshops were funded and are covered in this Journal. The results of earlier OR studies conducted under the sponsorship of the UN Population Fund are also included. The concept of OR was developed to provide managers with timely answers to their everyday problems through appropriate research. OR forces social scientists to overcome prejudices against this kind of applied research and forces program managers to learn to rely on research findings instead of on hunches. OR also forces both parties to work as a team. An important intent of this Journal is to encourage the dialogue which must precede the institutionalization of OR and to indicate to social scientists and program managers that OR has a personal relevance to their work. The research reported in this Journal will contribute to the building of theories through the many convergences in the conclusions reached about such issues as home visits, suboptimal clinic conditions, inadequate provision of FP information, and the role of outreach workers.     

Fecundability, coital frequency and the viability of Ova

Summary An extension of Barrett and Marshall's model expressing fecundability as a function of coital pattern is proposed. In particular, this extension includes the probability that the ovum remains alive. The extended model has been applied to Barrett and Marshall's data, a series of cycles for which basal body temperature curves and the date of coitus have been recorded. It was thus possible to estimate the daily probabilities of fertilization and, under certain assumptions, the proportion of lost ova. This proportion was estimated to be above 50 per cent, and increases with age. The increase of fecundability with frequency of intercourse is more moderate than that predicted by Barrett and Marshall's model.     

Natural family planning: A comparison of continuers and discontinuers

Little research has been done on social-psychological variables related to the use of natural family planning. The objective of this study was to analyze variables that differentiated between continuers and discontinuers of natural family planning (NFP). Questionnaires were obtained from couples who had received instruction in the sympto-thermal method of natural family planning at a large urban hospital. Subjects who were attempting to become pregnant or who were using other methods of contraception in conjunction with NFP were deleted from the analysis, leaving N of 74. With Pearson correlation, variables significantly related (p<.05) to NFP continuance were: religiosity, planning more children, perceived severity of pregnancy, support from spouse and relatives, dissatisfaction with other contraceptive methods, attitudes toward NFP, perceived effectiveness of NFP, attitudes toward abstinence, and importance of intercourse.     

A chronology of the study of older women's health: data, discoveries, and future directions

Women have been traditionally ignored in health and medical research. Some reasons for this mentality include a fear of harming a woman's reproductive ability, fear that variations in the menstrual cycle could confound results, fear that a woman's body could not withstand the rigors of clinical research, and an assumption that male and female body chemistry is similar. Thankfully, these fears and assumptions are being challenged and several major data-bases, designed specifically to study women's health, have emerged. The purpose of this paper is to: (1) characterize the major longitudinal studies on women's health, (2) summarize the major discoveries from these studies that are relevant to older women, and (3) pose several future directions for research throughout the paper.     

The Mathematics of the menstrual cycle

Attempts have been made to rebut criticisms by Professor Potter of a rhythm method of contraception described by the author.

There is a correlation between the lengths of adjacent cycles within the menstrual histories of some women.     

Injectable contraceptives: how safe are they?

Controversy still surrounds the use of the injectable contraceptive, Depo-Provera, in 3rd world countries, when it has yet to be approved in the US, Canada, Japan, and other developed nations. Some medical professionals maintain Depo is both safe and effective and could curb rapid population growth worldwide. With no conclusive decision made, some countries have approved Depo while others have not yet decided. Originally approved for a variety of uses, Depo is approved in the US only as a treatment for advanced endometrial cancer; however, it is now available in 65 countries and is used as a contraceptive in the Philippines. Depo and its companion Norigest are both progestonogenic injectables and were developed in the late 1950s. Injectables inhibit ovulation and thicken cervical mucus, thereby preventing fertilization. The reservoir usually lasts from 3-6 months, and its action cannot be reversed until the body has completely absorbed the drug. Injectables are highly effective; most accidental pregnancies occur shortly after the 1st injection before the drug has taken effect or at the end of an interval when its effect is wearing off. Overall the rate of fertility return corresponds to the rates for the pill and the IUD. Injectables have the advantage of preventing side effects brought on by estrogens; thus they would be beneficial to women desiring to use contraception but who cannot manage pill side effects. They do not interfere with lactation and have the lowest failure rate of the reversible methods. Important to developing countries is that injectables require no effort on the part of the user. Injectables do disrupt the menstrual pattern and Depo use often results in weight gain. Little is known about the longterm risks of Depo; however, in 1973 the US Food and Drug Administration withdrew approval of Depo for pregnancy-related uses because of links to birth defects. Other recent studies have uncovered other possible effects including uncertainty about whether injectables affect the composition of breastmilk or whether they raise blood glucose levels. Ethics have entered into the controversy with the "contraceptive double standard" where Depo has been exported to 3rd world nations when it has been ruled unsafe for American women. Campaigns have been organized against the distribution and use of injectables in the developed nations and a few in the 3rd world have begun to organize. While the Philippines has approved Depo, it is not yet considered an official method of the National Population Program. Policymakers await a more thorough analysis of factors for and against the promotion of the drug.     

Full-time workers reach out to the villages

The Philippine Commission on Population (Popcom) has fielded 2721 fulltime outreach workers (FTOWs). The FTOWs are the outcome of a shift from a clinic-based, motivation-oriented family planning effort to the Rural Outreach Program which is part of the new Total Integrated Development Approach (TIDA). Organizationally, the workers are under local government supervision and their purpose is to make the family planning program more responsive to community needs. This article profiles the average FTOW, describes recruitment and training procedures and discusses problems of the program -- funding, transportation, inadequate training, lack of educational materials, shortage of contraceptive supplies -- and possible solutions.     

Reducing unsafe abortion in Kenya

In Kenya, where abortion is permitted only to save a woman's life, unsafe abortion accounts for over one-third of maternal deaths and hospital emergency rooms are overcrowded with women suffering complications of induced and spontaneous abortions. Postabortion care, a service linking emergency treatment of abortion complications with family planning counseling and comprehensive reproductive health care, is under review by the Population Council as a method of reducing maternal mortality and morbidity as well as the incidence of repeat unsafe abortion. An operations research study conducted by the Kenyan Ministry of Health identified several obstacles to such care: lack of information on abortion management, limited service provider skills, inconsistent supplies, and a lack of empathy for women presenting with incomplete abortion. Although 86% of abortion patients from 6 Kenyan hospitals expressed an interest in contraceptive counseling, only 5% reported actually receiving such information. As part of the operations research, these 6 hospitals introduced postabortion care, including, in 3 hospitals, use of manual vacuum aspiration. All 6 hospitals provided contraceptive counseling and psychosocial support. Based on the success of this experience, the Ministry of Health is considering introducing postabortion care to all hospitals in Kenya.     

Depo-Provera: clarifying the issues

In this interview, deputy executive director Ester B. Sy-Quimsiam of the Commission on Population talks on Depo-Provera, the latest method officially accepted by the Philippine Population Program. Medically, Depo has been proven to be safe, effective, long-acting, and reversible. A single dose of this drug can prevent a woman from pregnancy for 3 months. In clinics where the nurse or the midwife is trained in comprehensive family planning technology the drug will be introduced. Clinics in areas where prevalence of the more effective method is low must be targeted. Managers, supervisors, trainers of service providers, and fieldworkers will be trained to implement the information and education campaign and generate demand among married couples of reproductive age who are most eligible for Depo. Family planning services will continue to be subsidized by the program, but the cost of contraceptive supplies will be shared by the user. But there will still be subsidized supplies for those who cannot afford them. Service providers must be well informed; they must not only at the contraceptive, they must also consider a prospective client as a total person.