For good or ill, if Natural Family Planners seek acceptance of natural family planning methods by health care professionals, they must use terms which are understood by the intended audience, many of whom are sceptical if not disdainful of methods involving periodic abstinence. Fertility suppression methods - contraceptives - are either used correctly or incorrectly, but only have one goal, the avoidance of conception while having sexual relations. Natural Family Planning is different because it can be used not only to avoid but to achieve pregnancy. Reaching autonomy in Natural Family Planning requires first, a correct understanding of the physiological marker or markers of fertility and secondly, coming to terms with regulating one's sexual life in terms of the goals of the family. In practical terms, it means learning to live with periodic abstinence. The "in house debate" begins when different provider groups put different emphases on the components of Natural Family Planning. While no one disputes that ultimately the presence or absence of fertility determines whether or not conception can occur, different providers weight the couple's motivation variously. In attempting to come to terms with this, a meeting of Natural Family Planning physician providers and two representatives from the National Institutes of Health met in Los Angeles in 1981 and arrived at the following categories.[1]

1. Method Related Pregnancy - The method was used correctly and consistently but the woman conceived.
2. Informed Choice Pregnancy - The Couple understood their fertility, had intended to avoid pregnancy, but had intercourse during the time of recognized fertility.
3. Teaching Related Pregnancy - There was misunderstanding of the method, due either to the user or to the teacher.
4. Unresolved - Insufficient information to categorize the pregnancy.

Typical use figures are generally cited for the first year of use. These differ from the older method-related and user-related computation of the Pearl Formula or the Life Table, which aggregated all exposure cycles. The Trussell and Kost computation separates perfect use from typical use cycles and calculates rates separately.[2]

Using any computation, "perfect use" pregnancies with Natural Family Planning are very low, ranging from 0-2.8%[3] A debate arises in categorizing unplanned pregnancies which resulted from a "conscious departure from the rules." These "informed choice pregnancies" may stem from a variety of motives: the motivation to avoid pregnancy may not be as strong as the desire for intercourse for any number of reasons. A couple may disagree as to whether or not they want to start another baby at a given time. Or the couple may be into risk-taking. After all, the probability of conception is 33% with intercourse on peak day. Some people are willing to risk these odds! It is important to separate motivation, intent, and behavior. The informed choice pregnancy classification does that -- at least it recognizes that there are three components, any of which may be determinative. But motivation, intent and behavior are distinct. As Kambic says[4] "if I jaywalk, do I want to get hit by a car?"

Another viewpoint is to assume that biology is the only operating factor and state, as Hilgers and Stanford do in their article,[5] that the "couples are taught that de facto, when they begin using days of fertility, they have abandoned the method as a means of avoiding pregnancy and have adopted it as a means of achieving pregnancy." And yet, components of their publication which were published earlier show that fully half of the pregnancies reported under the "achieving related" category were surprise pregnancies. In reporting the Marquette Trial, Fehring et al. cite the effectiveness rates which are quoted also in Hilgers and Stanford - 98.8% method effective and 98.0% use effective, 24.4% use effectiveness for achieving pregnancy. Yet in the discussion section of his paper, Fehring stated that if the WHO terminology were used, the unplanned pregnancy rate is 12.8%.[6] Clearly the philosophical basis of pregnancy designation of Hilgers' group is different from most other family planners.

Looking only at biology to determine a couple's family planning intention raises considerable incredulity among general family planners with resultant downgrading of Natural Family Planning. On the other hand, one may speculate about its genesis. It may simply be a male way of thinking, not sufficient when dealing with heterosexual couples. In approaching any subject, men tend to be focused in a more single-minded way, possibly as a function of their brain structure. Since 1990, studies of the neural pathways of men and women have been made possible by PET scanning. Over-simplified, we learned that men work with one or the other cortical hemisphere at a given time, while women work with both, possibly thanks to the increased connections afforded by the corpus callosum, which is twice as wide in women as in males.

Authors from different disciplines have written about the differences between males' and females' behavior, whether in the private or public areas. Generalizations are always just that, and admit of many exceptions. But, as already stated 20 years ago in "Positive Woman or Negative Man?" [7] women have too often been disparaged through the ages, and have adopted many behaviors in order not to "threaten" the men. Even today, Deborah Tannen[8] documents how professional women are often belittled, their ideas not heard until a male repeats them, and the ideas are then, often as not, attributed to the male. The possible connection to brain structure which I am postulating is this: because women engage both cortical hemispheres simultaneously, they can think and feel at the same time. As a result, they are able to pick up not only the cognitive content of any communication, but also the emotional feeling tone. This can be either help or hindrance, depending on the situation. Men, on the other hand, generally either think or feel; they tend to pursue a single path to the exclusion of any distractions. Hence they may be perceived as insensitive by their wives. For example, if the man is working on his taxes, he will be oblivious to everything around him, including fighting or screaming children. Gender differences currently have a high profile in popular psychology, for instance, Men are from Mars, Women are from Venus [9] Clearly understanding the different functioning of thought processes of men and women is a great advantage, not only in public life, but in marriage. Failure to understand these differences may also help explain the enormous area of ambivalence which exists not rarely between spouses who practice Natural Family Planning. Already, during the learning phase, the pressure on the woman to make her observations and interpret them correctly is associated with emotion, particularly a fear of incorrect observations and therefore, incorrect interpretation. Very often, at follow-up, husbands appear to understand the method more readily than wives, but that may be because they are not as subjectively involved in the signs. At the same time, women are intuitive, and very often think they know what their husbands want, without having verbalized their desires or perceptions. Not surprisingly, sometimes a woman thinka her husband is ready for another baby, when in fact, he isn't. Once the pregnancy is established, the different perceptions surface and negotiation is necessary.

Another area where motivation, intent, and behavior may not be congruent is in any area of marriage where male/female dominance/equality questions have not been resolved. Men have traditionally wanted to be in control of things and of their marriage. Witness the statement in Ephesians V, that the man is the head of the woman. Often overlooked is the first sentence of that passage: "Submit to one another for the sake of Christ" which John Paul II never tires of reiterating. Nonetheless, because the man's fertility is constant, while the woman's is cyclic, the man must adapt his pattern of sexual intercourse to his wife's fertility if their intention is to avoid conception. In other words, he has to submit to her fertility. This may engender a certain amount of ambivalence, if his self-worth as a man and as a spouse is based on being in charge of things. For this, and many other reasons, I believe that the area of informed choice pregnancy in Natural Family Planning is not only complex, but must be retained to preserve the freedom of the couple, rather than to assume that biology alone is determinative.

There are other reasons for ambivalence, which may be intrapersonal. For instance, one of our early clients who had had a heart valve replaced because her own had been damaged by rheumatic heart disease. She was on antibiotics prophylactically, already had three children, and had been advised against attempting further pregnancies. She was well educated and learned the Billings Method easily. Nevertheless, she had serious concerns applying the method because she felt she was "playing God." And so she stopped practicing the method. She said, "I want God to surprise me." I suspected He would, and soon learned that I was correct. God did indeed "surprise" her. Blessedly, her pregnancy and delivery progressed well and she returned to us. At this time, she was ready to practice the method seriously. We discussed the passage in John 15:14-17 where Christ tells his disciples that he no longer calls them servants but friends because servants don't know what the Master is about. Surely this passage also means that we should be able to understand the language of our God-given bodies and what it is telling us about our fertility, and then behave appropriately. The question is: What constitutes appropriate behavior?[10]

In the above situation, no reasonable person would suggest she continue to risk an early cardiac death leaving her children motherless and her husband a widower. Women receiving chemotherapy for breast cancer fit the "absolute" category, at least until chemotherapy is passed. This is true of any serious physical illness and impairment. In these situations, couples usually follow the rules for pregnancy avoidance very carefully. But there are other situations not so closely allied to imminent death which may also require a decision to use Natural Family Planning, not only to space, but to avoid pregnancy entirely. There are other psychological, marital, and social indications. While no newly married couple can imagine how their lives and hearts will be expanded in meeting the challenges of their marriage, there are human limitations. Blessedly, prolactin has been called the "hormone of mother love." It mediates the maternal instinct in women and disposes them to think of the child and its welfare ahead of their own, but nevertheless, there are limitations. Some couples may be able to handle three children well, while others can manage 12. Children require not only material support, but parental time and presence. While this can be arranged in more than one way, and many mothers of large families acquire admirable management skills in the process--it cannot be presupposed for everyone. Child-rearing styles differ. Some parents rear a large family as a group, while others want to raise each child as if it were an only child. It is the latter who usually find almost insurmountable difficulties. Conversely, children who are raised as a group have different outcomes. Some have sturdy personalities who feel that life has been good to them, while quite often in a large brood, one or two children fail to mature and spend 10 or 20 years after reaching physical adulthood still looking for the connection with their mother and father which they feel they missed. So the question is not simple. Perhaps even more fundamental is the attitude of both parents. Some fathers participate fully in the rearing of their children, while others believe that their main responsibility is to provide the material means, leaving most of the work of child-rearing to their wives. Such wives may be over-burdened and feel exploited in the process. So the decision of limiting the number of children has to be ultimately that of the couple in the face of God. With natural methods, one's priorities and goals are apt to shift, so that a change of procreative intent is not unusual. When we studied one of our acceptor cohorts over 24 months, we found that 41% of those who entered as "limiters" (wanted no more children) changed to "spacing" (open to more children later) or "trying to achieve pregnancy."[11]

Sociological reasons to limit family size can be accepted fully by the couple, or may be faced under duress. An example of the former may be living with a limited income, which precludes seeking a larger living space, which in turn would be necessary to raise a larger family. This in turn may be due to the earning capacity of the father and mother, or the limitation of the society in which the couples live. For example, many countries of the former Soviet bloc have only very large blocs of apartments, each of which contains a very limited living space. In many of these countries, there simply is no other housing available at this time, and many young couples limit the number of their children because of this alone. While this may be changed politically, they live in their present situation. Another external reason may be governmental regulation, for instance, China's one-child policy. While most Chinese couples traditionally have wanted many children, they also know that if they have more than the one child permitted, they may be forced to abort additional babies and be sterilized, as well as suffer financial repercussions. For that reason, they may well choose to conceive only once.

There are also couples who believe any family limitation is contrary to the scriptural command to "go out and multiply and fill the earth". Some who believe this are not persuaded by the Roman Catholic Church's consistent teaching of responsible parenthood. Grounding the response in scripture, as the late Father Paul Quay did, may be more useful: One reason that marriage and children were so prized by the people of the Old Testament was that they expected the Redeemer to be born from one of them. Since the Redeemer has come, there is no need to keep on having children in the hope that one will be the redeemer.[12]

It is necessary to try to understand not only the couple's procreative interest but the motivation for it, if one is dealing with a couple whose behavior is not consistent with their expressed intent, and they desire assistance. Thus follow-up until the couple reaches autonomy is an integral part of teaching NFP. We have defined two stages: 1) method autonomy: understanding one's fertility signs. 2) Couple autonomy: the couple is comfortable making decisions about intercourse in terms of their fertility in line with their intentions for family size. Usually, couple autonomy is reached in 3-6 months. The couple are free to contact the teacher as needed, especially if the reproductive circumstance changes i.e. lactation or premenopause.

Limiting the understanding of informed choice pregnancy to the biology of the act actually prevents couples from working through any areas of ambivalence. Dealing with such a complex question on an either/or basis may not only be perceived as controlling or fostering dependency but lead to incorrect perceptions of the effectiveness of the various natural family planning programs.

References

[1].. Brennan JJ, Klaus H. Terminology and Core Curriculum in Natural Family Planning. Linacre Quarterly 1981, 48:313-5.

[2].. Trussell J and Kost, K, Contraceptive Failure in the United States: a critical review of the literature. Stud Fam Plan 1987; 18:237-283.

[3].. Klaus H. Natural Family Planning a Review. 2nd edit. 1995

[4].. Kambic R Personal Communication, May 1, 1998

[5].. Hilgers TW and Stanford JB, Creighton Model NaPro Education Technology for Avoiding Pregnancy. Use effectiveness. Journal of Reproductive Medicine 1998, 43:495-502.

[6].. Fehring RJ, Lawrence D, Philpot C. Use Effectiveness of the Creighton Model Ovulation Method of Natural Family Planning. Journal of Obstetrical, Gynecological & Neonatal

[7].. Klaus H. Positive Woman or Negative Man? Linacre Quarterly 1976:43:4:244-248.

[8].. Tannen D Talking from Nine to Five, Avon Books, 1995.

[9].. Gray J Men are from Mars, Women are from Venus, 1992, Harper Collins.

[10].. Humanae Vitae, #10.

[11]..Klaus and MU Fagan, "Natural family planning: analysis of change in procreative intention,"
J Am Med Women's Assoc 1982; 37:231-241, September

[12].. Quay, P.M. The Scriptural Foundations of Natural Family Planning, in: Mastroenni, A J. Ed. The Church at the Service of the Family, pp 109-136. Proceedings, The Fellowship of Catholic Scholars 16th Convention, 1993 Orange CA. Franciscan University edition, Steubenville OH.